Recommendation:
1. We suggest reducing access to lethal means to decrease suicide rates at the population level.
2. There is insufficient evidence to recommend for or against community-based interventions targeting patients at risk for suicide.
3. There is insufficient evidence to recommend for or against community-based interventions to reduce population-level suicide rates.
4. There is insufficient evidence to recommend for or against gatekeeper training alone to reduce population-level suicide rates.
5. There is insufficient evidence to recommend for or against buddy support programs to prevent suicide, suicide attempts, or suicidal ideation.

Discussion:
Implementing lethal means safety, including firearm restrictions, reducing access to poisons and medications associated with overdose, and barriers to jumping from lethal heights, is a means to reduce population-level suicide rates

Access to firearms is a risk factor for death by suicide. Firearms are used in half of suicides in the U.S.,[136] and approximately 90% of suicide attempts involving firearms result in death. Recent studies have shown that differences in state laws regulating firearms access, and that higher state-level firearms ownership rates, are associated with firearm-related and overall suicide rates, even after accounting for important demographic and geographic factors. Veterans and military Service Members are more likely to use firearms as a method for dying by suicide compared to the general population.[ Military Service Members often have ready access to firearms, and Veterans have higher rates of firearm ownership compared to their civilian counterparts.

One systematic review reported statistically significant increased risk of suicide with presence of firearms in the house. DoD healthcare providers, like their VA and civilian counterparts, have no restrictions regarding inquiries and recommendations pertaining to weapons ownership or carriage. The DoD has long had mechanisms for leaders to arrange sequestration of military and civilian-issued weapons in armories, for operational units during leave periods, for individuals under treatment for behavioral health conditions, or for any individual exhibiting behaviors of concern.

Weapons restrictions in individuals are buttressed by state and Federal law and policy measures in both VA and DoD. For instance, felons cannot own or carry weapons. Sentences of over one year in courts-martialresult in a report to a national database that prohibits weapons purchase and ownership. Population-based weapons restrictions have been effective in a Western military population, even if limited in generalizability by geographic variability and changes in gun statutes, cultural attunements, and greater rates of weapons ownership in the U.S. compared to other Western nations. A naturalistic epidemiological study in the Israeli Defense Forces ascertained the effect of unit-by-unit weapons storage on bases for 18-21 year old soldiers on weekend leave, showing a dramatic reduction in suicide death on weekends, but not weekdays, in this population-based cohort.[143] Randomized studies have yet to systematically ascertain effects of population-based weapons restrictions.

Means safety counseling (MSC; also referred to as “lethal means counseling”) approaches have been developed in an effort to reduce deaths by firearms and other means. MSC consists of discussions between clinicians and persons at elevated risk for suicide. Less than half of U.S. gun owners report safely storing their firearms (defined as all guns stored in a locked gun safe, cabinet, or case; locked into a gun rack; or stored with a trigger lock or other lock), and that one third of Veterans store at least one firearm loaded or unlocked. Examples of MSC recommendations, depending on level of risk, include storing firearms in locked cabinets, using gunlocks, giving keys to these locks to family, caregivers or friends, temporarily transferring firearms to someone legally authorized to receive them, removing firing pins, or otherwise disabling the weapon. MSC approaches have not been shown to reduce suicide, but have been shown to impact firearm storage practices.

Another commonly used method for suicide among Veterans and military Service Members is poisoning, including medication overdose. Access to opioid medications has been associated with increased rates of intentional and unintentional overdose death. One study demonstrated that increased access to paracetamol (acetaminophen) were paralleled with increased rates of suicide attempts and death by suicide via overdose in the United Kingdom.

One study examined the impact of legislation to reduce pill pack size of paracetamol on paracetamol-induced poisoning. Rates of death were decreased for individuals with death ruled as suicide or “undetermined.” Two studies examined restriction of access to pesticides. One observational study compared rates of suicide before and after bans of paraquat, dimethoate, and fenthion in Sri Lanka. One randomized, controlled feasibility study examined the impact of providing centralized storage facilities for pesticides versus no intervention in four villages in India.Both studies reported a decrease in both pesticide suicide deaths and suicide from all causes. One systematic review of nine pre-post studies considered the impact of the installation of barriers or structural measures designed to prevent suicide by jumping from a height. Jumping suicides at sites with structural barriers was decreased while jumping at other sites nearby without barriers increased. Overall, jumping suicides at all sites were decreased. This analysis did not consider suicide rates in the studied regions from other causes, so it is not possible to determine whether individuals chose a different method other than jumping or whether all-cause suicide was decreased

Gatekeeper training for suicide prevention—a key tool for increasing engagement into preventative services for suicide, which includes programs such as Question, Persuade, and Refer (QPR) and Applied Skills in Suicide Training (ASIST)—has not been found to improve population-level suicide rates in each of the U.S. states, VA, and DoD. Buddy support, incorporated into programs such as Comprehensive Soldier Fitness, which have a practical and theoretical nexus to military suicide prevention and resilience programming, does not have a sufficient evidence base to demonstrate efficacy in preventing suicide, suicide attempts, or suicidal ideation.

