July 7, 2021

Building a New Model for Suicide Prevention

An experiment in Colorado “might change the trajectory of suicide in the U.S.,” says EDC’s Jerry Reed.

Ever since Pueblo County joined the Colorado National Collaborative (CNC), it has been a community united to end suicide. The evidence is everywhere.

Every month, representatives from law enforcement, the public schools, and local social services—as well as dozens of residents—gather to discuss the county’s suicide prevention programming. Each of the five health systems that operate in the county are implementing the Zero Suicide initiative, a comprehensive approach to patient care and safety that aims to eliminate suicide in health care settings. Billboards across the county advertise the state’s crisis services line for those in need. And in local cafes, the to-go coffee cups have stickers promoting hope, connectedness, and resilience.

But most notably, the issue of suicide is no longer taboo.

“At first nobody was talking about suicide,” says Heather Pelser, who has directed the county’s suicide prevention efforts since 2018. “Now everyone is talking about it. It’s not a dirty word anymore.”

Pueblo County has one of the highest suicide rates in Colorado, a state with one of the highest suicide rates in the country. That makes it an ideal testing ground for an innovative, comprehensive effort to address suicide as a public health crisis.

The nation’s first attempt at a statewide response to suicide prevention, the CNC is a collaboration between a number of public and private partners, including EDC, the state of Colorado, the Centers for Disease Control and Prevention, the American Foundation for Suicide Prevention, the Substance Abuse and Mental Health Services Administration, and six county public health departments. It has the bold goal of reducing Colorado’s suicide rate 20 percent by 2024.

If the CNC achieves even part of its goal, it may just change the way the nation addresses suicide.

Jerry Reed, a national expert on suicide prevention, says that the idea for the CNC came up in 2014, when EDC was co-leading the Injury Control Research Center for Suicide Prevention (ICRC). Funding individual communities, tribes, and schools to address suicide was not making an appreciable dent in suicide rates. Would implementing a comprehensive “bundle” of evidence-based interventions in a single state—and then fostering coordination among those interventions—yield better results?

“If you only look at suicide as an individual mental health problem, you will think it is solved in a clinician’s office,” says Reed. “But when you look at it as a public health problem, you can see a role for everyone in the community. You can intervene in multiple sectors and on multiple levels to bring the burden down.”

Reed and other ICRC members began to look for a state to partner with to test this theory. Colorado stood out immediately—partly because of its high rate of suicide and partly because of its previous work to address the issue. It had an established public-private partnership to oversee suicide prevention efforts in the state, as well as a data dashboard to chart violent deaths.

Reed says that if the CNC model is demonstrated to reduce suicide in Colorado, the implications for the field could be significant.

“This model would be replicable across the country,” Reed explains. “And that might change the trajectory of suicide in the U.S., and show that this public health approach is the missing piece, rather than leaving each community to handle suicide prevention by itself. We need to implement what we know.”

A Comprehensive Approach to a Public Health Crisis

Communities participating in the CNC implement multiple health, economic, and social interventions that have been shown to be effective at reducing risk factors for suicide. These interventions are grouped into six “pillars”:

1. Increasing access to responsive care
2. Improving connectedness
3. Decreasing access to lethal means for those at risk
4. Providing postvention supports
5. Increasing education and awareness
6. Improving economic stability

Reed’s contention is that a bundled collection of best practices, implemented together, may have more impact than any one best practice alone.

That impact is in evidence in Pueblo County. Pelser says that the number of visits to the county’s Crisis Center has increased; so too has the volume of calls to the state’s suicide prevention line. Both are sure signs that people are implementing prevention and referral skills learned at trainings. She’s also been approached by local health professionals and businesspeople who ask her how they can better address suicide in their practices and workplaces.

“Suicide prevention can be a million different things,” Pelser says. “The CNC has given us the six pillars, evidence-based practices, and a framework to put all of those things together.”

The CNC has also provided a platform for collaboration. During monthly meetings, county-level practitioners share ideas, struggles, and successes with state and federal health administrators, as well as with Reed and EDC’s Kristen Quinlan, who offer technical assistance.

Sarah Brummett, the director of Colorado’s Office of Suicide Prevention within the Colorado Department of Public Health and Environment, describes these meetings as a “really energizing space” that contributes to programmatic improvement. She recalls one meeting where a county-level coordinator spoke about the difficulty of discussing lethal means in their community, which had high rates of gun ownership and firearm suicide.

“They couldn’t get anywhere with the conversation around firearms,” Brummett says. “It was a total no-fly zone.”

Then coordinators from another community shared how they had also wanted to address access to lethal means. Their solution was to create a coalition that brought together gun advocates and the suicide prevention community around the shared goal of safety. Perhaps, they said, that collaborative approach could provide a path forward?

The advice helped, and the community was eventually able to broach the issue of lethal means without alienating the people they were trying to help.

That success “stemmed from having those conversations and hearing from other communities about what they were doing,” says Brummett. “There’s so much fertile ground for collaboration.”

A Broad Approach to Prevention

200 miles north of Pueblo County, Larimer County is also adopting a public health approach to suicide. There, local prevention practitioners are using CNC funding to address food and housing insecurity alongside more traditional community connectedness and safety programs.

Scott Smith, the executive director of the Alliance for Suicide Prevention of Larimer County, says that a comprehensive view of suicide prevention is necessary because suicide doesn’t just stem from mental illness. Residents who lack basic services are also at risk.

“Our data shows that a lot of adult males who died by suicide have experienced substance use issues, a divorce, or lost a job,” says Smith. “So when you understand this complicated landscape of risk factors, it really is broad and touches different parts of peoples’ lives.”

Before the CNC, most of the suicide prevention programs in the county were focused on serving youth and adults in crisis. Smith knew that these traditional programs were just a small part of what a comprehensive approach to suicide prevention could look like—but he struggled to find funding and buy-in to pursue more upstream approaches to the issue.

The CNC has been “a real game-changer” in this regard, says Smith, as it has helped him build a more comprehensive set of services centered around community health.

“Not only was the CNC able to bolster existing efforts, but it also enhanced our ability to create work groups to take an upstream approach to suicide prevention,” Smith says. “This has really unified all our efforts.”

For now, Colorado’s success in the fight against suicide is largely anecdotal. Preliminary data from 2020 does reveal that suicide rates dropped in the state, but that was true nationwide as well—so it’s difficult to prove how much of an impact the CNC made during the pandemic year.

However, there are signs that the CNC is helping Colorado’s public health community chart a path forward for comprehensive suicide prevention. Federal funding for the CNC has helped stabilize the state’s suicide prevention budget, which now stands at $6 million annually. (Brummett adds that the collaborative nature of the CNC has revealed other sources of funding that communities can draw upon, too.) A new dashboard charting the results of participating counties’ suicide prevention efforts—and helping to guide future ones—is being built. And, finally, more people are involved in suicide prevention in Colorado than ever before.