Psychiatric Annals

Case Report 

Harnessing the Power of Community to Prevent Pediatric Suicide

Louis T. Joseph, MD; Chun-Yi Wu, PhD; Denise Joseph, JD

Abstract

In early 2017, within Brevard County, Florida, a community-based Task Force was assembled to intervene when the pediatric suicide rate reached one of the highest rates in the state of Florida. Pediatric mental health was previously identified as a top priority on multiple community health needs assessments performed by organizations throughout the region. Within the ensuing 24 months, the pediatric suicide rate was reduced to near zero, the lowest rate the region had seen in more than 20 years.

Over the past decade, the rate of suicide has continued to climb in the United States.1,2 Pediatric mental illness continues to take center stage as school shootings and other unfortunate outcomes related to mental illness are becoming commonplace in society.

The state of Florida is consistently ranked among the lowest for mental health care expenditure per capita.3 Within Brevard County, FL, the pediatric suicide rate for 2017 was one of the highest in the state and represented ongoing significant increases from prior years. Postmortem review of the suicide deaths from the Brevard County Medical Examiner's investigative reports indicated that most of these deaths did not have a health system contact in the months preceding the suicide. The opioid epidemic had also taken its toll on Brevard County, leading to the third highest rate of overdose mortality within the state of Florida.4 In this context, multiple members of the community called upon regional health network leadership (L.T.J., the Chairman of Psychiatry and Behavioral Health Services) to guide them in the pursuit of reducing pediatric suicide. Said leadership assessed the situation and advised that elimination of pediatric suicide was within the realm of possibility. L.T.J introduced the concept of a community Task Force and provided vision and advisement on every level and at every stage of its activity.

Eliminating pediatric suicide was the goal of the community Task Force. Given the fact that most of the suicide victims did not have contact with any health system in the months prior to their deaths, the intervention needed to be focused heavily within the community. Many previously published suicide prevention initiatives, including the Zero Suicide movement, primarily functioned within the confines of the health system.5–7

The Task Force was initially comprised of numerous community activists, school teachers, concerned parents, students, and a few mental health system leaders who gathered together to discuss the problem. In the past, when such tragedies struck the community, there was a tendency to have a discussion that did not lead to the longitudinal, cross-sectional interventions that could systematically address the problem at hand. Upon advisement from L.T.J., it was decided that a town hall discussion was not the answer, and the notion of an ongoing workgroup was introduced and agreed upon. The Task Force was initially led by L.T.J., a school teacher, and a community activist. The initial undertaking was to determine what the optimal composition of the Task Force should be given the overarching goal, and how to create momentum to charge the community with the unique challenge of preventing pediatric suicide. Because the Task Force was completely voluntary and community-based, the decision was made to welcome anyone who wanted to join but to also extend strategic invitations to leaders in various sectors across the region with some ability to influence a child. Capitalizing on momentum generated by community activists, these invitations were sent to leaders within law enforcement, the school system, state legislature, the community 211 Agency (a referral agency for community health and social service supports),8 faith communities, municipal leadership, multiple health care organizations, health insurance organizations, the YMCA, and the Boys & Girls Clubs of America.…

In early 2017, within Brevard County, Florida, a community-based Task Force was assembled to intervene when the pediatric suicide rate reached one of the highest rates in the state of Florida. Pediatric mental health was previously identified as a top priority on multiple community health needs assessments performed by organizations throughout the region. Within the ensuing 24 months, the pediatric suicide rate was reduced to near zero, the lowest rate the region had seen in more than 20 years.

Over the past decade, the rate of suicide has continued to climb in the United States.1,2 Pediatric mental illness continues to take center stage as school shootings and other unfortunate outcomes related to mental illness are becoming commonplace in society.

The state of Florida is consistently ranked among the lowest for mental health care expenditure per capita.3 Within Brevard County, FL, the pediatric suicide rate for 2017 was one of the highest in the state and represented ongoing significant increases from prior years. Postmortem review of the suicide deaths from the Brevard County Medical Examiner's investigative reports indicated that most of these deaths did not have a health system contact in the months preceding the suicide. The opioid epidemic had also taken its toll on Brevard County, leading to the third highest rate of overdose mortality within the state of Florida.4 In this context, multiple members of the community called upon regional health network leadership (L.T.J., the Chairman of Psychiatry and Behavioral Health Services) to guide them in the pursuit of reducing pediatric suicide. Said leadership assessed the situation and advised that elimination of pediatric suicide was within the realm of possibility. L.T.J introduced the concept of a community Task Force and provided vision and advisement on every level and at every stage of its activity.

