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Proceedings of a Workshop
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From page 1...
... School, workplace, and community-based interventions can help reduce the incidence of suicidal behavior, as can better access to care and reduced access to lethal means of suicide (Hogg et al., 2021; National Action Alliance for Suicide Prevention, 2017; Pistone et al., 2019)
From page 2...
... The second webinar on July 28 focused on building 9-8-8, the new nationwide emergency number designated to the National Suicide Prevention Lifeline, and participants discussed current crisis systems, gaps, challenges, and needs for marginalized populations. Appendix A contains the workshop Statement of Task, and Appendix B contains the workshop agendas, respectively.2 Appendix C contains biographical sketches of the speakers and the moderators of the workshop.
From page 3...
... (Bridge) • From 1999 to 2019, suicide rates among American Indian and Alaska Natives children and adolescents were significantly higher than among any other racial subgroup in the United States.
From page 4...
... (Brenner) • Lethal means safety is an intentional, voluntary practice to reduce access to lethal methods of suicide in order to reduce suicide risk.
From page 5...
... Suicide Risk Identification Strategy Program (Risk ID) is a national standar dized process for suicide risk screening using high-quality, evi denced-based tools and practices to facilitate and encourage fidelity to best screening and evaluation practices.
From page 6...
... will connect the caller with the National Suicide Prevention Lifeline. (Everett)
From page 7...
... (Armstrong) Building Cultural Competence Within Crisis Services • The PersIn Approach to developing personalized, evidence-based interventions for culturally diverse populations entails three steps: identifying factors and understanding potential dimensions upon which personalization for culturally diverse populations may need to occur.
From page 8...
... Promoting mental health from a young age should be emphasized and include anti-bullying training, and there should be an effort to highlight evidence-based practices for Latinx behavioral health and to create partnerships between family, commu nity, and schools to promote resilience and heal trauma.
From page 9...
... (Schneider) • It is imperative for the nation to build a universal behavioral health system for prevention, early identification, and intervention to mini mize crises while also addressing the failings of the current crisis response system for children.
From page 10...
... . There is a gender paradox regarding suicide and suicidal behavior in that suicide rates for males have remained four times higher than for women over that time span, while the rate of suicide attempts by young females is three to four times higher than by young males.
From page 11...
... SOURCES: Presented by Jeffrey A Bridge on June 22, 2021, at the workshop on Strategies and Interventions to Reduce Suicide.
From page 12...
... Bridge on June 22, 2021, at the workshop on Strategies and Interventions to Reduce Suicide; Ramchand et al., 2021. individuals ages 10 to 19 years old, are higher among non-Hispanic individuals, though the gap between non-Hispanic and Hispanic females ages 10 to 19 years old is small (see Figure 5)
From page 13...
... Bridge on June 22, 2021, at the workshop on Strategies and Interventions to Reduce Suicide; CDC, 2021a. research examining the causes for these differences, people have proposed several explanations.
From page 14...
... SOURCES: Presented by Jeffrey A Bridge on June 22, 2021, at the workshop on Strategies and Interventions to Reduce Suicide; Bridge et al., 2018.
From page 15...
... SOURCES: Presented by Jeffrey A Bridge on June 22, 2021, at the workshop on Strategies and Interventions to Reduce Suicide; CDC, 2021a.
From page 16...
... In addition, NIMH's intramural program supports approximately 600 scientists. Mental health care services, said Barksdale, are a critical component of suicide prevention efforts, and those services addressing suicide prevention can occur in a variety of settings, including crisis centers, health centers, clinics, in the home, and other locations specific to the population.
From page 17...
... For this reason, Barksdale noted, it is important to understand help-seeking behaviors in order to promote effective suicide prevention efforts and answer questions such as whether a person has or has not considered mental health care, whether they have sought advice from family and friends about getting care, and what their experience with the care they have received has been and if it helped them get better. "Overall, we want to provide and make available culturally and linguistically appropriate mental health care services that meet the needs of individuals at risk, and then encourage individuals to see these services as an option to address their needs," said Barksdale.
