Individual

Since 2005, the National Suicide Prevention Lifeline has been offering crisis intervention through 24/7 crisis lines for people in suicidal distress or loved ones inquiring how to help.⁸ The federal government created the Lifeline for Vets which has answered over a quarter million calls over 21 years.⁹ Nationally, Lifeline answered over 10 million calls, with approximately a quarter of those individuals expressing distress.¹⁰ There has been an understanding that suicide risk includes more than depression and other mental health burdens. For many people who seek help on the crisis lines, suicidal thoughts and behaviors (STB) occur in the wake of life-altering events: e.g., divorce, custody disputes, bankruptcy, intimate partner violence, child abuse histories, and the death of a loved one^{Reference Conner, Cerulli and Caine11} which involve people's relationships to others, including family members and colleagues. Given the service these crisis lines provide, perhaps more county, state, and federal lawmakers might consider legislation providing financial support for the services as well as evaluation strategies. As an example, Minnesota funded a statewide service called Text4Life.^{Reference Serres12} Crisis lines require us to wait for someone to be at the state of needing a crisis line, what if people coming into courts and other settings for services identified at risk were then referred to a system of care prepared to holistically address their needs?

As people work to resolve these relationship issues, they often find themselves in contact with the court system — both civil and criminal, and other helping social service agencies, rather than the mental health system. In studies conducted in court settings, both victims and perpetrators of violence exhibit higher rates of STB.¹³ It may be possible to create a mechanism for suicide prevention that utilizes medical-legal partnerships (MLPs) as an option to provide individuals at risk for STB with a therapeutic bond to begin reducing isolation and creating treatment plans. Such referrals could be bi-directional — referring people in the medical or mental health service side with STB who are facing legal difficulties to preventive legal counsel, and vice-versa.^{Reference Regenstein, Trott, Williamson and Theiss14} One such example is explored.

Relationship Level

The University of Rochester Strong Memorial Hospital has implemented a MLP that may be a potential model program for suicide prevention. The program, Healing Through Education, Advocacy and Law (HEAL),¹⁵ incorporates legal remedies at the relationship level. When a person is identified as having intimate partner violence or any interpersonal violence experiences, a HEAL professional can work with that patient. The team within this MLP includes social workers, doctors, lawyers, mental health providers, and domestic violence advocates. The HEAL Collaborative provides on-site safety planning, including protection orders, and integrated care. Cases have come into the HEAL clinic which involve patients experiencing STB. Quick action by the clinicians, trained on suicide prevention strategies, contributes to the prevention of suicides. In partnership with emergency personnel and quality community emergency mental health ambulatory care, a collaborative approach can work. While we have always treated individuals at risk for suicide through screening and assessment when they present in certain venues, we often focus on the symptoms and not the root cause. By having interdisciplinary teams and relationships built with people at risk, we do not ignore a patient's lived experiences. It is important for those patients living in current violent relationships, or who have histories resulting in trauma, that we consider STB where the patients present for care, including clinics that offer protection orders co-located with mental health treatment. For such integrated care to occur, institutions must be willing to consider suicide prevention initiatives beyond traditional screening and referral and offer new holistic approaches to care: multidisciplinary and integrated.

Community Level: Statewide Effort in Selected Colorado Communities

At the community level, we may consider an institution, county, or state as a community entity — using an approach to reducing STB. This varies from the societal level approaches, discussed below, which include public health campaigns. Here, we discuss a statewide effort in multiple Colorado communities that use legal leverage to implement suicide reduction strategies. Colorado, currently at 10th in the nation for suicide, is an example of a state that has been working on multiple levels to reduce suicide. In 2017, a record number of people died by suicide in Colorado — 1,175,¹⁶ with men more likely to commit suicide than women by 3 to 1. Suicide is the leading cause of death in Colorado's 10-24 year-old age group. While targeted youth suicide prevention strategies were needed, so were public health awareness strategies. Concerned public health leaders came together and formed the Metro Public Health Behavioral Health Collaboration (Collaboration). Colorado mental health leaders, including the Collaboration, and advocates such as Mental Health Colorado, worked together in 2018 to successfully introduce legislation to try to stem the tide of suicide. In 2018, three proposed bills targeted youth suicide reduction. Although none of these legislative proposals passed, their introduction was an important step in moving suicide prevention out of the individual level of the SEM into the community level. The three bills¹⁷ were: HB 18–1177, Youth Suicide Prevention proposing multiple approaches to prevent suicide among youth, SB 18-114, Suicide Prevention Enhance Student Life Skills to prevent youth suicide by strengthening life skills; and SB 18–153, Behavioral Health Care Related to Suicide Ideation. This bill would have required a study of best practices to address gaps in suicide and opiate prevention and to coordinate communication among multiple professionals.

At the 11th hour of Colorado's 2018 legislative session, a 4th bill, SB 18–272, was enacted creating the Crisis and Suicide Prevention Training Grant Program, for comprehensive suicide prevention strategies and training in schools. Importantly, a financial appropriation was included and grants are now being distributed by the Colorado Department of Public Health and Environment (CDPHE).

Societal Level

At the societal level, Colorado also provides important strategies for shifting to a culture of open conversation about mental health. The Collaboration developed a stigma reduction education campaign, Let's Talk CO, with support from the Colorado State Innovation Model (SIM), a governor's office initiative, funded by the Centers for Medicare & Medicaid Services (CMS).^{Reference Collins18} The messaging is aimed at low-income Coloradans and their providers in federally qualified health centers and safety net clinics. The Collaboration reached out to partners like health systems, community mental health centers, and volunteer organizations to convene a group that could design a communication campaign with the local health departments in the seven-county metro Denver region. The campaign included phrases such as “Let's talk about our mental health”; “Mental health isn't just in our head”; and “Mental health is a big part of our health and well-being”.

The Let's Talk CO Campaign (see Figure 2)¹⁹ works by encouraging people to have the awkward conversation about mental health, emotions, and other life stressors. Let's Talk provides community members with links to providers and other community resources to address any mental health questions, issues, or ways to support the campaign. By providing tools to encourage conversations about mental health, the Let's Talk CO campaign may help support people at risk for suicide.²⁰ It teaches communication skills, and links people to resources that help them manage challenges with their relationships, jobs, health, or other concerns. Most importantly, Let's Talk CO aims to connect people at risk to crisis services and effective and coordinated mental and physical healthcare.

Figure 2

Most people who attempt or complete suicide do not have a current mental health diagnosis, and societal stigma deters those experiencing situational challenges from seeking help. Better understanding of mental health and well-being, and of skills and behaviors that contribute to well-being, changes the societal context of thinking about suicide.^{Reference Tinker21}