On the line, Santiago runs through a series of questions to get a sense of the seriousness of the call. Her voice is soothing, lilting even, but firm.
“You obtained a DWI in which county?”
“Has alcohol been an ongoing issue for you?”
“Any thoughts of suicide or hurting anybody else?”
The operators routinely ask callers whether they have suicidal thoughts, even on non-suicide prevention calls, because there’s no way to tell whether a substance abuse call could quickly turn into a suicide call. You just have to ask. That way, you increase your chances of helping them upstream.
The queue doesn’t let up. Several people are on hold. More are talking to operators. Once a crisis counselor has finished a call, each one is logged in to a database with a report number and a brief description. They get three minutes to log it in and take a breath before the phone rings again.
“Hello, LifeNet,” Santiago says. “How may I help you?”
Casting a Wide Net
Many programs that receive federal funding, like the National Suicide Prevention Lifeline, are widely advertised nationwide, something DJ Jaffe thinks should be targeted instead to those most at risk.
Jaffe is the founder of Mental Illness Policy Org and got involved after his sister was diagnosed with schizophrenia in the mid-1980s. “A lot of suicide prevention campaigns are based on reaching out for help if you’re feeling depressed rather than calling if you’re truly suicidal,” he says. “That’s being funded with suicide dollars. Telling someone who’s feeling bad to reach out. Is that going to reduce suicide? Spending massive amounts of money marketing to the public via television shows, PSAs, billboards? It’s a giant waste of money because we know where we can focus it.”
AAS’s Berman is similarly critical of public awareness campaigns promoting services like the lifeline. “The general zeitgeist in the field is public education is good, and it’s better that people know about the problem and really know that prevention is possible,” he says. “But I don’t know that public awareness campaigns work for the people you most want to reach, the people who are already suicidal.”
A 2009 study in the journal Psychiatric Services looked at 200 publications between 1987 and 2007 describing depression and suicide awareness programs targeted to the public and found that the programs “contributed to modest improvement in public knowledge of and attitudes toward depression or suicide,” but could not find that the campaigns actually helped increase care seeking or decrease suicidal behavior. A similar study in 2010 in the journal Crisis actually found that billboard ads had negative effects on adolescents, making them “less likely to endorse help-seeking strategies.”
According to the National Institutes of Mental Health, 90 percent of people who die by suicide in the U.S. suffer debilitating mental illness. Other risk factors include prior suicide attempts, a family history of mental disorders and violence in the home. If we know who’s most at risk, people like Jaffe and Berman argue, shouldn’t we target them in a smarter way? If a factory closes, for example, shouldn’t efforts be made to market suicide prevention services in that community?
SAMHSA is the government’s arm in the field of suicide prevention, and while mental health coverage has been expanded for tens of millions of Americans as part of the Affordable Care Act, SAMHSA’s funding requests for suicide prevention efforts have been decreasing. For fiscal year 2014, SAMHSA requested $50 million for its suicide prevention measures, $8 million less than in 2012. Funding for National Suicide Prevention Lifeline crisis centers to provide follow-up to suicidal callers and evaluate the lifeline’s effectiveness, also decreased by almost $1 million when compared to 2012. SAMSHA did however request a $2 million increase for the National Strategy for Suicide Prevention, which, among other things, would be used to develop and test nationwide awareness campaigns.
AAS’s Berman characterizes the national strategy as including both public and targeted approaches to prevention but is concerned that SAMHSA is too focused on “upstream” measures like increasing overall awareness.
“The bottom line is that the people most at risk are people who don’t get into treatment, and a public health approach shifts attention from high-risk patients to large populations of folks who might develop mental health problems,” he says.
However, Richard McKeon, SAMHSA’s acting chief of the Suicide Prevention Branch, says federal efforts have always had a significant focus on people most at-risk. “Much of our suicide portfolio focuses on those who are actively suicidal,” he says. McKeon cites efforts like the collaboration with the National Association of State Mental Health Programs directors, which produced a white paper for state mental health officials so they could better focus on people with serious mental disorders.
McKeon says that focus is evident in the National Strategy, which was revised last year and lays out a comprehensive approach to preventing suicide at the local level. He also cites the National Suicide Prevention Lifeline and says it deals not just with people who are depressed, but also with people every day who are at high risk of suicide, 25 percent of which are actively suicidal. But still, the behavioral health of the entire population is a priority for SAMSHA, McKeon says.