Mark Your Behavioral Health Calendars!

November 2016



November 11: Veteran’s Day


November 17: Great American Smokeout


November 19: International Survivors of Suicide Day

Altarum Institute’s Twitter Chat on Behavioral Health

No Behavioral Health Twitter Chat is scheduled for November, but stay tuned for another #AltarumBHchat soon. Follow Altarum on Twitter for the latest notifications.

Note from the Director

Let’s Talk About Suicide

The suicide rate in the United States has surged to its highest level in nearly 30 years, a Federal data analysis has found. In all, 42,773 people died from suicide in 2014, compared with 29,199 in 1999. Many suicide attempts, however, go unreported or untreated. According to the American Foundation for Suicide Prevention, surveys suggest a million or more people engage in intentionally inflicted self-harm annually—25 attempts for every death by suicide.

Suicide FactsStrong correlation exists between issues of behavioral health—both mental health and substance use—and suicide. Robin Williams’ suicide placed the link between depression and addiction in the spotlight. The National Institute on Health’s Epidemiologic Catchment Area study found that a third of people who die by suicide have a substance use challenge along with a diagnosable mental illness. Substance use, even without the diagnosis of depression, ranks a close second. In fact, research has shown that the strongest predictor of suicide is not a psychiatric diagnosis, but alcoholism, which is directly linked to approximately 50 percent of all suicides

Too often, the language used when discussing suicide and suicide prevention is stigmatizing: the terms committed suicide, completed suicide, or successful suicide are frequently used to describe these tragedies. The word commit presents a particular problem since it is also used for criminal offenses, such as homicide and assault. Use of the term successful to describe a suicide death does not reflect the reality that every suicide is a tragedy. Likewise, to describe a suicide attempt that does not result in death as a failure is also misleading.

Suicide Prevention HotlineLanguage that instills a caring, understanding, and nonjudgmental viewpoint offers hope for family members and communities grieving death by suicide of a loved one. Suicide is not a criminal act. Death by suicide, died by suicide, or suicide more accurately describe the reality and respect the needs of those left behind; these terms more accurately reflects what has occurred. Speaking of Suicide provides guidance on using language that does not stigmatize those who die by or attempt suicide, or their loved ones.

In support of International Survivors of Suicide Day, the theme of this issue of Altarum Institute’s BHchat Corner: News You Can Use is suicide prevalence and prevention. As we speak of the tragedy of suicide, let’s seek to be sensitive about what we say and about the other meanings our words might have as we continue to help vulnerable people and those who love them.

Sincerely, Diana Williams, Director, Behavioral Health Technical Assistance Center (BHTAC)


Stories of Recovery


All stories of recovery are unique, and we want to hear yours. Submit your story online to be shared on social media for the #WeAreRecovery campaign and inspire others. Your story may be featured in an upcoming issue of BHchat Corner: News You Can Use.


We Are Recovery #MyRecovery began when the gun didn't discharge when I pulled the trigger as the barrel touched my temple during this third attempt. I was diagnosed with Bipolar disorder 7 years prior and did not know how to handle it because I did not understand what it meant.

As a Black man, I allowed fear, ignorance, and ego determine my actions by not pursuing the help that I needed to manage my symptoms and learn how to live with this mental illness. When the bullet did not leave the chamber, my eyes opened and I got the help that I needed.

Each day is not the best, but I realize that it is not the worst. I take it one step at a time as I try to help others acknowledge, address, and deal with their own mental health challenges. 

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No Puff Piece


Puff PieceResearch has shown that smoking is associated with an increased risk of suicide. This does not mean that smoking causes suicide, but the association appears to be significant and dose-dependent. One study found an estimated increase in risk of suicidal death of 24 percent for each increment of 10 cigarettes smoked per day. A recent paper published in the journal Nicotine & Tobacco revealed that smokers have two to four times higher risk for suicide than non-smokers. Last year, in a letter published in New England Journal of Medicine, researchers found that women who smoked were 4.4 times more likely to die by suicide compared with women who had never smoked, and male smokers were 3.2 times more likely to die by suicide than men with no history of smoking.

An association between smoking and suicide is not surprising considering they both disproportionately are found in individuals who are low income, have a behavioral health diagnosis, and experience physical illness. People often say that smoking relaxes them, which is true as nicotine satisfies a craving and prevents symptoms of withdrawal. But nicotine also increases heart rate, blood pressure, and respiration, which escalate the smoker’s stress. Research has shown that ex-smokers feel less stress and anxiety than smokers, in part because of the diseases and other health consequences of tobacco use. Moreover, smoking reduces an individual’s levels of serotonin and monoamine oxidase. These chemicals are associated with mood—low levels are associated with more aggression, depression, and suicide. If people self-medicate using tobacco, the relief is temporary and followed by withdrawal symptoms, such as depression and anxiety. Quitting smoking is associated not only with better health, but better mood.

