Healthy communities: America must smash silos to stop rural suicide

Since 1999, more than half a million Americans have killed themselves. Suicide in the United States is increasing – it is now one of the country’s leading causes of death — and the rate is higher in rural areas.

Rural western states such as Colorado suffer disproportionately from suicide, along with the mountainous Appalachia and Ozark regions, according to a report by Jama Network Open, which added to a body of research highlighting US rural suicide as especially problematic.

The complex range of risk factors for suicide mean a collaborative approach is essential to tackling the problem, and is the key recommendation of the 2012 US National Strategy for Suicide Prevention.

The strategy’s first objectives call for collaborative and sustainable suicide prevention programming at state level, and across government bodies. “Because suicide affects many different groups and is related to mental health, substance abuse, trauma, violence, injury, and other issues, many federal agencies have a role to play in suicide prevention,” said the strategy.

A Young Field

But the US is not on track to meet the its target of reducing suicide by 20% by 2025, said Jerry Reed, co-author of the national strategy and Suicide, Violence, and Injury Prevention Lead at the Education Development Centre, a nonprofit.

There have been challenges around coordination and planning — particularly while trying to respect a simultaneously top-down and bottom-up agenda — and organising and tracking the disparate data collected by various agencies.

Reed said suicide prevention is a “relatively young field” that is still developing, having only been addressed as a worthy public policy concern since 1996.

“We’re still learning a lot and made some progress, including on the importance of building a national infrastructure, so that there can be a coordinated and collaborative response at the community and state level and across agencies,” said Reed.

This infrastructure did not exist in the early 2000s. “Now every state has a suicide strategy and suicide prevention coordinator, and we’re seeing lots of departments, such as Veteran’s Affairs, coming aboard,” he added.

In this time, wider social attitudes to suicide have also changed, and the topic is less taboo than it was.

Following a call to action by the Surgeon General in 1998, Congress began funding the National Suicide Prevention Resource Centre (SPRC). It serves as a central knowledge base and maintains relationships with state suicide prevention staff, including providing training and hosting annual meetings.

Engagement and advocacy with groups across government and society has led to the development of an extensive “hub and spoke” model, emphasising the “perspective of the individual who is struggling” according to Reed.

“It helps us identify all the right places that we need to take our suicide prevention work, no matter what the federal agency is,” Reed said. He added this approach — “having the right people at the table” — was being mirrored at state and community levels.

This is embodied by the Action Alliance for Suicide Prevention, a public-private partnership which uses regular meetings to bring representatives from government departments and agencies alongside citizen groups and the private sector, including hospitals and tech companies.

It includes a Federal Working Group, comprised of senior representatives from seven departments (Defence, Health and Human Services, Justice, Homeland Security, Education, Transport and Veterans Affairs), providing high level legitimacy and oversight to suicide prevention efforts throughout the country. An executive order to tackle suicide among veterans has also supported government efforts.

But Reed said thinking on the topic remains somewhat siloed, and suicide is ultimately best addressed locally, in communities. “The solutions to something like suicide will be horizontal,” he said. “They won’t be vertical.”

Local priorities

Even while suicide prevention is a key state and national objective, in Colorado’s highly decentralised political system, “local priorities and local partners must be at the forefront and at the table with all of our projects,” said Brummett, from the Colorado Office of Suicide Prevention. “Because if they are not brought in, it’s not going to happen.”

Collaboration and partnerships focused on reducing suicide in the US are both bottom up and top down, and are a crucial element of Colorado’s holistic approach to suicide prevention. Collaboration takes place across four areas: healthcare, training and education, building resilience and community connectedness and data and systems. Put together, the stakeholders in these areas — from hospitals to schools to law enforcement — make up huge swathes of public life.

The Colorado Office of Suicide Prevention also works with other state level organisations. The State Suicide Prevention Commission, for instance, is a “great vehicle for working through information and prioritising and looking at data and making recommendations,” said Brummett.

A cabinet also brings executive directors of state agencies together regularly to share their ideas and findings, and yet another separate state body, the Colorado National Collaborative, works with the Action Alliance, SPRC, Centre for Disease Control and other specialist organisations.

But the different relationships require differing approaches. Local partners are engaged by building consensus, but Brummett’s team must also be aware they may have limited capacity for additional work and want to avoid burnout.

Conversely, the relationship with the other specialist bodies is “incredibly collaborative,” said Brummett. “It’s a pretty small community and we all want the same thing, so a success in another state or nationally that we can implement here – we all see that as a win.”

Competition between the various agencies would likely be more pronounced if there “was more money to fight about” she added, though acknowledged that “there would always be competing priorities and limited bandwidth” across agencies.

A useful tool for working with both sets of partners is an interactive data dashboard which visualises the impact of suicide fatalities to national and local partners – who can zoom into their communities.

Coordinating such a vast network of partners is a “constant work in progress,” said Brummett. It is done through high level actions, such as with the State Suicide Prevention Commission, or smaller ones, like a quarterly newsletter to hospitals, highlighting funding opportunities and other resources.

Engaging communities

Engaging communities is also crucial to reducing suicide among rural veterans, according to Dr Lisa Kearny, Deputy Director for Suicide Prevention at the Department of Veteran’s Affairs.

Kearny said widespread passion for the issue across society — from the President down — was important to achieving "buy-in" from rural communities, as was the perception their needs were being listened to.

But despite the importance of grassroots action, the public servants interviewed say having high level support and an overarching framework is still vital.

“You need to be bottom-up and top-down, that is the challenge,” said Dr Richard McKeon, head of the Suicide Prevention Branch at the Substance Abuse and Mental Health Services Administration of the Department of Health and Human Services.

McKeon, who also leads the Federal Working Group on Suicide Prevention, added that there should be a balanced approach that allowed for community wishes. “But also, so it’s not so disparate and fragmented that different places are all doing different things and it’s hard to know whether you’re having any impact,” he added.

Kearny also stressed in the benefit of “obtaining top-level leadership support from agencies to garner early commitment to the process, and the developing of strong transition planning into the partnerships as leaders and stakeholders staff turn over.”

Integrating plans across the state, county, and local level help to avoid duplicating efforts, she added. — Will Worley

(Picture credit: Pixabay)