To solve public health problems—including suicide—CDC uses a systematic process called the public health approach. This approach has four steps: define the problem, identify risk and protective factors, develop and test prevention strategies, and assure widespread adoption of prevention principles and strategies. For further information on the public health approach, see CDC’s Injury Fact Book 2001–2002.

 
Step 1: Define the Problem

National Electronic Injury Surveillance System (NEISS)
NEISS is operated by the U.S. Consumer Product Safety Commission. It provides data about all nonfatal injuries treated in U.S. hospital emergency departments. CDC uses NEISS data to generate national estimates of nonfatal injuries, including those related to suicide.

National Violent Death Reporting System (NVDRS)
State and local agencies have detailed information from medical examiners, coroners, police, crime labs, and death certificates that could answer important questions about trends in violence. However, this information is fragmented and difficult to access. CDC initially funded 13 states to establish the NVDRS (Alaska, Colorado, Georgia, Maryland, Massachusetts, North Carolina, New Jersey, Oklahoma, Oregon, Rhode Island, South Carolina, Virginia, and Wisconsin). The purpose of NVDRS is to gather, share, and link state-level data about violence. When fully implemented, NVDRS will enable CDC to pull together vital state-level information to gain a more accurate understanding of the problem of violence. This will enable decision makers and community leaders to make educated decisions about violence prevention strategies and programs, including those that address suicide. 

School-Associated Violent Deaths Study
With the Departments of Education and Justice, CDC is conducting an ongoing national study of school-associated violent deaths. Since 1992, this study has played an important role in monitoring trends related to school-associated violent deaths (including suicide), identifying risk factors, and assessing the effects of prevention efforts.

Suicide Prevention Research Center (SPRC)
CDC has established the SPRC at the Trauma Institute of the University of Nevada School of Medicine. The Center has developed a pilot surveillance system to help states integrate data from death certificates, emergency departments, and mental health departments. This new system provides a more accurate and complete measure of suicide rates than surveillance systems that rely on mortality data alone.

Setting Uniform Definitions for Suicide
Standard definitions for suicide do not exist, and definitions in federal and state legislation vary dramatically. CDC is convening an expert panel to review the existing state of suicide surveillance and recommend definitions to use during data collection. Acquiring better data about suicide will help shape prevention efforts and provide valuable insight to help decision makers and communities make informed public health decisions for allocating prevention resources.

WISQARS
WISQARS^TM (Web-based Injury Statistics Query and Reporting System, pronounced "whiskers") is an interactive database that provides injury-related morbidity and mortality data useful for research and for making informed public health decisions.

 
Step 2: Identify Risk and Protective Factors

Assessing Linkages between Various Forms of Violence
CDC is conducting a study to identify the links between different forms of interpersonal and self-directed violent behaviors in adolescents. The study will help scientists understand the prevalence and consequences of different types of aggressive behaviors; the association between dating violence and other forms of peer violence; and the manner in which these types of violent behaviors vary by sex, developmental stage, and other factors.

Assessing Suicide Risk in Adolescents
CDC is funding Battelle Centers for Public Health to complete a survey of high-school-aged youth from an urban school district. The research will

• enhance the overall knowledge of youth suicidal behaviors and associated risk and protective factors; (2) create a viable research and clinical instrument to evaluate suicide risk; and
• examine the utility of this instrument as both a screening tool and as an outcome measure. The goal is to design better preventive interventions and thereby reduce suicide risk.

Injury Control and Risk Identification Survey (ICARIS)
CDC conducts the ICARIS to assess a wide variety of injury risk factors. The survey includes questions on attitudes and behaviors associated with suicide among U.S. adults. CDC researchers analyze the information and look for suicide-related trends.

Longitudinal Adolescent Health Survey (Add Health)
Add Health is a school-based study of health-related behaviors of adolescents in grades 7 to 12. The study includes suicide attempts and explores the causes of suicide-related behaviors by emphasizing the influence of social context. Data were collected in surveys of students, parents, and school administrators. Additional information can be found on the Add Health website.

Northwestern Juvenile Project
This longitudinal study, funded by CDC, randomly samples adolescents who were newly detained in the Cook County Juvenile Temporary Detention Center in Illinois (1995 and 1998). The three goals of the study are to (1) investigate the service and treatment needs for alcohol, drug, and mental disorders; (2) investigate the barriers, pathways, and patterns of alcohol, drug, and mental disorder service use; and (3) investigate the pathways and patterns of involvement in risky behaviors (i.e., substance abuse, violence, suicide attempts, or behaviors that increase the risk of becoming infected with HIV/AIDS).

Suicide Risk During Transition to Early Adulthood
The rate of suicide increases as adolescents transition into early adulthood. There is a need to understand this transitional period and to identify interventions that will reduce suicide risk. This research enhances knowledge about the etiology of suicide, assesses suicide risk during an important transitional period, and examines the long-term effectiveness of a prevention program to reduce suicide risk. The project adds two surveys to an existing database (created, in part, by CDC and Department of Education grants). The original survey represented a random sample of high school-aged youth from an urban school district, stratified by risk of school dropout. Researchers are using the data collected to generate models of the effects of early suicide-related risk behaviors, early related risk factors (e.g., drug use), and other risk (e.g., family distress) or protective factors (e.g., social support) on suicide risk in early adulthood.