A recent study considered whether anti-tobacco interventions reduce suicide risk. State-level policy interventions—increases in cigarette excise taxes and strengthening of smoke-free air laws—were examined. Data show that where policies to limit smoking have been enacted, suicide rates have declined. It was concluded that these two policies exhibit protective associations with suicide. It has been suggested that State public health interventions, such as cigarette excise taxes and indoor smoking bans, could reduce rates of suicide by as much as 15 percent. These results provide support for the proposition that population interventions to curtail smoking could also reduce risk for suicide.

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Spotlights and Highlights


Hope for Life DayTo change the public conversation around suicide and suicide prevention in American Indian/Alaska Native (AI/AN) communities, the AI/AN Task Force, a public-private partnership formed to help reduce suicide in AI/AN communities, developed the AI/AN Hope for Life Day toolkit. The toolkit is geared towards professionals and grassroots organizers working in AI/AN communities to implement a community-wide Hope for Life Day on September 10 of each year.

This Hope for Life Day toolkit will help community organizers take specific steps to change the conversation around suicide, initiate action for awareness, and foster hope in the effort to reduce or eliminate suicide in their communities. Organizers are encouraged to host culturally tailored events in their community to promote hope, life, cultural resiliency, and community transformation.

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It is tragic when anyone takes his or her own life, but somehow it seems even more tragic when the individual is a young person. Suicides among young people continue to be a serious problem. Each year in the United States, thousands of teenagers commit suicide. According to the American Academy of Child and Adolescent Psychiatry, suicide is the third leading cause of death for 15- to 24-year-olds, and the sixth leading cause of death for 5- to 14-year-olds.

MillersafeTALK is a half-day suicide alertness training for anyone 15 or older, regardless of prior experience or training, to become a suicide-alert helper. safeTALK-trained helpers are taught to recognize the words and actions of others who are at risk of self-harm. They learn to take action by connecting these individuals with life-saving intervention resources, such as caregivers trained in ASIST (Applied Suicide Intervention Skills Training). Developed in 2006, safeTALK has been used in more than 20 countries. safeTALK-trained helpers are an important part of suicide-safer communities, working alongside intervention resources to identify and avert suicide risks.

Youth M.O.V.E. (Motivating Others through Voices of Experience) National is a youth-led organization devoted to improving services and systems surrounding mental health, juvenile justice, education, and child welfare. One of its main focuses is suicide prevention, and it works to make communities safer from suicide by offering safeTALK suicide alertness trainings to young people throughout the country. Visit the Youth M.O.V.E. National website to find a local Youth M.O.V.E. chapter.

Youth Move IndianaIndiana Addictions Issues Coalition, a subsidiary of Mental Health America of Indiana, works closely with Youth M.O.V.E. Indiana, which has four ASIST-trained members and 20 more members trained in safeTALK.  Executive Director Kim Manlove notes: “Our young people are on the frontlines every day of teen suicide and are often first responders to a peer’s attempt to end his or her life. This is why youth suicide prevention education programs are so incredibly important. Youth can learn to recognize the warning signs of suicide in their peers as early as possible to prevent a tragic outcome.”

Other resources specifically for young people include a Crisis Text Line, where text messages are delivered to a trained mental health counselor, and a smart phone app called My3, in which the young person creates a contact list of three people they can call in a crisis. The app also includes a button to link users with the national suicide hotline and 911 and a step-by-step process for creating a safety plan.

Youth Mental Health First Aid is a course designed to teach adults who regularly interact with young people—parents, family members, caregivers, teachers, school staff, peers, neighbors, health and human services workers, and other caring citizens—how to help an adolescent experiencing a mental health or addictions challenge or is in crisis. The course introduces common mental health challenges for youth, reviews typical adolescent development, and teaches a five-step action plan for how to help young people in both crisis and non-crisis situations.

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Photo and CaptionIn June 2009, Army Specialist Chancellor A. Keesling died by suicide while serving in Iraq. Because he died by suicide, his family was not entitled to receive a presidential condolence letter sent to the family of every other service member who dies in combat or as a result of noncombat incidents in a war zone. Upset when they learned a suicide did not merit a letter from the President, Keesling’s parents wrote to the President and the Army chief of staff requesting the policy be changed. They argued that their son's suicide should be treated in the same way as an accident or other non-battle death in a war zone.

Keesling’s parents, working closely with Indiana Congressmen André Carson and Dan Burton and later joined by United States Senator Barbara Boxer and a bipartisan group of 11 senators, led the effort to change this national policy. In July 2011, President Obama changed the policy as part of his administration’s broader effort to improve mental health services for members of the military. Senator Boxer stated, "This will ... do a great deal to reduce the stigma surrounding mental health treatment that prevents so many from seeking the care they need."

“This decision was made after a difficult and exhaustive review of the former policy, and I did not make it lightly,” said President Obama. “This issue is emotional, painful, and complicated, but these Americans served our nation bravely. They didn’t die because they were weak ... we need to do everything in our power to honor their service and to help them stay strong for themselves, for their families, and for our nation." Upon notification of the policy change, Gregg Keesling stated, "It's bittersweet. It does not bring our son back, but I think it does send a powerful message that mental health in our military can be addressed."

