Almost 800,000 people die each year by suicide. For each completed suicide, there are more than 20 suicide attempts. Aside from the pain and emotional toll of the attempt survivors, suicide has a ripple effect on families, friends, colleagues, communities, and societies (1). The Ruderman Foundation determined that first responders have a suicide rate 20% higher than the general population, with more first responders dying by suicide than in the line of duty (2). The actual number of suicides may be even higher as many first responder suicides go unreported due to the stigma surrounding mental health.    

Suicide also has economic costs for individuals, families, communities, states, and the nation as a whole. These include medical costs for individuals and families, lost income for families, and lost productivity for employers. Economic costs of suicide are staggering.  A recent study (3) estimated the average cost of one suicide at $1,329, 553. More than 97 percent of this cost was due to lost productivity. The remaining 3 percent were costs associated with medical treatment. In 2013, the total cost of suicide and suicide attempts was estimated at $93.5 billion. The same study indicated that every $1.00 spent on psychotherapeutic interventions and interventions that strengthened linkages among different care providers saved $2.50 in the cost of suicides.

By bringing awareness to the economic costs of suicide, and to the savings resulting from suicide preventing measures, private organizations such as the American Foundation for Suicide Prevention (AFSP) can help convince policymakers and other stakeholders that suicide prevention is an investment that will save dollars as well as lives. By doing so, they advocate for suicide prevention policies.

As Patton discusses in her book (4), an advocacy plan can take many forms depending on the desired goals. Implementing a plan involves goal refinement, application of influence, strategic issue framing, and targeting of the message to an audience. In order to sustain any kind of plan, including suicide prevention efforts, Patton suggests first identifying resources and support that are readily available, as well as those that need to be acquired, including people and manpower, data, finances, and communication capabilities (4).

The AFSP is an example of organizations that provide manpower, “research, education and advocacy to take action against this leading cause of death” (5). As stated in AFSP mission statement, they are “dedicated to saving lives and helping those affected by suicide. They create a culture of mental health awareness by funding scientific research, educating the public about mental health and suicide prevention, advocating for public policies in mental health and suicide prevention, and supporting survivors of suicide loss and those affected by suicide in our mission” (5).

During a State Capitol Day organized by the AFSP earlier this year, the AFSP provided all the participants with brochures on the latest suicide data. They scheduled meetings with the legislators, and also provided information on the two bills advocated by the AFSP, HB 2072 and HB 2321. HB 2072 would provide loan forgiveness for licensed mental health professionals, which would encourage new graduates to pursue careers in mental health and to provide services to underserved communities. HB 2321 would create a legal process for Severe Threat Orders of Protection and prohibit a person at risk for suicide from having a firearm in his or her possession for a period of up to one year.

Policymaking does not happen overnight. It is a process that takes time and continuous effort on the part of legislators, and public and private sector. Longest (6) explains that in the healthcare arena there is a preference for incrementalism, or continual modification of policies at small, modest increments, rather than large scale modifications. He explains that incrementalism in policymaking increases the likelihood of reaching compromises among the diverse interests in the political marketplace. It also allows for the results and consequences of incremental decisions that are more predictable and stable than those of decisions not made incrementally. To implement and sustain any kind of innovation related to suicide prevention in Arizona, it would be beneficial to adopt the way of incrementalism, as the slower pace would allow the “economic and social systems to adjust without being unduly threatened by change” (6).

1. WHO (2020). Suicide prevention. Retrieved from https://www.who.int/health-topics/suicide#tab=tab_1
2. Heyman, M., Dill, J., & Douglas, R. (2018). The Ruderman white paper on mental health and suicide of first responders. Retrieved from http://rudermanfoundation.org/ white papers/ police- officers-and-firefighters-are-more-likely-to-die-by-suicide-than-in-line-of-duty/
3. Shepard, D., Gurewich, D., Lwin, A., Reed, G., Jr., & Silverman, M. (2015). Suicide and suicidal attempts in the United States: Costs and policy implications. Suicide and Life-Threatening Behavior. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/sltb.12225
4. Patton, R., Zalon, M, & Ludwick, R. (2014). Nurses making policy from bedside to boardroom. New York, NY: Springer publishing company.
5. American Foundation for Suicide Prevention (2020). About AFSP: Mission. Retrieved from https://afsp.org/about-afsp/
6. Longest, B. (2014). Health policymaking in the United States (5th ed.). Chicago, IL: Health Administration Press.