Intervention

Eliminating pediatric suicide was the goal of the community Task Force. Given the fact that most of the suicide victims did not have contact with any health system in the months prior to their deaths, the intervention needed to be focused heavily within the community. Many previously published suicide prevention initiatives, including the Zero Suicide movement, primarily functioned within the confines of the health system.5–7

The Task Force was initially comprised of numerous community activists, school teachers, concerned parents, students, and a few mental health system leaders who gathered together to discuss the problem. In the past, when such tragedies struck the community, there was a tendency to have a discussion that did not lead to the longitudinal, cross-sectional interventions that could systematically address the problem at hand. Upon advisement from L.T.J., it was decided that a town hall discussion was not the answer, and the notion of an ongoing workgroup was introduced and agreed upon. The Task Force was initially led by L.T.J., a school teacher, and a community activist. The initial undertaking was to determine what the optimal composition of the Task Force should be given the overarching goal, and how to create momentum to charge the community with the unique challenge of preventing pediatric suicide. Because the Task Force was completely voluntary and community-based, the decision was made to welcome anyone who wanted to join but to also extend strategic invitations to leaders in various sectors across the region with some ability to influence a child. Capitalizing on momentum generated by community activists, these invitations were sent to leaders within law enforcement, the school system, state legislature, the community 211 Agency (a referral agency for community health and social service supports),8 faith communities, municipal leadership, multiple health care organizations, health insurance organizations, the YMCA, and the Boys & Girls Clubs of America. Over time, all of the aforementioned organizations joined the Task Force and participated to varying degrees. The Task Force also enlisted the volunteer efforts of a health system-based Six Sigma black belt (an accredited expert in process improvement),9 who guided the ongoing efforts in process improvement and assisted in facilitating select meetings. The Task Force initially met monthly. After introductory meetings and a review of several approaches to target suicide in a community, the decision was made to use the 2017 Centers for Disease Control and Prevention (CDC) technical package entitled “Preventing Suicide: A Technical Package of Policy, Programs, and Practices.”10 This evidence-based roadmap for transformation was ultimately chosen because of the heterogeneous composition of the Task Force and because of its emphasis on transformational change in a community versus a more narrowly tailored intervention housed within the health care system.

After selecting the roadmap, the Task Force divided itself into multiple committees based upon each strategy category of the 2017 CDC Technical Package. Task Force members were asked to join committees based on their self-perceived ability to create positive change and contribute on the committee subject matter (Table 1).

Task Force Committee Subjects

Table 1.

Task Force Committee Subjects

The committee meetings were held 1 to 2 times per month. Leaders of the committees were selected by the committees themselves or by Task Force leadership, and they were responsible for guiding the meetings and holding members accountable to action items. At the monthly Task Force meeting, each committee leader would report on progress. Committee leaders would also use general Task Force meetings for ongoing support, further recruitment for their committees, planning, and quality improvement.

To strengthen access and delivery to care, we worked with health insurance organizations to include coverage provisions allowing home-based or school-based services for their members. Lack of transportation hindered many children from being able to attend mental health-related appointments. To target that problem, a successful ride-sharing initiative was developed. Multiple Task Force members with key affiliations played roles in its design, funding, and implementation to identify and support people with risk factors, and numerous “gate keeper” (ie, an individual in a position of influence that can identify and refer those at risk) training sessions were conducted within the community and school system.11–14

Task Force members participated in ongoing efforts working with the health system, standardizing pediatric mental health risk assessment across health settings, and removing communication barriers to the health and school systems. Within the school system, substantial, ongoing changes were made to the timeliness and appropriateness of mental health screening, referral to services, and communication of salient health information. The school system added staff and redefined the staff roles to focus more intensely on student mental health and wellness, removing occupational emphasis from the administrative tasks with which they were previously burdened. To serve the dual aims of promoting connectedness and teaching coping skills, the Task Force selected, funded, piloted, and assisted in the dissemination of evidence-based mental wellness programs throughout the school system and in certain faith communities. Mental health experts from the Task Force also served as ongoing guides and collaborators for the school system as it further developed a “Social-Emotional Learning” curriculum. To promote connectedness and to create protective environments, regional media outlets were used to provide ongoing coverage of Task Force efforts. Task Force members were also given the opportunity to write regular newspaper columns on topics related to mental health. The subject matters of the columns were deliberately crafted with the intention of dampening stigma and increasing help-seeking behavior, drawing upon any available evidence-based data when formulating the content. Social media was used to the same end. Student members of the Task Force played an ongoing active role in that domain.

