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. 2017 Nov;76(11):310–313.

Medical School Hotline

Advancing Suicide Prevention in Hawai‘i

Deborah Goebert 1, Jeanelle Sugimoto-Matsuda 1
Editors: Satoru Izutsu2, Kathleen Kihmm Connolly2
PMCID: PMC5694974  PMID: 29164015

Suicide is a serious, complex, preventable public health problem that can have lasting harmful effects on individuals, families, and communities. It is a leading cause of death in Hawai‘i, with more people dying from suicide than traffic-related injuries and drowning.1 That is, about one suicide occurs every other day. Furthermore, in the last few decades, suicide death rates in the United States have significantly increased for nearly every age group, with the greatest increases among indigenous groups.2 There has been an increasing trend in the number of people treated for nonfatal suicide attempts in emergency departments across the state.1 Native Hawaiian and Pacific Islander adolescents exhibit the highest risk for suicide-related behaviors, especially those who reside in rural areas.3

Suicide prevention is a priority for the University of Hawai‘i, John A. Burns School of Medicine, Department of Psychiatry (JABSOM-DOP). For more than two decades, JABSOM-DOP has been a leader in suicide prevention efforts. JABSOM-DOP has been actively engaged in research and evaluation; education, training, and awareness; policy; and community and clinical service to reduce suicide deaths and attempts, and improve the well-being of the people of Hawai‘i.

JABSOM-DOP is home to Hawaii's Caring Communities Initiative for Youth Suicide Prevention (HCCI). With the goal of preventing youth suicide and increasing early intervention, projects positively impact communities that have higher rates, as well as the statewide suicide crisis infrastructure in Hawai‘i. JABSOM-DOP was well-positioned to obtain federal funding of our research and evaluation work cultivated by the National Center for Indigenous Hawaiian Behavioral Health. HCCI is having a ripple effect on communities throughout Hawai‘i as public awareness on suicide prevention is enhanced, more youth are identified and referred, and more youth, families, and communities are empowered to prevent future attempts.

Research and Evaluation

JABSOM-DOP conducts mixed-method, community-informed research and evaluation on suicide. Ultimately, our research and evaluation will help inform ways to improve program content and delivery to underserved populations and reduce health disparities related to suicide.

Indigenous Suicide

Since Hawai‘i began collecting suicide statistics in 1908, rates for Native Hawaiians have been increasing and are among the highest in the world for youth. 4–7 Youth Risk Behavior Survey (YRBS) studies from 1999–2009 show that Native Hawaiian and Pacific Islander adolescents self-reporting the highest rates of suicide-related behaviors (eg, depression, suicide ideation, suicide planning, suicide attempts, and suicide attempts requiring medical attention).8 Furthermore, more Native Hawaiians from rural communities seek care in emergency rooms due to suicide attempts than other ethnic groups.3 Comprehension of local and indigenous perspectives of suicide and well-being enhances our ability to develop better suicide prevention programs and services.9–12

Risk and Protective Factors

JABSOM-DOP research has identified talking with parents, higher levels of family cohesion, family organization, and parental bonding as family factors for preventing youth suicide attempts.5 Families may also influence youth's choice of prosocial friends. A positive school climate increases social connectedness. Additionally, the community serves as a protective factor by enhancing the sense of connection and caring.13 Risk factors associated with youth suicide in Hawai‘i include previous attempts, anxiety and depressive symptoms, alcohol and other substance use, high parental expectations, violence (cyberbullying, dating violence, victimization, perpetration), and historical trauma.5,14–18

Intervention Research

Through Hawaii's Caring Communities Initiative (HCCI) for Youth Suicide Prevention, youth and community members were trained as trainers to provide education and develop awareness projects and activities using evidence-based practices.19 Our HCCI program was tailored to meet cultural needs that were identified by community leaders, which emphasized the importance of honoring community knowledge and prioritizing relationship.20

Education, Training, and Awareness

JABSOM-DOP has taken a leadership role in ensuring education and training needs are met in clinical and community settings. Physician education in suicide prevention has been shown to reduce suicide rates.21–22 Furthermore, primary care physicians who feel competent in suicide prevention are more likely and willing to assess and treat suicidal patients in health care and community settings.23–24 One of the goals of the National Strategy for Suicide Prevention is to increase the proportion of health care providers who receive training in the assessment and management of suicide risk.25 The risk of suicide death can be significantly reduced (20%–70%) by training community-based health providers to recognize and respond to individuals feeling suicidal.26 JABSOM-DOP has integrated suicide prevention into problem-based learning cases for medical trainees, serving as a leader in the country.27–28 We also provide in-service training for health care providers.29–30 Based on our experience, such training has sparked interest among participants in developing protocols and receiving additional training in asking about suicide, dealing with crisis situations, and lethal-means counseling.