Suicide continues to be a major public health issue and one of the leading causes of death. Technological innovations offer an opportunity to implement useful tools to assess suicide risk, identify high-risk and suicidal behavior, and potentially prevent suicide. In 2015, the White House and the Obama Administration hosted “the Partnerships for Suicide Prevention event, as part of Global Suicide Prevention Month and Global Mental Health Day. The event had a mission statement of “Using Data to Strengthen Mental Health Awareness and Suicide Prevention.” The White House also organized a five-city suicide prevention “hackathon” that brought together data scientists, innovators, designers, and next-gen technologists from several different organizations. They were challenged to collaborate and develop products, tools, or data analysis on suicide prevention” (1).

          One of the technological advances that could aid in suicide prevention are mobile apps (e.g., Better Stop Suicide, Suicide Prevention App, Suicide Safety Plan, Suicide Safe by SAMHSA, etc.). These apps offer a range of suicide prevention strategies, including public health techniques, screening tools, help accessing support, mental health treatments, and follow-up strategies following a suicide attempt (2)

Facebook has joined in the suicide prevention efforts years ago when it allowed its users to report Facebook posts that they felt were indicative of someone thinking about suicide. That flagged the posts for review by trained members of Facebook Community Operations team, who would  connect the poster with support resources as needed. In the last few years, Facebook has begun using machine learning by getting a computer to recognize suicidal expression in order to expand their ability to help people in need. This new tool uses signals to identify posts from people who might be at risk, such as phrases in posts and concerned comments from friends and family (3).

Some emerging evidence suggests that computerized suicide prevention approaches may also be useful (i.e., the use of automated cognitive behavioral therapy (CBT) that delivers a course of therapy without involvement of a human therapist). Speech and facial emotions may also provide a window into detecting suicidal thinking. Using computerized speech analysis, researchers may be able to find differences in how depressed and/or suicidal people talk. People who become suicidal may have differences in the sound frequency of their speech. Research has also shown that people with depression exhibit a reduced acoustic range to their speech. Current research is also looking into using computerized real-time facial emotion monitoring to detect subtle changes in the facial expressions of people with suicidal thoughts (4).

As companies embrace new technologies in their efforts to prevent suicide, they must consider data, privacy, and ethical implications that come with it. Making sure that these new technologies do not cause harm is a priority. Privacy concerns is another significant issue. The algorithm created by Facebook automatically scores all posts in the US and select other countries on the scale of 0 to 1 for risk of imminent harm. While the algorithm was created with the intent of detecting signs of potential self-harm and addressing the rapidly increasing suicide problem, many see it as unethical (5). In a way, Facebook is collecting data and conducting research without individuals’ consent or protection they would normally receive in a study. There is also a possibility that some people flagged by the algorithm as suicidal may not be at risk yet be forced into treatment. Many questions remain unanswered at this point. What happens with all the sensitive, mental health related information that Facebook collects? Should it be protected under HIPAA? What happens if there is a data breech and all this sensitive information becomes public? These questions require careful consideration as we use technology more and more to prevent suicide.

1. Patil, D., & Honey, K. (2016). Open data and innovation for suicide prevention: #MentalHealthHackathon. The White House website. Retrieved from https://www.whitehouse.gov/blog/2015/12/09/open-data-and-innovation-suicide-prevention-mentalhealthhackathon
2. Larsen, M., Nichols, J., & Christensen, H. (2017). Apps for suicide prevention What the research says. Psychiatric Times. Retrieved from https://www.psychiatrictimes.com/telepsychiatry/apps-suicide-prevention-what-research-says
3. Facebook (2018). How Facebook AI helps suicide prevention. Retrieved from https://about.fb.com/news/2018/09/inside-feed-suicide-prevention-and-ai/
4. Vahabzadeh, A., Sahin, N., & Kalali, A. (2016). Digital suicide prevention: Can technology be a game-changer? Innovations in Clinical Neuroscience, 13 (5-6): 16-20.
5. Goggin, B. (2019). Inside Facebook’s suicide algorithm: Here’s how the company uses artificial intelligence to predict your mental state from your posts. Business Insider. Retrieved from https://www.businessinsider.com/facebook-is-using-ai-to-try-to-predict-if-youre-suicidal-2018-12