Task Force members met with delegates from the Florida State Legislature to call on them to assist in the advancement of legislation that would support aspects of the CDC roadmap for the state of Florida. The legislature ultimately incorporated Task Force requests within legislation that was subsequently codified into law.

The work toward the roadmap is ongoing. Projects described above continue to be part of the Task Force efforts. Additionally, new targets continue to be developed. These include working with law enforcement agencies to use standardized-actionable suicide risk assessment tools and destigmatizing the involuntary commitment process.

Task Force membership was voluntary, and members donated their time to participate.

Funding sources for particular Task Force initiatives that required funding varied. However, all funding was procured from community-based sources, which included donations from community philanthropic organizations, health care organizations, and the school system.

Discussion

The outcome of this community wide effort was a 90% reduction in the pediatric suicide rate in Brevard County when compared to the start-up year rate (Figure 1). From baseline year (2014) to follow-up year (2018), the pediatric population within Brevard County ranged from 116,973 to 118,500.15

Pediatric suicide rate (age 0–19 years) per 100,000 for Brevard County, Florida.

Figure 1.

Pediatric suicide rate (age 0–19 years) per 100,000 for Brevard County, Florida.

The observed pediatric suicide rate was 3.4 per 100,000 during 2014 to 2015, and it increased to 5.1 per 100,000 at baseline (2016). At the start-up year (2017), the pediatric suicide rate was 8.5 per 100,000 and decreased to 0.8 per 100,000 in the follow-up year (2018) (Julie McLeod, Administrative Secretary, Florida District 18 Medical Examiner's Office, written communication, January 25, 2019 and March 7, 2019).

Poisson regression was used to test the difference of suicide rate among pre-baseline (2014–2015), baseline (2016), start-up (2017), and follow-up years (2018). There was no statistical difference in suicide rate between pre-baseline (2015) and baseline years (2016) (P = .067). The suicide rate is significantly higher in start-up year (2017) compared to the baseline year (2016) (rate ratio = 1.67; 95% confidence interval [CI], 1.18–2.36; P = .0039). In addition, the suicide rate for the follow-up year (2018) was significantly lower than that for both the baseline year (rate ratio = 0.16; 95% CI, 0.074–0.33; P < .0001) and the start-up year (rate ratio = 0.09; 95% CI, 0.046–0.20; P < .0001). On the other hand, the Florida pediatric suicide rate has not significantly changed during the time period from 2014 to 2018 (degree of freedom = 4; chi-square value = 1.51; P = 0.83) but has shown an upward trend.

The suicide data was obtained directly from the county Medical Examiner's office and from the Florida Department of Public Health (Julie McLeod, Administrative Secretary, Florida District 18 Medical Examiner's Office, written communication, January 25, 2019 and March 7, 2019).

According to postmortem investigation from the Medical Examiner's Office, the one suicide in the studied population that occurred in 2018 did not have contact with the health care system in the months preceding this person's death (Julie McLeod, Administrative Secretary, Florida District 18 Medical Examiner's Office, written communication, January 25, 2019 and March 7, 2019). However, this suicide occurred in an area of the county where the school-based interventions and screening initiatives were at an earlier stage of their implementation.

In an attempt to ensure other relevant external factors were not affecting the suicide rate, we also examined the county unemployment rate, firearm licenses, and census divorce rate, all of which were relatively stable throughout the years examined.15–17 The 2018 divorce rate was not available at time of this writing.

Given the fact that this health initiative encompassed a portfolio of sub-interventions targeting suicide housed within the CDC roadmap, it is difficult to elucidate the impact of each specific intervention on the final outcome.

Challenges the Task Force encountered have been primarily related to the stigma associated with mental illness. The Task Force continues to address stigma through various messaging campaigns and other interventions. The Task Force hopes to develop measures of impact of such interventions.