Every state in the nation, and federal agencies including VHA, DoD, and SAMHSA, has fostered a community-based approach to suicide prevention since the turn of the century. Community-based suicide prevention may be constrained, however, by the immense complexity of population processes, including sociocultural variables, and historically suboptimal interactions between healthcare systems and suicide prevention programs. Gatekeeper training is illustrative. An initial systematic review of studies published from 1980-1995 found that knowledge about suicide improved in gatekeeper training but there were both beneficial and harmful effects in terms of help-seeking, attitudes, and peer support. Mann et al.(2005) made a qualified endorsement of gatekeeper training, provided that formalized roles and care pathways were available. The review noted some community-b ased awareness programs are not evidence based and do not reflect current knowledge of suicide prevention or provide routine evaluation of effectiveness and safety for preventing suicidal behavior. For this guideline, the Work Group evaluated a recent systematic review which looked at gatekeeper training studies in emergent community gatekeepers such as military personnel, public school staff, peer helpers, youth workers, Indigenous people, and designated healthcare worker gatekeepers including nurses and social workers. No RCT showed that gatekeeper training alone affects suicide rates.

Research gaps exist in community-based interventions as mechanisms to reduce suicide risk. A Canadian RCT in First Nations community members—family members, police, teachers, and clergy—demonstrated that the ASIST training had no positive impact on self-reported gatekeeper skills.[160] Also, compared to a resilience retreat, the ASIST training was associated with a slightly higher likelihood of reporting suicidal ideation. This study was not included in the evidence review for this CPG and did not influence the above recommendations.

One non-comparative study examined the feasibility of using an online gatekeeper to direct individuals searching for suicide-related keywords to a website encouraging use of an e-mail consultation service. The results were limited, and strength of evidence was very low, but modest levels of treatment engagement and improvement in mood were seen.

No studies that address the effects of crisis lines or peer-to-peer counseling lines met inclusion criteria. These lines have existed for decades, yet there is insufficient evidence to comment on their effectiveness in reducing population-level suicide rates.

The Work Group systematically reviewed evidence related to the five recommendations above. The Work Group’s confidence in the quality of the evidence on lethal means safety was very low. The body of evidence did have fewer limitations than the evidence for community-based interventions, however, particularly in regard to benefit-risk profiles and outcome measures. Therefore the Work Group made a “Weak for” recommendation for reducing access to lethal means. The Work Group’s confidence in the quality of the evidence for community-based interventions was also very low. The body of evidence had limitations including confounders in the analyses. Community-based interventions, including gatekeeper training and buddy support, had insufficient evidence to make recommendations for or against their use. There was a lack of evidence that potential benefits (e.g., definitive management of suicidality resulting in an aggregate decrease in death) outweigh the potential harm of adverse events, which could include fostering contagion or bypassing evidence-based care. Patient values and preferences for care emanating from community-based training can vary greatly, with a balance needing to be struck between potentially stigmatizing care delivered in the healthcare system and confidential care delivered by non-privileged community gatekeepers. Other judgements made by the Work Group concerned variability among studies, which often measured process or self-efficacy. Importantly, programmatic evaluations of military suicide prevention efforts have not been promising. Finally, differences in resource use, equity, acceptability, and feasibility of interventions exist in many military and Veteran settings. Thus, the Work Group decided to make no recommendation for or against community-based interventions, including gatekeeper training, to reduce suicide risk in military and Veteran populations.

-The Assessment and Management of Suicide Risk Work Group (2019) VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide. Department of Veterans AffairsDepartment of Defense, Version2.0, p. 50-53. Retrieved at https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf

Communication Strategies for Talking about Lethal Means

When initiating conversations with patients about suicide-related topics, including lethal means, there are a number of ways that this can be done including directly asking the patients about suicidality as part of the routine intake interview or asking about suicide within the context of other relevant variables. Clinicians are advised to show empathy and build rapport with the patient when asking that patient about suicide and suicide-related topics, such as lethal means.