When it comes to advancing any kind of health policy, including suicide prevention policies, private sector has always been one of the major players and key stakeholders. De Wolf & Toebes (2016) state, “Private sector participation in health care is not a new phenomenon. The involvement of private actors in the provision of health care—whether as direct providers of services (e.g., physicians, pharmacies, and hospitals) or as the providers or manufacturers of materials and technologies used in health care provision—has a long history. These actors include (multi)national corporations, nongovernmental organizations, private institutions (including charitable bodies and other nonprofit entities), and private individuals, such as general practitioners and consultants” (1). Private sector has the ability to influence lawmakers at local, state, and national levels by raising awareness of issues, organizing advocacy events, meeting with legislators, and promoting House and State Bills they support. Longest (2014) indicated that private sector health policies play a crucial role in how society views and pursues health (2).

Some of the organizations that promote suicide awareness are American Foundation for Suicide Prevention (AFSP), Center for Firefighter Behavioral Health (CFBH), First Responder Lifeline by American Addiction Centers, National Fallen Firefighter Foundation, Law Enforcement Suicide Prevention and Awareness by International Association of Chiefs of Police, Suicide Prevention Resource Center, the Code Green Campaign, Blue H.E.L.P., National Alliance on Mental Illness (NAMI), and American Association of Suicidology.

 I was fortunate enough to be able to participate in American Foundation for Suicide Prevention (AFSP) State Capitol Day earlier this semester. AFSP is a “voluntary health organization that gives those affected by suicide a nationwide community empowered by research, education and advocacy to take action against this leading cause of death” (3). AFSP is dedicated to saving lives and helping those affected by suicide. They create a culture of mental health awareness by funding scientific research, educating the public about mental health and suicide prevention, advocating for public policies in mental health and suicide prevention, and supporting survivors of suicide loss and those affected by suicide in our mission (3).

The two bills advocated for by AFSP during the Suicide Prevention Advocacy Day were HB 2072 and HB 2321. HB 2072 would provide loan forgiveness for licensed mental health professionals, which would encourage new graduates to pursue careers in mental health and to provide services to underserved communities. HB 2321 would create a legal process for Severe Threat Orders of Protection and prohibit a person at risk for suicide from having a firearm in his or her possession for a period of up to one year. AFSP organized a meeting with Senator Rick Gray who was appreciative of the opportunity to hear about the bills that could impact first responder suicide rates in Arizona. Senator Gray expressed his support for the two Bills advocated for by AFSP. It felt truly empowering to be surrounded by so many other people who care about suicide prevention and want to make a difference.

References

1. De Wolf, A., & Toebes, B. (2016). Assessing private sector involvement in health care and universal health coverage in light of the right to health. Health and Human Rights Journal, 18 (2). Retrieved from https://www.hhrjournal.org/2016/12/assessing-private-sector-involvement-in-health-care-and-universal-health-coverage-in-light-of-the-right-to-health/

2. Longest, B. (2014). Health policymaking in the United States (5th ed.). Health Administration Press, Chicago, IL.

3. American Foundation for Suicide Prevention (2020). About AFSP: Mission. Retrieved from https://afsp.org/about-afsp/

Health is central to human physical and mental well-being and happiness. Healthy people live longer, and are more productive, which makes population health essential to nations’ economies. Public health makes an important contribution to economic progress. Health status and a country’s ability to provide quality health services for its people are affected by many factors (World Health Organization, 2020). Healthy People 2020 names five broad categories of determinants of health that influence health status: policymaking, social factors, health services, individual behavior, and biology and genetics. It also identifies some of the barriers to health services including high cost of care, inadequate or no insurance coverage, lack of availability of services, and lack of culturally competent care. Barriers to accessing health services lead to unmet health needs, delays in receiving appropriate care, inability to get preventive services, financial burdens, and preventable hospitalizations (Healthy People 2020, 2020). Public health interventions can operate at the local, state, and federal levels affecting individual and population health and health inequalities. The main purpose of health policy is to enhance health or facilitate its pursuit by supporting people in their quest for health (Longest, B., 2014).     