Youth Risk Behavior Surveillance System (YRBSS)
CDC’s YRBSS monitors priority health risk behaviors that contribute to the leading causes of death, disability, and social problems among youth and young adults in the United States, including behaviors that play a part in unintentional injuries and violence. The YRBSS consists of national, state, and local school-based surveys of representative samples of 9th through 12th grade students. The school-based surveys are conducted biennially and provide information on a variety of behaviors, including suicide and interpersonal violence-related behaviors both on school property and in the community.

 
Step 3: Develop and Test Prevention Strategies

Carbon Monoxide Detectors for Motor Vehicles
CDC is funding an effort to assess the feasibility of developing carbon monoxide (CO) detectors for motor vehicles to prevent intentional and unintentional deaths due to motor vehicle exhaust (MVE) poisoning. Each year in the United States, MVE CO poisoning kills over 1,500 people (1,300 suicides; 200 unintentional deaths; and 40 undetermined causes). These detectors would identify dangerous CO levels before death or injury could occur. The goal is to modify existing automotive technology and thereby detect dangerous CO levels with a minimum amount of added hardware or cost.

Community-based Cognitive Therapy for Suicide Attempters
The University of Pennsylvania is being funded to determine the efficacy and effectiveness of a cognitive therapy intervention for suicide attempters. Trained therapists at community mental health centers will conduct the intervention. The primary group, suicide attempters, largely comprises ethnic minorities and economically disadvantaged individuals who have high rates of mental health and substance-use disorders.

Evaluation of Telephone Crisis Services for Adolescents
CDC is working with the New York State Psychiatric Institute to evaluate a program designed to enhance awareness, utilization, and effectiveness of hotline services for adolescents. The evaluation is being conducted in six New York area high schools. Students in the 9th through 12th grades are participating in baseline and follow-up surveys that assess help-seeking attitudes and behaviors. Follow-up interviews include questions about students’ use of hotlines, their compliance with any information or advice they were given, and their assessment of the effectiveness of the help they received. This study will help identify factors that facilitate or inhibit use of hotlines by teenagers and determine whether hotlines are an effective intervention.

Family Intervention for Suicidal Youth: Emergency Care
This project, funded by CDC, rigorously evaluates one component of a Family Focused Intervention for Suicide Prevention (FISP). It involves a brief intervention conducted in the emergency department that represents a collaborative effort among psychology, emergency medicine, psychiatry, and public health specialties. The project capitalizes on the opportunity offered by an emergency department visit to deliver an effective intervention, improve adherence to follow-up care, decrease the risk of repeat and potentially fatal suicide attempts, and improve clinical and functioning outcomes. The FISP helps patients and families reframe the suicide attempt as a critical event that requires treatment. It motivates them to attend follow-up treatment sessions; further, it teaches and reinforces coping behaviors. The results of FISP will contribute to a national program for injury prevention and further the development of effective interventions for suicidal youth.

Group Intervention for Black Female Suicide Attempters
Emory University is being funded by CDC to study intervention outcomes for African American female suicide attempters. The study is comparing the usual treatment to a psychoeducational group intervention. The intervention includes the usual treatment plus a 10-session culturally competent, gender-sensitive group intervention. The group intervention is designed to reduce suicidal behaviors and risk factors, while enhancing protective factors. Group interventions focus on providing suicide education, suicide safety planning, reducing psychological symptoms, reducing aggression, increasing effective coping skills, and increasing support.
 

Step 4: Assure Widespread Adoption

Enhancing States' Youth Suicide Prevention Efforts
CDC has funded a series of regional meetings for youth suicide prevention. Representatives from various states will meet to develop and discuss their prevention plans. Partnering organizations include the Association of State and Territorial Health Officials, National Association of State Mental Health Program Directors, National Governors Association, the National Conference of State Legislatures, and the Council of Chief State School Officers. Following these meetings, teams consisting of state officials from health, education, and mental health, as well as legislators and advocates, will convene to further develop their state’s suicide prevention plans.

Multi-state Assessment of State Suicide Prevention Planning
CDC is conducting an in-depth, multi-state examination of the development and implementation of state suicide prevention plans. The findings will help other states develop suicide prevention plans and gain the support of stakeholders so that these plans can be put into practice. Insights gleaned from this study will help inform state-based prevention efforts in other public health problem areas (i.e., violence against women and child maltreatment).

State Injury Prevention Program Implementation
CDC is funding Maine and Virginia state injury prevention experts to develop evidence-based suicide prevention programs. They are designing and implementing a suicide prevention program tailored to the needs of their state.

 
Next Steps

With extensive input from research centers, national nonprofit organizations, and other federal agencies with a stake in injury prevention, CDC has identified the top research priorities for preventing suicide. These are research priorities that CDC must address to fulfill its public health responsibilities. They have been published in the CDC Injury Research Agenda and will receive CDC’s greatest attention and resources.