SALT LAKE CITY - If you tell your iPhone to find a bridge you can jump from, Siri will ask if you want her to dial a suicide crisis line.
Query Google about ways to kill yourself, and the first response is a link to the National Suicide Prevention Hotline, with a button to launch live chat.
A teenager struggling at most Utah schools can readily find a trained peer from Hope Squad to listen and help. Even a Facebook post that indicates suicidal thought may be answered by a crisis counselor from the national crisis line.
These personal and technological prompts mark progress in a journey to prevent teen and other suicides but policymakers, legislators and others say the road to reducing suicides is very much under construction as lawmakers prepare to gather for the start of the 2017 legislative session Jan. 23.
“In Utah, we are doing a little bit of a lot of things,” said Kimberly Myers, suicide prevention coordinator in the state’s Division of Substance Abuse and Mental Health. “I think to truly move the needle, almost all of them have to scale up.”
Myers co-chairs the Utah Suicide Prevention Coalition with Andrea Hood, the Utah Department of Health's suicide prevention coordinator. The actions include efforts by the Utah Legislature, but also by local governments, local foundations, volunteers and families.
Most teenagers don’t struggle with suicide ideation, but in Utah, suicide has passed accidents as the leading cause of death for those age 10 to 17, and the state ranked No. 8 in youth suicide nationally in 2012-2014, according to a health department report. More than one in eight teens surveyed said they’d considered self-harm or suicide, which aren't always synonymous. The Deseret News recently looked in-depth at teen suicide and the challenges in urban and rural communities.
"The sky is not falling,” said Greg Hudnall, educator and executive director of Hope4Utah, who noted most people don’t try to kill themselves. “But of all deaths, suicide is the most preventable by far. We need to support and grow proven existing programs.”
Teaching and learning
It seems easier for technologies like Siri to ask people if they're suicidal than it is for even close companions. People tend to shy away from addressing mental health or suicide. But they must, said Hudnall, who thinks education is crucial to save lives. “More suicides are prevented by family members, peers, co-workers, fellow students and others than by any professional. The biggest challenge is the fear of talking about it.”
Hope4Utah has taught more than 40,000 people in schools, churches and businesses in 65 Utah cities that it’s necessary to discuss suicide. Participants have learned warning signs, risk factors and what to do and where to get help.
Hudnall saw the training work recently when a middle school bus driver overheard a student say something that could be construed as self-destructive. That prompted him to call the school district, which contacted the parents, law enforcement and mental health experts. Between them, they found the student, who had planned to die that night.
“They were able to intervene because one person was listening,” Hudnall said.
Utah is both teacher and student when it comes to stopping suicide. Experts learn from what works in their own and other communities, building on each others’ initiatives. Several states have also provided useful models for suicide prevention efforts.
The New Hampshire Gun Shop Project, led by that state's Firearm Safety Coalition, teaches gun sellers and firing ranges how to identify those at risk for suicide. The five-year-old program has been adopted in at least 20 states and demonstrates how the gun industry can play a role in prevention. Experts agree responsible gun ownership and storage are among the most effective ways to prevent suicide because firearms are by far the most deadly method.
Most gun deaths, said gun enthusiast and lobbyist Clark Aposhian, chairman of the Utah Shooting Sports Council, are suicides — more than homicides, police-involved shootings and accidents combined.
In a recent Utah suicide prevention video, he talks about putting time and space between people pondering suicide and weapons. Temporarily removing guns can be an effective form of "means restriction" — removing access to ways to kill oneself such as keeping guns or potentially deadly medications out of reach during crisis. Keeping a gun somewhere else or locked away is comparable, said Myers, to holding onto the keys when someone has been drinking. No one’s trying to take away the car.
Washington state offers another example of prevention via gun safety. Last year, the state passed HB2793, establishing a task force to educate gun store owners on suicide prevention and distribute safe gun storage devices in two high-risk communities. The task force will work with firearm retailers to develop incentives for participating in the education program.
Utah is working on a voluntary training program for gun shop staff. The state has also distributed brochures and 30,000-plus gun locks in the last couple of years, said Myers.
Policymakers frequently look to Colorado, where in 2016 the governor signed a Zero Suicide Bill based on the zero suicide model, representing a bold but not impossible goal and supported by prominent national organizations. The bill creates a statewide prevention plan focused on uniting entire communities around leadership, training, identification, patient engagement, treatment, transition and quality improvement.
Utah has adopted the model, and one of its zero suicide goals is ensuring health care providers are able to provide suicide-related care. Myers said a 2014 survey asked 8,000 Utah clinicians if they felt they had the skills, training and support to engage with someone at risk of suicide; just one-third said yes. Utah has since ramped up efforts to train clinicians on evidence-based skills and interventions to engage and treat someone who is suicidal, she said.