Over the last couple of decades, in spite of increased awareness, suicide has become a serious public health problem in the U.S. and around the world. In the U.S., suicide is one of the leading causes of death among young people. It is the third leading cause of death among 15-24 year olds and the second leading cause of death among 25-34 year olds. Suicide rates among first responders are 20 percent higher than general public (Ruderman Family Foundation, 2018). Continuous exposure to “critical incidents” of human pain, trauma, and death leads to high rates of anxiety, depression, PTSD, and substance abuse among first responders which often remain untreated. According to the study, PTSD and depression rates among firefighters and police officers are 5 times higher than the rates within the civilian population, which causes these first responders to commit suicide at a considerably higher rate (firefighters: 18/100,000; police officers: 17/100,000; general population 13/100,000) (Ruderman Family Foundation, 2018). Stigma surrounding mental health, shortage of mental health providers, inadequate mental health insurance coverage are just some of the reasons why first responders fail to get the help they need.   (191 words)Just a few years ago, individual and small group health insurance plans were not required to cover mental health and substance use disorders. Over the years, numerous efforts were made to improve private insurance benefits. The Mental Health Parity Act (MHPA) of 1996 required group health plans with fifty or more employees that offered mental health coverage to apply the same lifetime and annual dollar limits to mental health coverage as those applied to coverage for medical/surgical benefits. Unfortunately, the health plans were able to circumvent the law by tightening restrictions on the number of hospital days and outpatient mental health services, and by greater “cost-sharing” with patients and families. In spite of its limited scope, the 1996 MHPA brought to light the parity issue, and with the encouragement of mental health advocacy groups, prompted state legislators to consider more comprehensive parity laws (Barry, 2010).

In 2008, the Mental Health Parity and Addiction Equity Act (MHPAEA) was passed. The objective of MHPAEA was to eliminate historical disparities between insurance coverage for behavioral health treatment and coverage for medical treatment.  It was a federal law that prevented group health plans and health insurance issuers from imposing less favorable benefit limitations on mental health or substance use disorder benefits than on medical/surgical benefits. It was originally applied to group health plans and group health insurance coverage and was amended by the Patient Protection and Affordable Care Act. In 2010, it was amended further by the Health Care and Education Reconciliation Act to also apply to individual health insurance coverage (Centers for Medicare and Medicaid Services, 2016).   

The current requirement that health plans cover mental health and substance use disorders at the same level as other health conditions remains critical as we seek to better address mental health needs and lower the estimated $300 billion annual economic cost of mental illness. By ensuring equitable mental health coverage, individuals with mental health disorders would be able to get the help they need before they lose all hope and decide to end their life. Jay Ruderman, President of the Ruderman Family Foundation said, “First responders are heroes who run towards danger every day in order to save the lives of others. They are also human beings, and their work exerts a toll on their mental health. It is our obligation to support them in every way possible – to make sure that they feel welcome and able to access life-saving mental health care”. 

Centers for Medicare and Medicaid Services (2016). The Mental Health Parity and Addiction Equity Act (MHPAEA). Retrieved from https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet

Barry,C., Huskamp, H., & Goldman, H. (2010). A Political History of Federal Mental Health and Addiction Insurance Parity

Healthy People 2020 (2020). Determinants of health. Retrieved from https://www.healthypeople.gov/2020/about/foundation-health-measures/Determinants-of-Health

Longest, B. (2014). Health policymaking in the United States (5th ed.). AUPHA. Arlington, VA.