Showing Empathy and Building Rapport with the Patient
Suicidal patients’ speech content can become singularly and profoundly negative which can naturally affect the clinician and cause you to react in was that are positive and encouraging, but lacks empathy. Some of these types of responses can include:

• This too shall pass.
• Suicide is a permanent solution to a temporary problem.
• Let’s focus on what’s been going well in your life.

These types of responses can cause a problem because if these are used to counter patient negativity, patients may come to a conclusion that the clinician “doesn’t get them,” and will hold on more strongly to their negative perceptions. In this case, using empathetic reflections can help the clinician to connect to the patient’s unbearable distress and depressive symptoms.

The “completely miserable and hopeless” reflection can be useful to the clinician in two different ways: First, this type of reflection demonstrates the clinician’s willingness to be with the patient in the middle of the patient’s despair; Second, this type of reflection could function as an amplified reflection, meaning that the patient could respond with talk of positive change.

When the clinician also uses validation and reassurance, this can also facilitate rapport with the patient. When using this type of conversation, it is important to remember that as long as your response is authentic, using immediacy or brief self-disclosure is a type of validation strategy that can deepen the alliance between the clinician and the patient.

Sometimes suicidal patient can become extremely irritable and can cause difficulties in the clinician developing rapport with the patient. Irritable patients can provoke negative emotional reactions from the clinicians. In this case, using a three-part response is recommended: 1) reflective listening, 2) gentle interpretation, and 3) a statement of commitment to keep working with and through the irritability.

Asking Directly about Suicide Ideation
Asking patients directions about their suicide ideation can trigger the patient to have clinician anxiety and can the clinician to have difficulty in finding the right words for the patient to give an honest and open patient response. Using a balance of positive and negative questioning is recommended, in other words, if you ask the patient about sadness, it is also important to ask the patient about happiness.

Mood Scaling with a Suicide Floor
This strategy uses a scaling question to explore patient mood and possible suicide ideation. This strategy is a like a general map that can be used more or less by the clinician, who uses their judgement to judge which direction to take the conversation with the patient. The numbers in the rating scale can be useful in rating the patient’s mood, however, the numbers will be variable subjectively because every patient is unique.

This strategy offers several advantages for clinicians. First, it is a process that facilitates engagement, and this engagement or in other words, interpersonal connection, is a central part of suicide interventions. Second, when patients are able to connect their low and high moods to concrete external situations, the clinician is able to gain the knowledge about the triggers that lift and depress the patient’s mood. Third, the mood scaling procedure can be abandoned (either temporarily or permanently) in favor of other opportunities. Fourth, the mood scaling can flow smoothly into safety planning or other suicide interventions through opening a discussion.

There are a number of conversation strategies that the clinician can utilize in order to open up the discussion of suicide and suicide ideation, including conversations about lethal means, with the patient. The list above is not all inclusive and is subject to the clinician’s judgement as to which strategy he or she might believe would be the better option for their patient.

- Sommers-Flanagan, John Ph.D. Conversations About Suicide: Strategies for Detecting and Assessing Suicide Risk. National Register of Health Service Psychologists. Winter 2018.

Update
Music-Based Interventions
in Community Settings: Navigating
the Tension between Rigor
and Ecological Validity

- Habibi, A., Kreutz, G., Russo, F., & Tervaniemi, M. (2022). Music-based interventions in community settings: Navigating the tension between rigor and ecological validity. Annals of the New York Academy of Sciences, 1518(1), 47–57.

Peer-Reviewed Journal Article References:
Gehrmann, M., Dixon, S. D., Visser, V. S., & Griffin, M. (2020). Evaluating the outcomes for bereaved people supported by a community-based suicide bereavement service. Crisis: The Journal of Crisis Intervention and Suicide Prevention. Advance online publication.

Hill, K., Somerset, S., Schwarzer, R., & Chan, C. (2021). Promoting the community's ability to detect and respond to suicide risk through an online bystander intervention model-informed tool: A randomized controlled trial. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 42(3), 225–231.

Hill, R. M., Oosterhoff, B., & Kaplow, J. B. (2017). Prospective identification of adolescent suicide ideation using classification tree analysis: Models for community-based screening. Journal of Consulting and Clinical Psychology, 85(7), 702–711. 

Hilt, L. M., Tuschner, R. F., Salentine, C., Torcasso, G., & Nelson, K. R. (2018). Development and initial psychometrics of a school-based screening program to prevent adolescent suicide. Practice Innovations, 3(1), 1–17. 

QUESTION 26
What is a three-part response that is recommended for clinicians to use with patients who are extremely irritable? To select and enter your answer go to Test.

Test
Section 27
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