Acad Psychiatry DOI 10.1007/s40596-014-0127-6

EMPIRICAL REPORT

The Public Health Approach to Reducing Suicide: Opportunities for Curriculum Development in Psychiatry Residency Training Programs Michelle M. Cornette & Amy E. Schlotthauer & Jon S. Berlin & David C. Clark & Lisa M. French & Melissa L. Miller & Heidi M. Pfeiffer

Received: 2 April 2013 / Accepted: 11 October 2013 # Academic Psychiatry 2014

Abstract The authors review the current status of suicide prevention curricula in psychiatry training programs, describe the public health approach to suicide prevention, discuss public health strategies for reducing suicides and the unique role played by psychiatrists with respect to suicide prevention, and offer public health-oriented suicide prevention curriculum guidelines for psychiatry residents. Keywords Suicide prevention . Psychiatry residency training . Curriculum . Public health Suicide is currently the tenth leading cause of death in the USA, accounting for more than 38,000 deaths in 2010 [1]. This equates to one suicide death approximately every 14 min. In the same year, 464,995 individuals were treated in emergency departments for self-inflicted injuries. It has been suggested that for every suicide, there are at least six survivors, and that approximately 4.7 million survivors are living in the USA today M. M. Cornette (*) American Association of Suicidology, Center for Deployment Psychology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA e-mail: [email protected] M. M. Cornette e-mail: [email protected] A. E. Schlotthauer : J. S. Berlin : D. C. Clark Medical College of Wisconsin, Milwaukee, WI, USA L. M. French Center for Deployment Psychology, Bethesda, MD, USA M. L. Miller Duke University, Durham, NC, USA H. M. Pfeiffer University of Wisconsin-Milwaukee, Milwaukee, WI, USA

[2]. It has been reported that suicide accounts for an estimated $34.6 billion in direct and indirect costs annually [1]. The toll of suicide and attempted suicide has a significant public health and community impact. It is, therefore, critical to consider what strategies, in what contexts, are best utilized to reduce the public health burden of suicide, and how in turn, to most effectively train those who work to prevent and treat suicidal behaviors. Suicide is most commonly seen in the context of mental illness, such as disorders of mood, reality testing, personality, and substance use. As a result, suicide has almost exclusively been the province of psychiatry, psychology, and other mental health disciplines. In the last three decades, a consensus has emerged that modern practice is a clinical enterprise that integrates biological, psychological, social, and more recently, existential perspectives. This is commonly characterized, after Engel, as the biopsychosocial model [3]. It offers a sophisticated and growing set of tools and concepts that enlighten day to day diagnosis, treatment, and research. Psychiatry training programs expect their residents to become well-versed in the array of biological treatments, psychological therapies, family and systems approaches, and levels of care that provide environments tailored to varying degrees of behavioral dyscontrol. Many of these interventions have demonstrated some effectiveness in mitigating suicide risk. Newer global phenomena such as endemic terrorist suicide and socially acceptable assisted suicide for the terminally ill force consideration of intellectual frameworks beyond Engel’s original conception. In the arena of suicide prevention, research pointing to the important role of public health approaches [4] presses our thinking to the edge of the traditional model. It is, therefore, time that the residency curriculum includes the contribution that public health makes to our understanding of suicide. The primary aim of this manuscript will be to offer public health-oriented suicide prevention curriculum guidelines for psychiatry trainees. We will also (1) describe the current status

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of suicide prevention curricula in psychiatry training programs, (2) describe the public health approach to suicide prevention, (3) discuss public health strategies for reducing suicides, and (4) discuss the unique role played by psychiatrists with respect to suicide prevention.

Current Status of Suicide Prevention Curricula in Psychiatry Training Programs Self-inflicted injury is the hallmark of psychiatric emergency—the equivalent of a heart attack in cardiac medicine. In other areas of medicine, specific intervention protocols are in place to address events for which mortality is a likely outcome (e.g., heart attack and stroke); such protocols are taught routinely in medical schools and residency programs. Suicidal behavior also has high potential for lethality. It has been estimated that 10 to 15 % of suicide attempts result in death by suicide [5]. Yet, far less attention has been paid in the literature to developing a specific psychiatry training protocol for suicide prevention. The need for suicide prevention training in medical training has been recognized for decades (e.g., [6, 7]). More recently, investigators have acknowledged the need for more specific curricular guidelines. According to Fang and colleagues [8], “There is currently no requirement by the Residency Review Committee that education about suicide, also called suicide care, be taught in psychiatry training programs. Although emergency psychiatry is a required rotation, there are no specific guidelines for suicide education” [9]. There is no mention of public health approaches to reducing the burden of suicide in the Accreditation Council for Graduate Medical Education (ACGME) standards. In recent years, the American Psychiatric Association published the Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors [10]. The emergence of this consensus document suggests that perhaps we are on the cusp of a more formal training protocol for psychiatry trainees. Yet, no formal public health training recommendations have been brought forth to date, and even in the clinical practice guideline, public health approaches to suicide prevention are given short shrift. Some research suggests that in addition to the lack of formal guidelines, the degree to which suicide prevention is directly addressed in residency training curricula is limited. One survey [11] indicated that only one third of the residents reported receiving education on the impact of suicide on trainees or “postvention.” Several authors (e.g., [8, 12]) agree that such postvention topics ought to be addressed more frequently in psychiatry training programs. One might consider postvention education to be particularly important for psychiatry trainees for a number of reasons. First, it is important to reduce the psychological impact of the suicide loss on the resident, for the sake of the resident’s own mental health,