Ruderman Family Foundation (2018). The Ruderman White Paper on Mental Health and Suicide of First Responders. Retrieved from https://rudermanfoundation.org/white_papers/police-officers-and-firefighters-are-more-likely-to-die-by-suicide-than-in-line-of-duty/

World Health Organization (2020). Health and development. Retrieved from https://www.who.int/hdp/en/

Health policymaking is a complex process. Regardless of the form the policy takes (i.e., laws, rules or regulations, operational decisions, or judicial decisions), and the level (federal, state, or municipal), all policies are made through similar processes. Health policy encompasses various determinants of health that often overlap and must be taken into consideration by everyone involved (Longest, 2014).

In the United States, policies are made in the executive, legislative, and judicial branches of the government. Elected legislators (i.e., members of the U.S. Congress, state legislatures, or city councils), members of the executive branch (i.e. the President, governors, mayors, and other senior public sector executives), and the courts are the major actors in the policymaking process. While legislative and executive policymaking takes place in the wide-open arena, the courts focus on issues involved in specific cases, interpreting the U.S. Constitution, or ambiguous laws, or establishing judicial procedures which later become a policy (Longest, 2014).

Policymaking process is a fluid, continuous cycle in which decisions are made and then later revisited as necessary. The three components of the policymaking process, policy formulation, policy implementation, and policy modification, are interactive and interdependent. Policy formulation involves agenda setting and legislation development. Once the new laws and health policies are passed, they must be implemented effectively to affect the determinants of health (Longest, 2014).

Meeting with Senator Rick Gray during American Foundation for Suicide Prevention (AFSP) State Capitol Day was a truly delightful experience. He explained that reading hundreds of pages of Senate bills is part of his daily job, and as such, he expressed his appreciation for the opportunity to be informed about the bills that could directly or indirectly impact suicide rates in Arizona.

The two bills advocated for by AFSP were HB 2072 and HB 2321. HB 2072 would provide loan forgiveness for licensed mental health professionals, including psychiatrists, psychologists, advanced practice nurses, professional counselors, clinical social workers, marriage and family therapists, and chemical dependency counselors, who make a commitment to provide at least five years of consecutive service in the State Department of Corrections or at a correctional facility operated by or under a contract with the State Department of Corrections or the Department of Juvenile Corrections. Having all or a portion of student loans paid off would encourage new graduates to pursue careers in mental health and to provide services to underserved communities and populations, which in turn would increase the number of providers available overall for people in need of mental health services across the state of Arizona. HB 2072 is a Partisan Bill (Republican 3-0), first introduced in House on January 13, 2020, and voted on and passed by the House Appropriations Committee on February 12, 2020.

HB 2321 would create a legal process for Severe Threat Orders of Protection which would prohibit a person at risk for suicide from having a firearm in his or her possession for a period of up to one year. Severe Threat Orders of Protection can fill a gap that currently exists for families who want to protect a loved one who owns a firearm but who isn’t able or willing to take voluntary steps to ensure safety during a suicidal crisis. HB 2321 is a Partisan Bill (Democrat 12-0) that has not yet been read in the House of Representatives.

Having a teen suicide survivor in our group steered the conversation with Senator Gray in the direction of suicide prevention among adolescents. Senator Gray expressed his full support of The UBU Project, an arts education outreach organization specializing in K-12 suicide prevention, substance abuse prevention and anti-bullying residencies. He emphasized the importance of the work done by the UBU Project and suggested that schools across Arizona would benefit from it. He also suggested that more funds should be allocated towards counseling services at schools as a suicide prevention measure. He thanked the suicide survivor in our group for being active and transparent in sharing her story with others. Hearing this story of survival gives others hope and courage to share their thoughts and feelings with mental health professionals. It encourages them to get the help they need for their suicidal ideations. As senator Gray stated, we need community connections. Having students involved in such an important cause is extremely powerful and life-changing for many.

Participating in the AFSP Suicide Prevention rally and meeting with Senator Gray was a very empowering experience. Nurses can make a real difference. They can influence policy development, implementation, and legislation in a variety of ways. Whether it is through meeting with policymakers, actively engaging in professional organizations, serving on a board of directors, voting, volunteering for a political campaign, running for office, or finding their voice and providing testimony, nurses must stand up for what is important (Patton et al., 2019).