Essential components of our provider trainings include recognizing the warning signs for suicide, evaluation, triage and crisis numbers, and protocol development. Local and national crisis numbers are:

  • Crisis Line Hawai‘i

    O‘ahu: 832-3100; Neighbor Islands: 1-800-753-6879

  • Crisis TEXT Line: 741-741

  • National Suicide Prevention Lifeline

    1-800-273-TALK (8255) Veterans Press 1

  • Military One Source

    1-800-342-9647

  • Trevor Helpline

    (LGBTQ Youth) 1-866-4-U-TREVOR (488-7386)

  • Hawai‘i Poison Hotline

    1-800-222-1222

JABSOM-DOP coordinates statewide suicide prevention training efforts. With a contract from the Hawai‘i State Department of Health, Emergency Medical Services, and Injury Prevention System Branch, JABSOM-DOP provides and coordinates suicide prevention trainings statewide and maintains a trainer network. We have sponsored and supported evidence-informed suicide prevention trainings for trainers. We have master trainers for youth suicide prevention programs (Connect Suicide Prevention Program and Mental Health of America of Hawaii's Ho‘olohe Pono-Listen Well, a youth suicide and bullying prevention curriculum) as well trainers in SafeTalk. JABSOM-DOP faculty and staff are active Connect trainers for community members, as well as, social service, emergency department, and mental health providers. JABSOM-DOP provides suicide prevention and postvention training to community members and Native Hawaiian and rural youth. Since 2011, JABSOM-DOP has trained over 700 community members and more than 500 youth annually.

JABSOM-DOP implements awareness activities in culturally relevant ways while using evidence-based practices of suicide prevention and safe messaging.31–33 For example, our HCCI youth groups have partnered with cultural practitioners to hold workshops on hula, lei-making, basket-weaving, and fishing, to promote the strengths of the community. They have also conducted social media and radio campaigns, sign-waving, and shopping-mall presentations to provide a broad reach to all members of their community.

Policy

The Prevent Suicide Hawai‘i Taskforce is a statewide partnership of organizations and community groups that provides leadership, develops strategies, coordinates activities, and monitors the progress of suicide prevention efforts in Hawai‘i. JABSOM-DOP faculty have been involved since its inception, serving on the leadership committee, facilitating strategic planning, and developing and evaluating programs. Dr. Sugimoto-Matsuda currently chairs the Taskforce (2014, 2017–2018). On behalf of the Taskforce, JABSOM-DOP has coordinated two legislative briefings to highlight the magnitude of the problem, highlight gaps and community activities, and provide recommendations aligned with the State's strategic plan (2012, 2016). In 2016, the House Concurrent Resolution (HCR 66) was passed which calls for the Prevent Suicide Hawai‘i Taskforce to develop a strategic plan to “reduce suicides in Hawai‘i 25% by 2025.” The legislation named JABSOM-DOP as a member of the group tasked with facilitating this process and developing the plan. The report to the legislature is due December 2017. For the current strategic plan, see the Hawai‘i Department of Health's website.34 The new plan will be posted on this site, once it is released.

