After 30 years working in child and adolescent behavioral health, I have seen amazing advances in behavioral healthcare. We have identified genetic links to some mental health diagnoses; we have developed medications to better treat mental health disorders such as depression, anxiety, and schizophrenia; we have more available platforms to talk about mental illness and substance use to name just a few.

However, despite these advances, we continue to struggle as a society with seeing someone’s mental well-being as important as someone’s physical well-being. This is apparent in insurance reimbursement for providers, quality insurance coverage for all levels of behavioral healthcare, barriers to access behavioral healthcare especially in rural areas, a severe national shortage of child and adolescent behavioral health specialists especially child psychiatrists, and a national crisis in pediatric suicide rates.

In 2016, the U.S. Centers for Disease Control and Prevention (CDC) released its latest National Vital Statistics. The results showed that suicide moved from the third leading cause of death for youth ages 10-24 to the second leading cause of death. Suicide deaths are just under unintentional injury as a leading cause of death.

Of even more concern is that while death by suicide in pediatric populations is rare, suicidal thoughts and suicide attempts are far less rare. In May of 2017, the Children’s Hospital Association (CHA) published an article stating the suicide admission to children’s hospitals had doubled over the last decade. I lecture frequently to pediatric groups from both primary care and hospital settings and am continually surprised that the audience is unaware of these significant statistics.

Ensuring that suicidal thoughts, suicide attempts and deaths by suicide become something that we all feel comfortable talking about is an important step. As healthcare providers, knowing what verbiage to use and not use when referring to suicide is essential. Using phrases such as died by suicide, took his/her life, ended his/her life or attempted to end his/her life helps to destigmatize suicide, while phrases such as committed suicide, completed suicide and successful suicide further add to the stigma associated with suicide.

Healthcare providers play a key role in dispelling myths about suicide, such as “talking about suicide can give someone the idea to try suicide,” which has no research to support its validity. Physicians also need to understand that talking about suicide within families can pose many challenges. Families may have significant shame related to suicide that ranges from, “I failed my child” to “why would my child do this, he had so much to live for, what will people think?”

We need to help our families and pediatric patients understand that talking about suicide is important. It is essential that we convey messages of hope, connect our patients to behavioral healthcare and understand the risk factors involved.

Some key risk factors are:
• Previous suicide attempt
• Close family member who has died by suicide
• Past psychiatric hospitalization
• Recent losses
• Social isolation and/or hopelessness
• Co-occurring mental and alcohol or substance abuse disorders
• Impulsive and/or aggressive tendencies
• Exposure to violence in the home or social environment
• Firearms in the home, especially if loaded
• Parental psychopathology
• Chronic physical illness
• Bullying

A previous suicide attempt is the largest predictor of future suicide, so knowing this is valuable. Awareness of the warning signs for suicide is another necessary component of prevention.

Warning signs for suicide include:
• Talking about wanting to die or kill oneself
• Looking for ways to kill oneself
• Sleeping too little or too much
• Withdrawing or feeling isolated
• Increasing use of alcohol or drugs
• Talking about feeling hopeless
• Experiencing extreme mood swings
• Acting agitated, restless or anxious
• Saying goodbye, giving away precious items
• Displaying sudden sense of calm/improvement

Awareness of these warning signs can help identify someone in need of help and connect that person to the appropriate care. Understanding these risk factors and warning signs allow healthcare providers to begin to have conversations with their patients and families around these topics and have conversations about protective factors.

Understanding protective factors that enhance mental well-being is critical. These include:
• Effective mental healthcare
• Connectedness to individuals, family, community and social institutions
• Problem solving skills
• Contact with caregivers

As healthcare providers, we play a pivotal role in collaborating with patients, families, schools, mental health providers and other youth-serving agencies to approach these protective factors as a united front.

In 2015, Georgia passed House Bill 198, known as The Jason Flatt Act. This bill requires schools to provide annual suicide education training to all certified school personnel and to adopt a policy on student suicide prevention.

In 2017, the Georgia Department of Education and Department of Behavioral Health and Developmental Disabilities conducted 10 regional Suicide Prevention Summits to support school districts where youth deaths by suicide had occurred. These summits brought school district personnel together to learn about suicide prevention best practices and to explore district-specific results of the GaDOE’s Student Health Survey.

This health survey is offered to all students from grades 6-12 and elicits specific data related to suicide and school climate in addition to many other important data points. According to GaDOE’s Safe and Drug-Free Schools, the data has shown that despite the increase in deaths by suicide reported in our state, the self-reported suicide attempts/ideation had remained steady until the 2017-2018 school health survey data. The recent survey showed a significant increase in self-reports for suicidal thoughts and attempts. This data, coupled with requests from school personnel for more direct support on designing and implementing comprehensive prevention plans, resulted in the suicide prevention summits evolving into training events grounded in peer learning.

With an emphasis on peer learning, the August trainings sponsored by GaDOE highlighted the work of both Henry County and Forsyth County school districts as well as the Georgia Suicide Prevention Action Network. Forsyth County’s approach to youth mental well-being is part of a new initiative that is making a great impact. This initiative, called the Total Wellness Collaborative, looks at strategies to address the protective factors in youth, specifically coping strategies, problem solving, the connection between physical and mental health, and community and family connectedness. This initiative has brought together youth, families, schools, local pediatricians and local mental health providers to begin to have conversations about mental and physical well-being and provide education through a Podcast series. This is a wonderful example of how a community can come together to address mental well-being and ultimately reduce stigma and encourage help-seeking behaviors. These are crucial in preventing suicide.

Another wonderful example of a community collaboration effort to encourage discussions around suicide and ultimately promote prevention is the release of the Georgia Bureau of Investigation’s (GBI) suicide prevention PSAs. GBI Director
Vernon Keenan, Special Agent in Charge Trebor Randle and Shevon Jones, MSW, Prevention Specialist, Child Fatality Review Unit all led the effort to bring together community partners to produce a peer-to-peer PSA and a parent-to-parent PSA to foster conversations about suicide. The ultimate goal is to convey messages of hope and educate on crisis resources such as the Georgia Crisis and Access Line.

The community partners included Children’s Healthcare of Atlanta, Voices For Georgia’s Children, Division of Family and Children, GaDOE and DBHDD. Like the Forsyth county initiative, this collaboration portrays the need to approach this national and state crisis from a collaborative approach, leveraging resources from the state and community organizations.

You can view the PSAs via www.gbi.ga.gov/cfr.

Healthcare providers play an essential role in helping families talk about mental health and well-being. Normalizing these conversations at well child visits can be a powerful way to destigmatize. Educating families who are at risk for suicide on the risk factors, warning signs and protective factors are important prevention methods. Helping families at risk to understand how to make their homes safer, including securing all medication in a locked location, securing all firearms and having open conversations with their children about seeking help, coping strategies, conflict resolution and connecting to care are key factors toward prevention efforts.

Providing local crisis support resources such the Georgia Crisis and Access Line (GCAL), 1-800-715-4225 is another prevention measure. GCAL is a 24/7 Georgia statewide call center that is staffed by licensed and specialized crisis clinicians who can talk to youth in crisis and, if needed, dispatch a crisis team to youth in the community.

Healthcare providers are valuable members of the prevention efforts. Collaboration among community, state and private entities ensure that we are attacking this crisis from all angles. It really does take a village to encourage mental well-being, help-seeking behaviors and ultimately bring discussing mental health out of the shadows with the purpose of reducing stigma.