From page 18...
... Barksdale concluded her remarks with a list of research opportunities available at NIMH detailed in Box 2. 5 Additional information is available at https://www.cdc.gov/violenceprevention/about/ social-ecologicalmodel.html (accessed October 25, 2021)
From page 19...
... Barksdale on June 22, 2021, at the workshop on Strategies and Interventions to Reduce Suicide. OPPORTUNITIES IN HEALTH CARE TO REDUCE SUICIDE RISK Following the two presentations, Holly C
From page 20...
... This is unfortunate, he said, because research has shown there is a sustained effect after consecutive years of programming, so starting that programming at a younger age might lead to an even larger positive effect on suicide rates in future years. The other implication of that finding is that suicide prevention programming cannot be "one and done." He also noted that the impact of Garrett Lee Smith grants was greater in rural communities than in other communities, though not in frontier communities (Walrath et al., 2015)
From page 21...
... When asked about the role the 9-1-1 emergency call system can play in suicide prevention, McKeon said the issue is whether suicidal thoughts should always be considered an immediate emergency, and whether the response to such an emergency would be to use whatever means possible to get someone to the emergency department. "There is reason to think that is not the most effective system," said McKeon McKeon, adding "To the extent to which we can make emergency departments less central as part of a comprehensive suicide prevention response, I think there are many significant advantages to that, simultaneous with trying to improve care in the emergency department and, very importantly, improve follow-up afterward." Based on a cohort study, explained McKeon, research has shown that people who made suicide attempts and who were seen in the emergency department had a 56-fold higher rate of death by suicide over the next 12 months, compared to general population patients who also visited the emergency department in the same 1-year period (Goldman-Mellor et al., 2019)
From page 22...
... Brenner noted that each recommendation has a "strength" notation that indicates how strong the evidence is in favor or against a specific clinical practice. As an example, she cited one of the screening and evaluation recommendations that states, We recommend an assessment of risk factors as part of a comprehensive evalu ation of suicide risk, including but not limited to current suicidal ideation, prior suicide attempt(s)
From page 23...
... For that reason, the VA clinical practice guidelines, as well as various medical and public health professional societies, promote lethal means safety counseling or firearm safety counseling for individuals with elevated suicide risk. He added that in the VA, discussing how to reduce access to firearms is a key focus of lethal means safety counseling because 70 percent of veterans who die by suicide do so with a firearm (see Figure 10)
From page 24...
... First, lethal means safety counseling is not a single intervention; rather, it needs to be provided across many different settings and through different messengers delivering different messages to a heterogeneous mix of at-risk populations. In addition, researchers are challenged to develop and disseminate interventions that are effective, feasible, and tailored to these different audiences and settings.
From page 25...
... . "It is unclear whether the past year has spawned these unique risk populations that we know very little about in terms of both their suicide risk and their firearm safety behaviors," he said.
From page 26...
... Suicide, she noted, is a significant issue to Indian country -- suicide is the eighth leading cause of death among all American Indian and Alaska Native communities across all ages -- and it is one that can take over entire communities. The Suicide Prevention and Care program, she explained, operates in conjunction with programs in mental health and substance use disorders and with the IHS Telebehavioral Health Center of Excellence9 to provide programs to tribal communities and tribal nations that focus on behavioral health care and suicide prevention.10 IHS, explained End of Horn, is a health care system, but, unlike the VA, it is more of a set of systems than one system in that it has federal partners, tribal partners, and local partners.
From page 27...
... This wide swath of sites requires adapting how the model is implemented to reflect local cultures. The pilot program, said End of Horn, established cooperative agreements with the tribal governments so that she and her colleagues could work closely with the tribes to understand how best to apply the model, how it works in different cultures, and what the tribes needed to do within their health systems to improve care and prevent suicides.
From page 28...