The Youth Leadership Council for Suicide Prevention was formed to provide a youth voice for statewide suicide prevention work, leadership development and training on suicide prevention, and civic engagement and community service opportunities. Youth leaders are connected with adults who support them as leaders in their home communities. Convened and coordinated by Mental Health American of Hawai‘i, JABSOM-DOP serves on the leadership team as a planner and supportive adult. JABSOM-DOP has created a toolkit of activities for members to use to promote suicide prevention in their communities.35

On a national level, faculty have served as contributors to the Suicide Prevention Resource Center (SPRC) and the National Action Alliance for Suicide Prevention relating to minorities, emergency departments, and community.36–38

Service

JABSOM-DOP is the largest provider of psychiatric services in Hawai‘i. Ensuring that effective, quality care for suicide risk is available is a fundamental component of our clinical services. It requires a systems approach that integrates community and health care services. A systems approach focuses on the interconnections among individuals, their families, providers, and organizations, and can improve health by considering the various elements involved in caring for each community member and the multiple factors influencing health. JABSOM-DOP has promoted local adoption of the Zero Suicide Conceptual Approach and Practice, a system-wide approach that aspires to improve care and outcomes for individuals at risk for suicide in health care systems.39

For suicide prevention efforts to be effective, providers and community members need to identify accurately those at risk. Most individuals (83%) have had health system contact in the year before suicide; however, few of them have a documented mental health diagnosis.40 Suicide screening and assessment are often conducted by behavioral health teams. JABSOM-DOP provides psychiatric services as part of these teams. Medical centers have initiated screening and evaluation of patients for suicidal ideation, improving recognition and treatment. While an increasing number of Hawaii's hospitals provide routine screening for suicide risk, only 20% of hospitals have access to on-site psychiatric consultation, such our primary training sites at The Queen's Medical Center and Kapi‘olani Medical Center.

The Queen's Medical Center's Family Treatment Center, an adolescent psychiatric inpatient unit, promotes the health and well-being of Hawaii's adolescents and their families by providing inpatient mental health services for youth of whom, the vast majority suffer suicidality. The Cultural Integration Program considers values that are essential for well-being. Developing prosocial cultural values can provide adolescents with a foundational guide for beliefs, social behavior, and attitudes that can lead to honest, socially acceptable, and responsible decisions.41 The goals of this program at The Queen's Medical Center, Family Treatment Center are to reinforce specific values in therapy as well as in the treatment milieu. Most recently, the unit began a collaborative project on healing through art, in which murals along its walls reflect Native Hawaiian cultural values.42

There are many empirically supported medication and non-medication treatments for mental health illnesses, including depression, bipolar disorder, and anxiety that have potential for suicide prevention.43–45 For example, cognitive behavioral therapy (CBT) has been adopted for suicide attempters, demonstrating significantly lower reattempt rates for those receiving CBT compared to the usual care group. Other related approaches, including dialectical behavior therapy, problem-solving therapy, developmental group therapy, and psychoanalytic approaches have also been shown to reduce suicidality. Brief behavioral interventions provide knowledge about suicidal behaviors and constructive coping strategies regarding treatment and referral, demonstrating a reduction in suicide risk when delivered by staff in primary care clinics and emergency departments targeting treatment and non-treatment seekers.46–47 Large studies on pharmacotherapy, particularly selective serotonin reuptake inhibitors (SSRIs), have shown that initiation is not associated with increased risk and continuation is related to decrease risk.44 Ketamine may be an effective and rapid treatment of suicidal thoughts with minimal side-effects.45 Our work has shown promise for reducing suicidality among geriatric patients using Ketamine.48 Electroconvulsive therapy has also demonstrated a rapid reduction in suicide risk.49 It is important that providers actively engage not only the person considering suicide, but also the care system, family, and community supports, when providing direct suicide intervention services, particularly for minority and indigenous populations.

Suicide has a devastating impact on families, friends, and communities. Postvention refers to activities to reduce risk and promote healing after a suicide death. JABSOM-DOP is working to increase the capacity of communities to respond effectively to suicide clusters and contagion within their cultural context, and support postvention implementation with education, training, and consultation. In response to community requests, JABSOM-DOP has mobilized a Suicide Postvention Response Team to promote healing and impart hope to survivors of suicide loss. Although post-vention is implemented after a suicide, it is essential that communities and organizations prepare for postvention before a suicide, usually through training and provision of resources.50

JABSOM-DOP is recognized for its ongoing efforts as leaders in formulating and implementing suicide prevention initiatives in Hawai‘i. However, this work is too big and too important to be accomplished by one department. JABSOM-DOP continues to partner to create suicide-safer communities across the Hawaiian Islands though innovative research and programs and evidence-informed education, policy, and service.

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