Longest, B. (2014). Health policymaking in the United States (5^th ed.). AUPHA, Arlington, VA.

Patton, R., Zalon, M., & Lutwick, R. (2019). Nurses making policy: From bedside to boardroom (2^nd ed.). Springer Publishing Company, New York, NY.

Suicide is a public, yet very personal, health problem. It impacts not only those who attempt or commit suicide, but also their surviving friends and family, leaving them heartbroken, with unanswered questions and feelings of devastation and guilt. Aside from the enormous emotional toll, suicide is associated with economic and medical costs for the individuals involved and healthcare in general.

What makes suicide so utterly devastating is that it is one of the most preventable causes of death. Depression, PTSD, chronic pain, substance use, and other mental ailments do not have to result in suicide. In my three years of being a psychiatric nurse, I have cared for many post suicide attempt patients, as well as the ones having suicidal thoughts. The reality is – the majority of them did not want to die. They just wanted the pain to stop, whether it was physical or emotional pain, unbearable depression, or PTSD symptoms.

First responders’ repeated exposure to human pain, suffering, and death, combined with long work hours, lack of sleep, hectic schedule, inability to debrief and recover between the calls predispose them to developing anxiety, depression and PTSD, which could contribute to thoughts of suicide if left untreated. According to Suicide Prevention Resource Center (SPRC), police officers and firefighters are more likely to die by suicide than in the line of duty.

First responders can do a few things to protect their own mental health (e.g., be more aware of signs of compassion fatigue in themselves and others, support one another, encourage clear communication, and use counseling services as needed). But that’s not enough. Having certain policies in place will ensure that first responders are getting the help they need to maintain their mental health.

As Longest (2014) points out in his book, public policymaking process is run and controlled by people who bring their own ethics to the table. “Ethical considerations help shape and guide the development of new policies by contributing to definitions of problems and the structure of policy solutions” (Longest, 2014, pp. 52-53). Ideally, the ethical behavior of all policymakers should be guided by the philosophical principles of respect for the autonomy of other people, justice, beneficence, and nonmaleficence.

The first philosophical principle, respect for autonomy, pertains to the rights of individuals to determine how they live their lives, including the integrity of their bodies and minds (Longest, 2014). While most people would agree that respecting people’s autonomy is important, it does not substantiate the “right to die”, especially when the individual has underlying mental conditions (i.e. anxiety, depression, PTSD, substance abuse) caused by the hazardous environment of their job (Clark, D., 1999). Being aware of the problem, talking about it with colleagues and counselors, getting the help needed in a timely manner would get the mental issues under control and decrease thoughts of suicide in first responders.

Justice, the second philosophical principle guiding the policymakers, is the foundation of all healthcare policies. It includes distributive justice which ensures fair distribution of health-related benefits and burdens (Longest, 2014). Implementing policies intended to provide more mental health resources to people who need them the most (e.g., first responders) would be an example of egalitarian perspective of the justice principle.

Beneficence in healthcare policy and decision-making, as related to suicide prevention among first responders, would be evident in policymakers acting with kindness and charity, and seeking to do good for the first responders (Longest, 2014).

Policy makers guided by the fourth philosophical principle, nonmaleficence, would be making decisions that minimize harm to the first responders (Longest, 2014).    

Policy makers must remember that their ethical considerations shape and influence new policies that affect real people. Their ethical behavior must always be guided by the four philosophical principles, and their decisions must be based on what’s in the best interest of the constituents (Longest, 2014).

References

Clark, D. (1999). Autonomy, rationality and the wish to die. Journal of Medical Ethics 1999; 25:457-462

Longest, B. (2014). Health policymaking in the United States (5^th ed.) AUPHA, Arlington, VA.

Suicide Prevention Resource Center (2020). Retrieved from                                 https://www.sprc.org/news/why-  suicide-top-cause-death-police-    officers-firefighters

This is an example post, originally published as part of Blogging University. Enroll in one of our ten programs, and start your blog right.

You’re going to publish a post today. Don’t worry about how your blog looks. Don’t worry if you haven’t given it a name yet, or you’re feeling overwhelmed. Just click the “New Post” button, and tell us why you’re here.

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