... They also plan to improve EHR functionality by adding alerts and establishing data-sharing agreements. IMPROVING SUICIDE PREVENTION: ADDRESSING KNOWN BARRIERS TO HEALTH CARE ACCESS Ursula Whiteside, chief executive officer at NowMattersNow.org and clinical faculty member at the University of Washington, introduced the next session by referring participants to the 2018 report from the National Action Alliance for Suicide Prevention, Recommended Standard Care for People with Suicide Risk,13 which aims to help health systems better identify and support people who are at increased risk of suicide.
From page 29...
... "This is not in an ‘It is going to be okay, I have all the answers' manner, but in a way that conveys they will help that person in crisis get through the next 5 minutes." IMPROVING SUICIDE PREVENTION: ADDRESSING KNOWN BARRIERS TO HEALTH CARE ACCESS FOR LGBTQIA+ PEOPLE IN INSTITUTIONAL SETTINGS With almost 2.1 million people, New Mexico is a culturally rich, mostly rural, economically challenged majority-minority state, explained Cathleen Willging, center director and senior research scientist at the Pacific Institute for Research and Evaluation's Southwest Center. Suicide is a lead
From page 30...
... . Some 60 percent of the state's residents live in mental health professional shortage areas, and in addition, the state's behavioral health system is fragmented and fragile, a situation exacerbated by the forced closure of community mental health centers in 2013 that created mental health care deserts throughout the state (Willging and Trott, 2018)
From page 31...
... More information can be found at https://impsciuw.org/implementation-science/ learn/implementation-science-overview (accessed November 29, 2021)
From page 32...
... (2016) has found that school staff often cite low mental health literacy and insufficient engagement among parents and guardians as major challenges in making sure students experiencing suicidal behaviors get support.
From page 33...
... In terms of what institutions can do to reduce access barriers and health disparities for LGBTQIA+ individuals, there are evidence-informed practices available. Schools, for example, can establish safe spaces and social groups on campus that promote school connectedness among LGBTQIA+ students, a major protective factor against suicidal behaviors.
From page 34...
... In that respect, adopting a structural competency framework to organize professional development can be useful by enhancing awareness of upstream factors such as stigma and discrimination that abet marginalization and give way to disproportionate risks for suicidal behaviors. Such a framework can also enhance the case for larger-order, focused interventions directed at changing implementation environments, overcoming institutional inertia, and doing something about adverse health outcomes for particular social groups.
From page 35...
... RISK ID: THE VA SUICIDE RISK IDENTIFICATION STRATEGY One way to improve the availability of suicide prevention services is by upstream screening and evaluation, which the VA has been striving to implement throughout its health care system, not just in mental health specialty care, said Brenner. The VA's Suicide Risk Identification Strategy program (Risk ID)
From page 36...
... Mental Health Residential C-SSRS Screener within 24 hours of admission and CSRE during Rehabilitation Treatment the first week of admission; updated CSRE within a week before Program discharge and C-SSRS within 24 hours before discharge Community Living Center C-SSRS Screener within 24 hours of admission and within 24 hours before discharge Inpatient Mental Health C-SSRS Screener within 24 hours of admission and within 24 hours before discharge Inpatient Medical/Surgical C-SSRS Screener within 24 hours of admission and within 24 hours before discharge Inpatient & Residential C-SSRS Screener within 24 hours of admission and within 24 Rehabilitation hours before discharge NOTE: C-SSRS = Columbia-Suicide Severity Rating Scale; CSRE = VA Comprehensive Suicide Risk Evaluation. SOURCE: Presented by Lisa Brenner on June 22, 2021, at the workshop on Strategies and Interventions to Reduce Suicide.
From page 37...
... , said Michael Lindsey, executive director of New York University's McSilver Institute for Poverty Policy and Research. Over the same period, he noted, suicide attempts for Black youth rose by 73 percent while falling for every other racial and ethnic group.
From page 38...
... The main finding from this study was that compared to youth of all other racial and ethnic groups, Black youth had higher odds of having an attempt only and no preceding thoughts or plans. "In terms of screening and prevention, this is scary when you think that the common warning signs we look for in terms of suicidal behavior might not be as apparent for Black youth," said Lindsey.