“He was a good soldier and that’s the part that I want to know—that the country appreciates that he fought [and] he did everything that he was asked to do. It didn’t turn out well for him, but at least this country could write a simple letter … and just say thank you for our son’s service,” Keesling’s father told CBS News. Because the policy change was not enacted retroactively, the Keesling family did not receive an official presidential condolence letter, but later received a letter from the White House thanking them for the service and dedication of their son.

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Latest in Research


Between 2001 and 2008, the suicide rate in the United States Armed Forces rose from 10.3 suicides to 16.1 suicides per 100,000 Service members. At that time, the Secretary of Defense designated a Defense Health Board Task Force to examine and improve efforts to prevent military suicide. The creation of Defense Suicide Prevention Office (DSPO), established in 2011, is a result of the Task Force recommendations. By 2012, the suicide rate had risen to 30 per 100,000 Service members. Military suicides dropped 20 percent in 2013 and have remained steady since.

A new study published in the Journal of the American Medical Association (JAMA) Psychiatry, finds that most soldiers who attempt suicide have not been deployed yet: the 40.4 percent of enlisted soldiers who had never been deployed accounted for 61.1 percent of enlisted soldiers who attempted suicide. Risk among those never deployed was highest in the second month of service, when soldiers are transitioning out of basic training and into regular service. Risk among soldiers on their first deployment was highest in the sixth month of deployment, the time most soldiers are released for their first visit home. These findings suggest it might be times of transition, rather than the ongoing strain of combat and long deployments, that stress veterans the most.

CrisisOne of the military’s effort to combat suicide was a $50 million, long-term study conducted by the Army that has produced algorithms for predicting which soldiers are most likely to commit suicide. The Department of Veterans Affairs has embraced the science and will soon launch a pilot program for helping its therapists concentrate efforts on those veterans with strong self-destructive tendencies.

The Pentagon has also instituted a crisis line for active-duty servicemen and women or their family members to call: 1-800-273-8255. It has been running public service ads and has high-profile officers encouraging military members to seek help without fearing stigma.

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In a new study from the Mayo Clinic, researchers found that a prior history of suicide attempt is a stronger predictor of death by suicide than originally reported. Using a new approach to data sampling from the Rochester Epidemiology Project, researchers estimate that this risk is nearly 60 percent higher than previously reported when individuals whose first lifetime attempt is fatal are included in the risk assessment.

According to J. Michael Bostwick, M.D., a psychiatrist on Mayo Clinic's Rochester campus and the lead author of the study published in the American Journal of Psychiatry, this study includes individuals whose first-ever suicide attempt presented to medical attention, as well as those who died as a result of the first attempt. Dr. Bostwick notes that those who die on their first attempt have been “routinely ignored in the calculation of risk.” Dr. Bostwick continues, "A large part of the reason that such a high proportion of the total suicides occurred on first attempt can be attributed to firearm usage. The results show that it is 140 times more likely for firearms to cause suicide, compared to all other methods. That means nearly three-fourths of all deaths at first suicide attempt were caused by using firearms. This shows that guns are, unfortunately, but not surprisingly, remarkably effective."

The study also confirmed previous findings that the risk of a death by suicide decreases in those who undergo a psychiatry appointment following a suicide attempt. Those who do die by suicide after an initial attempt are most likely to do so within the first year. This finding underscores the need for timely follow-up and support to prevent a repeat and fatal attempt.

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As confirmed by research, non-fatal suicide attempts are a risk factor for repeat attempt, but less is known about its effect on the method used to complete a successful repeat and fatal attempt. Using 9 years of suicide deaths in Colorado, researchers examined the risk associated with a history of a non-fatal attempt and the risks of eventual suicide death by either poisoning, hanging, or firearm.

Researchers found that suicide survivors were twice as likely to eventually die by suicide via self-poisoning rather than by firearm injury, with this association being stronger among males than females. The study findings lend themselves to prevention and intervention efforts that help reduce survivors’ access to potential sources of poisons, including prescription drugs, chemicals, inhalants, and similar poisoning agents.

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No Behavioral Health Twitter Chat is scheduled for November, but stay tuned for a new #AltarumBHchat soon. Follow Altarum on Twitter for the latest in behavioral health news and notifications about upcoming discussions. Visit BHTAC for a list of Altarum’s previous Twitter chat guests and Storify to view the full conversations.

The Altarum Behavioral Health team is on Facebook and Instagram. Be sure to “like” the pages to stay connected with the behavioral health community.

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Contact Information
Sarah Litton
Manager, Communications and Public Affairs


Altarum Institute's ( mission is to create a better, more sustainable future for all Americans by applying research-based and field-tested solutions that transform our systems of health and health care. Altarum employs over 400 individuals and is headquartered in Ann Arbor, Michigan, with additional offices in Portland, Maine; Silver Spring, MD; Rockville, MD; and Washington, D.C.