Myers and Hood say state efforts should focus on 1) clinical training that ensures health care providers know how to recognize, address and refer patients who may be struggling with suicide ideation, 2) appropriate funding for suicide-prevention coalitions statewide and 3) improving education and action around means restriction.
Utah legislators will consider in the upcoming legislative session several bills that expand suicide prevention resources.
Rep. Steve Eliason, R-Sandy, plans to reintroduce HB477, creating a suicide prevention education program like New Hampshire’s to teach firearm dealers to identify suicidal customers and avoid selling or renting them firearms. The bill would also provide funding to offset costs.
He believes the bill will pass easily; last session it cleared the House unanimously but died before the Senate had time to vote.
He also plans to run a bill creating a position in the Department of Health to collect detailed suicide-related data. When an individual dies by suicide, a police officer writes a basic report, but it doesn't provide enough information about what led the individual to kill himself — information that could substantially inform suicide prevention efforts.
Under the bill, a licensed social worker would be hired to delve more deeply into the underlying causes of suicide, conducting a “psychological autopsy” to see if the individual experienced bullying, spent time in the criminal justice system, struggled with gender identity or was receiving mental health treatment at the time of death. The investigation could include hair samples to see what drugs were in one’s system and if he had stopped taking a prescribed psychotropic medication.
Eliason and Sen. Daniel Thatcher, R-West Valley City, will co-sponsor three bills to improve emergency mental health resources.
One would increase funding to hire more crisis counselors for and design a higher education version of SafeUT, a smartphone app that allows someone in crisis or a concerned friend to call or text a crisis hotline and speak to a licensed clinician 24/7. Crisis counselors at the University Neuropsychiatric Institute at the University of Utah take 5,000 crisis calls and 1,000 texts a month, many from SafeUT, said Barry Rose, crisis services manager at UNI, which is rolling out a teen-targeted live-chat function in partnership with all Utah schools.
Eliason said the app’s tip feature has prevented over 20 planned school attacks this year.
“I don’t have the final numbers, but I can say with a pretty high degree of certainty that our youth suicides are down double digits in 2016 compared to the prior year. You can’t point to any one reason why, but we believe the app is definitely playing a significant role in combatting these issues,” Eliason said, insisting every child with a smartphone should have SafeUT installed.
Another bill would create a committee to streamline the state’s crisis lines and ensure each directs callers to appropriate care. Utah has a patchwork of at least 19 separate crisis lines; some connect to 911 dispatch, a phone tree or voicemail rather than a trained mental health professional.
The third bill would dedicate a statewide three-digit phone number connecting callers to a continuously manned mental health crisis hotline — an "N11" number like 611. That's challenging, because all N11 numbers are being used in some fashion.
Aside from procuring a three-digit number, Eliason doesn’t anticipate challenges to any of these measures.
“If you go back and look at suicide prevention legislation we’ve run, frequently it’s a unanimous vote and always bipartisan. That’s because it’s as nonpartisan an issue as issues come,” Eliason said.
Mental health professionals and policymakers also have more expansive goals on the horizon.
Eliason noted Utah must work toward solving a major two-fold issue: The uninsured and underinsured don’t have adequate access to mental health treatment, and those who do have coverage struggle to get an appointment. Access issues are particularly prevalent in rural Utah, where psychiatrists are few and far between. Rose said while crisis intervention is available, long-term treatment often entails long waits for an appointment.
Under a bill Eliason sponsored last year, Utah now offers a $10,000 tax credit to attract new psychiatrists. Eliason said future efforts must expand access to care by increasing the state’s mental health workforce and bringing more telepsychiatry services to rural areas.
Funding is a big challenge for suicide prevention, which competes with myriad important priorities for money.
The Legislature now provides $191,000 for suicide prevention efforts: About $45,000 is earmarked for clinical training of 120-150 individuals. For perspective, in Salt Lake County, the state contracts with some 430 clinicians for services — not counting those in private practice. So a modest number get trained from the total who might need to provide suicide prevention services statewide. Fifteen coalitions receive $10,000 to support program efforts — many use it for a mental health “first aid” program called Question, Persuade and Refer. But Salt Lake County alone could easily use 20 coalitions, so it's a small effort compared to need, too.
University of Utah suicide specialist Craig Bryan said the state would have its biggest impact if it funded a prevention center of excellence tied to a specialty outpatient clinic. The clinic would need to be one that uses only data-proven treatments and provides them at low or no cost, he said. The center’s missions also need to include training clinicians and conducting research to improve clinical services.
“Fund statewide training of mental health clinicians to use empirically supported treatments,” he said. “This training should go beyond workshops or continuing education … to include ongoing supervision, consultation and monitoring of clinicians.”
Only programs with “demonstrated outcomes” should be funded, he added. “Of note, satisfaction does not necessarily constitute outcomes.”
“If you want to save lives, you have to move upstream. Right now, we’re not investing in primary prevention,” said Hood. Adds Myers, “we’re rescuing people from the river.”
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