From page 39...
... House of Representatives passing the Pursuing Equity in Mental Health Act in May 2021 by a margin of 349 to 74. SUICIDE PREVENTION: STIGMA AND THE COVID-19 PANDEMIC Session moderator Erin Bagalman, director of the Division of Behavioral Health Policy in the Office of the Assistant Secretary for Planning and Evaluation at the U.S.
From page 40...
... One question is whether this period will represent a short-lived change or if firearm ownership has changed for a large proportion of the country. Brenner commented that she appreciated Lindsey noting that food insecurity and other factors not normally associated with suicide can, in fact, be suicide risk factors.
From page 41...
... Another opportunity is to revisit what is happening in schools with regard to so-called zero-tolerance policies and to instead provide the kinds of behavioral health supports that children need, including working with families to provide education about psychological issues. In fact, the whole idea of providing services in nontraditional settings can be used to combat stigma, he said.
From page 42...
... After 40 seconds of silence in memory of those who have died by suicide, she reiterated the key themes that emerged during the first webinar on June 22, 2021, which were the importance of cultural competency, health equity, and addressing the barriers to suicide prevention, such as the lack of access to health care services and health care provider shortages, that are exacerbated by COVID-19 and the ongoing civil unrest. Roary noted that sustainability needs to be built into planning for suicide prevention programs and that there is a need for an extended research focus that targets traditionally under-resourced and marginalized groups such as American Indians and Alaska Natives, members of the LGBTQIA+ community, Black youth, military veterans, and people who are homeless.
From page 43...
... "Imagine how we could help so differently, and imagine that this tragedy may not have had to occur at all." THE 9-8-8 LIFELINE: POTENTIAL AND IMPLICATIONS FOR CRISIS RESPONSE The Community Mental Health Services Framework In communities today, dialing 9-1-1 typically provides one of three options: police, emergency medical services, or fire, but as Anita Everett, director of the Center for Mental Health Services at SAMHSA, explained, 9-1-1 systems for the most part are not setup to respond to mental health emergencies or to provide behavioral health services, even though a large proportion of 9-1-1 calls relate to mental health emergencies. In recognition
From page 44...
... , will connect the caller with the National Suicide Prevention Lifeline. Everett said that SAMHSA's Center for Mental Health Services, in its efforts to lower the national suicide rate, is working in four main areas.
From page 45...
... However, she added, when the first national strategy was published in 2001, suicide crisis lines were not part of the strategy because the evidence for crisis line effectiveness was considered insufficient at the time. What did happen in 2001, though, was SAMHSA's funding of a national network of local certified call centers that eventually became the National Suicide Prevention Lifeline.
From page 46...
... Her team's evaluation of crisis chat functions found that almost 84 percent of people who chat report either current or recent suicidal ideation on a pre-chat survey, which is markedly higher than the estimated 23 percent of lifeline callers who are experiencing suicidal behavior on the day of or the day before their call (Gould et al., 2021a)
From page 47...
... Department of Defense clinical practice guidelines for addressing suicide risk. The Caring Letters initiative is now focused on expanding critical crisis intervention work to help veterans continue to feel supported and engaged, and the goal is to reach more than 90,000 veterans annually with nine letters over the course of a year after their call to the crisis line.
From page 48...
... These will remain active even after full activation of 9-8-8. 9-8-8 ROLLOUT: PRIVACY, CONFIDENTIALITY, AND EQUITY CONSIDERATIONS The 9-8-8 Workforce and Culturally and Linguistically Appropriate Services Sue Ann O'Brien, chief executive officer at Behavioral Health Link, said the advent of 9-8-8 will be transformational in helping people who are in a behavioral health crisis and getting them connected to care.
From page 49...
... Ensuring a sufficient workforce to meet the expected increase in demand will be an essential component for providing access to the full spectrum of care, and building that workforce cannot rely solely on licensed clinicians because they are already in short supply. Moreover, the majority of the behavioral health workforce in the United States is approximately 85 percent White according to some estimates, while the number of non-White residents is approaching half of the U.S.