References

  1. Hedegaard H, Curtin SC, Warner M. Suicide mortality in the United States, 1999–2017. NCHS Data Brief, no 330. Hyattsville, MD: National Center for Health Statistics; 2018.
  2. Miron O, Yu KH, Wilf-Miron R, Kohane IS. Suicide rates among adolescents and young adults in the United States, 2000–2017. JAMA. 2019;321(23):2362–2364. doi:10.1001/jama.2019.5054 [CrossRef] PMID:31211337
  3. Sherman A. PolitiFact Florida: Yes, Florida lags behind in mental health funding. Tampa Bay Times. January 23, 2017. https://www.tampabay.com/news/politics/stateroundup/politifact-florida-yes-florida-lags-behind-in-mental-health-funding/2310138/. Accessed February 13, 2020.
  4. Florida Department of Health. Drug poisoning deaths. http://www.flhealthcharts.com/charts/OtherIndicators/NonVitalIndDataViewer.aspx?cid=9869. Accessed February 5, 2020.
  5. Coffey CE. Pursuing perfect depression care. Psychiatr Serv. 2006;57(10):1524–1526. doi:10.1176/ps.2006.57.10.1524 [CrossRef] PMID:17035593
  6. Coffey CE. Building a system of perfect depression care in behavioral health. Jt Comm J Qual Patient Saf. 2007;33(4):193–199. doi:10.1016/S1553-7250(07)33022-5 [CrossRef] PMID:17441556
  7. Yarborough BJH, Ahmedani BK, Boggs JM, et al. Challenges of population-based measurement of suicide prevention activities across multiple health systems. EGEMS. 2019;7(1):13. doi:10.5334/egems.277 [CrossRef]
  8. Federal Communications Commission. Dial 211 for essential community services. https://www.fcc.gov/consumers/guides/dial-211-essential-community-services. Accessed February 5, 2020.
  9. International Association for Six Sigma Certification. Black belt certification. https://www.iassc.org/six-sigma-certification/black-belt-certification/. Accessed February 5, 2020.
  10. Stone D, Holland K, Bartholow B, Crosby A, Davis A, Wilkins N. Preventing suicide: a technical package of policy, programs, and practices. https://www.cdc.gov/violenceprevention/pdf/suicidetechnicalpackage.pdf. Accessed February 5, 2020.
  11. Hadlaczky G, Hökby S, Mkrtchian A, Carli V, Wasserman D. Mental health first aid is an effective public health intervention for improving knowledge, attitudes, and behaviour: a meta-analysis. Int Rev Psychiatry. 2014;26(4):467–475. doi:10.3109/09540261.2014.924910 [CrossRef] PMID:25137113
  12. Aakre JM, Lucksted A, Browning-McNee LA. Evaluation of youth mental health first aid USA: a program to assist young people in psychological distress. Psychol Serv.2016;13(2):121–126. doi:10.1037/ser0000063 [CrossRef] PMID:27148946
  13. Litteken C, Sale E. Long-term effectiveness of the question, persuade, refer (QPR) suicide prevention gatekeeper training program: lessons from Missouri. Community Ment Health J.2018;54(3):282–292. doi:10.1007/s10597-017-0158-z [CrossRef] PMID:28840363
  14. QPR Institute. What is QPR? https://qprinstitute.com/about-qpr. Accessed February 5, 2020.
  15. Florida Department of Health. All cause deaths. http://www.flhealthcharts.com/charts/DataViewer/DeathViewer/DeathViewer.aspx. Accessed February 13, 2020.
  16. Federal Reserve Bank of St. Louis. Unemployment rate in Brevard County, FL. https://fred.stlouisfed.org/series/FLBREV3URN.2019. Accessed February 5, 2020.
  17. Florida Department of Agriculture and Consumer Services. Concealed weapon/firearm license holders by county. https://www.freshfromflorida.com/content/download/7502/118869/cw_active.pdf. Accessed February 5, 2020.
  18. United Census Bureau. Marital status in Brevard County, FL. https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_17_5YR_S1201&prodType=table. Accessed February 5, 2020.

Task Force Committee Subjects

<list-item>

Strengthen access and delivery of suicide care

</list-item><list-item>

Promote connectedness

</list-item><list-item>

Teach coping and problem-solving skills

</list-item><list-item>

Identify and support people at risk

</list-item><list-item>

Lessen harms and prevent future risk

</list-item><list-item>

Create protective environments

</list-item><list-item>

Strengthen economic supports

</list-item>
Authors

Louis T. Joseph, MD, is the Chief Executive Officer, Open Sea Institute; and the Chairman of Psychiatry and Behavior Health Services, the Chairman of Policy and External Affairs, Parrish Medical Center and Health Network (a Mayo Clinic Care Network Member). Chun-Yi Wu, PhD, is a Research Area Specialist Lead, University of Michigan. Denise Joseph, JD, is the Chief of Clinical Operations, Open Sea Institute.

Address correspondence to Louis T. Joseph, MD, 532 27th Street, West Palm Beach, FL 33407; email: louisjosephmd@opensea.institute.

Disclosure: Chun-Yi Wu received funding from the Open Sea Institute for projects dedicated to pediatric and adult health and wellness. The remaining authors have no relevant financial relationships to disclose.

10.3928/00485713-20200205-01

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