From page 50...
... Patient-centered care in that context requires the health care provider to listen to the individual as they share what is happening to them and what they are experiencing; this can involve a translator for those individuals who feel more comfortable telling their story in their native language. "Including family, communication, relationship building, being open to cultural influences, and providing traditional treatment options allows Western medicine to meet the needs of Native people," she said (Sylliboy and Hovey, 2020)
From page 51...
... "I would argue that our current system is not designed to protect and nurture the individual experiencing the mental health emergency, but to protect the rest of us from the individual experiencing the mental health emergency, and that is wrong," said Armstrong. "The introduction of 9-8-8 will provide us an opportunity to mitigate those challenges and to correct that wrong." Because many people of color do not have access to outpatient services or crisis services in the communities where they live, their introduction to the mental health care system often ends up being in the back of a police car or in an acute care emergency department when they are in a state of crisis, and "that is not conducive to good clinical outcomes, nor is it likely to foster a positive relationship with the mental health system," said Armstrong.
From page 52...
... It can do so by supporting the creation of more mental health resources in communities of color and underserved communities. Those resources, he noted, can include mobile crisis care, facility-based crisis care, peer respite, and others designed to divert individuals away from emergency departments and jails.
From page 53...
... "We need to utilize the peer workforce, pay them a living wage, and build them into our crisis continuum to respond to individuals experiencing mental health emergencies at a time when they most need someone who understands their immediate challenges," adding We can increase the percent of historically marginalized populations receiving behavioral health services by building and earning trust between historically marginalized communities, behavioral health care providers, and funders as we bring them to the table in planning our 9-8-8 model. It is possible, he stated, to reimagine the nation's approach to mental health and build an equitable mental health care system.
From page 54...
... "My life experience tells me that if we do not build equity into 9-8-8 on the front end, the most powerless and vulnerable among us will not receive equity, justice, or access to the mental health resources they need and deserve," he said. BUILDING CULTURAL COMPETENCE WITHIN CRISIS SERVICES A Potential Framework for Developing Culturally Responsive and Personalized Evidence-Based Mental Health Interventions for Culturally Diverse Populations May Yeh, associate professor of psychology at San Diego State University, described the PersIn Approach to developing personalized, evidence-based interventions for culturally diverse populations (McCabe et al., 2020)
From page 55...
... This conceptualization of culture says not to lump all American Indians and Alaska Natives into one group because that takes away from the individuality and uniqueness of each tribal nation, said End of Horn.
From page 56...
... One topic of discussion regarding health equity has been around how to handle calls from a non-native English speaker and where the responsibility of the 9-8-8 system morphs into the community's responsibility to provide language assistance. The discussions have also raised the possibility of training the people who provide translation services to serve in the call centers because
From page 57...
... She then noted that conversations at the state level have focused on suicide prevention as a form of social justice work, saying The more that we can create a life worth living for people, the more that people are going to reach out for the care that they need when they need it, and hopefully trust us enough to be able to be the folks that they reach out to. As a final comment, she reiterated the call to involve local communities in whatever plans are being made, as well as to reach out to local call centers and support them however possible.
From page 58...
... This population, he noted, largely depends on community health clinics for all their health care needs and only seek emergency services when faced with a life or death situation. This study also identified risk factors for suicidal behaviors that included exposure to violence and trauma, acculturation of absent family systems, social and linguistic isolation, economic stress, and family conflict.
From page 59...
... A second competition is in the works, said Zhang. 9-8-8, HEALTH EQUITY, AND FAITH WITHIN THE BLACK COMMUNITY Brandon Johnson, public health advisor to SAMHSA's Center for Mental Health Services, discussed how 9-8-8 can be used to improve outcomes for Black youth, who have twice the suicide rate of White youth and among whom those rates have been increasing at an alarming rate, as Lindsey discussed during the first webinar.
From page 60...
... Moreover, by emphasizing cultural humility, it should be possible to understand those aspects of the lived experience that may be driving suicidal behavior but may not have been accounted for and attended to in the past. As co-leader of the Faith Communities Task Force, which leads the National Action Alliance for Suicide Prevention's efforts to engage faith communities in suicide prevention, Johnson said that a focus on faith communities can: • help integrate and coordinate suicide prevention activities across multiple sectors and settings, • increase knowledge about the factors that offer protection from suicidal behaviors and that promote wellness and recovery, and • provide care and support to individuals affected by suicide deaths and attempts to promote healing and implement community strategies to help prevent further suicides.
From page 61...
... , vice president of advocacy and government affairs at the Trevor Project. Data collected by the National Survey on LGBTQIA+ Youth Mental Health show that 42 percent of LGBTQIA+ youth overall seriously considered suicide in the past year, but Brinton noted that there were differences in suicide risk among different populations of LGBTQIA+ youth.
From page 62...
... Not only would direct video call acceptance be linguistically affirming, but it would also be culturally appropriate as well, she noted. INCLUDING SCHOOLS IN THE CRISIS RESPONSE SYSTEM Sharon Hoover, professor and co-director of the National Center for School Mental Health at the University of Maryland School of Medicine, said it is imperative for the nation to build a universal system for behavioral health promotion and early identification and intervention to minimize crises while simultaneously addressing the failings of the current crisis response system for children.
From page 63...
... An essential component of comprehensive school mental health systems is crisis prevention and response. In fact, said Hoover, implementing comprehensive, multitiered systems of mental health support in schools has been demonstrated to reduce emotional and behavioral health crises (Bohnenkamp et al., 2021; Kase et al., 2017; SAMHSA and CMS, 2019; Stephan et al., 2015)
From page 64...
... Brinton noted that not every state legislature has passed legislation on 9-8-8 implementation yet, but they emphasized that every school should have a suicide prevention policy and that every teacher, faith community leader, and mental health professional should know about 9-8-8 and spread the word about it so that calling it becomes a normalized process. REFLECTIONS: OPPORTUNITIES TO BUILD INCLUSIVE CARE STRUCTURES To conclude the workshop, Barbara Limandri, a psychiatric nurse with the American Psychiatric Nurses Association and professor emerita at Linfield University, and David Covington, chief executive officer and president of RI International and a partner with Behavioral Health Link, offered their thoughts and reflections.
From page 65...
... They are detained, delayed, and denied care, and they spend time in hospital emergency departments -- and some people who are having a mental health crisis end up handcuffed in the back of a police vehicle. Nonetheless, the combination of the pressure from the COVID-19 pandemic on hospitals, discussions of race inequity, a reconsideration of the role of law enforcement in this process, and the galvanizing promise of 9-8-8 provides an opportunity to create something different for everyone in crisis, but particularly for people of color and the LGBTQIA+ community.
From page 66...
... 2020. Assessment of rates of suicide risk screening and prevalence of positive screening results among us veterans after implementation of the Veterans Affairs suicide risk identification strategy.
From page 67...
... 2018. Age-related racial disparity in suicide rates among US youths from 2001 through 2015.
From page 68...
... 2016. Helping callers to the National Suicide Prevention Lifeline who are at imminent risk of suicide: Evaluation of caller risk profiles and interventions implemented.
From page 69...
... 2021a. National Suicide Prevention Lifeline crisis chat interventions: Evaluation of chatters' perceptions of effectiveness.
From page 70...
... 2020. The feasibility and impact of a suicide risk screening program in rural adult primary care: A pilot test of the ask suicide-screening questions toolkit.
From page 71...
... 2017. Suicide risk assessment and prevention: A systematic review focusing on veterans.
From page 72...
... 2013. Behavioral health emergencies managed by school nurses working with adolescents.
From page 73...
... 2021. Behavioral health emergencies managed by school nurses.
From page 74...
... 2018. Outsourcing responsibility: State stewardship of behavioral health care services.


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