and in an effort to reduce the resident’s own risk for suicide/ suicide attempt. Indeed, mental health providers are a subgroup of suicide “survivors,” for whom we know suicide rates to be elevated following a suicide loss. Some have suggested that postvention efforts may reduce suicide risk among survivors [13, 14]. Second, the loss of a patient to suicide has the potential to impact how the resident chooses to practice in the future. For example, some providers who have lost a patient to suicide might choose to avoid seeing suicidal patients in their practice moving forward. Another outcome might include a tendency to practice overly-defensive medicine (e.g., hospitalizing patients who would be more effectively treated on an outpatient basis). Thus, another unfortunate result of patient losses to suicide could be a loss of these practitioners to the larger public health agenda. As will be later discussed, not only are psychiatry residents likely to encounter a patient suicide, but if they do, they may become turned off to the broader suicide prevention mission. Finally, postvention training has the potential to increase resilience for those who have not yet lost a patient to suicide, by normalizing the experience and teaching skills for coping with a patient suicide loss. Pilkinton and Etkin [11] found that only one third of program directors reported having a postvention policy in place. They further surveyed 166 child and adult psychiatry programs about suicide prevention education and postvention practices, and determined that most programs provide this training through seminars and clinical supervision; in some cases, the training/supervision was limited. Ellis et al. [15] found that only one half of residency training programs provided advance guidance for a possible patient suicide and few outlined postvention protocols. Lomax [16] also noted that most proposals for suicide prevention education are not based on the empirical literature. Melton and Coverdale [17] sampled the opinions of 106 chief residents at psychiatry training programs across the nation regarding suicide training. They found that 91 % of the programs offered formal teaching with regard to care for suicidal patients. The investigators surveyed a wide range of suicide prevention topics and found the topics most frequently addressed included risk factors, early warning signs and recognition, and standards of clinical care (see Table 1). Conversely, areas that required more attention included suicide in schools and prisons, postvention, and family-based interventions. The most common barriers to learning about suicide prevention reported by chief residents included: a lack of audio or video teaching materials and relevant texts (44 %), the emotional nature of the topic (11 %), and the lack of skilled individuals to teach about the topic (10 %). To date, there has been significant variability in the material that is taught to residents and the manner in which this material is presented. We identified only very limited standardized curriculum recommendations in the literature [18, 19]. Importantly, public health approaches to suicide prevention were not discussed in

Acad Psychiatry Table 1 Specific suicide topics in programs teaching management of suicide (Ten most frequently taught topics; adapted, with permission, from Melton & Coverdale [17]) Taught

Needs attention

Topic Risk factors Early warning signs, recognition Standards of clinical care Ethics of hospitalization Risk management and documentation Managing chronically suicidal patients Ethical terms Suicide prevention contracts

N 95 93 85 95 93 78 75 73

% 100 98 92 90 88 82 81 78

N 30 38 40 34 51 54 38 22

% 39 49 49 45 61 67 47 28

Critical appraisal of relevant papers Managing personal reactions

70 69

76 73

53 61

63 70

any of the articles on psychiatry residency curricula we reviewed. This article advocates for a standardized, comprehensive curriculum incorporating a public health injury prevention and control approach to suicide prevention in psychiatry residency training, and offers guidelines regarding how one might develop such a curriculum for use with their psychiatry trainees. Consistent with this aim, we recommend that suicide prevention training for psychiatry residents be expanded in the following ways: 1. Addressing suicidal ideation in populations and locations beyond those seeking treatment in healthcare facilities. 2. Incorporating population-based suicide prevention interventions that complement the interventions traditionally employed in clinical settings. 3. Developing leadership skills to fill the broadening role of psychiatrists in suicide prevention.

Public Health Approach to Suicide Prevention The public health approach has been recognized as a useful perspective to apply to suicide prevention because it provides a systematic method for identifying and addressing suicide risk. In fact, the 2012 National Strategy for Suicide Prevention contains a number of goals reflective of the public health perspective [20]. The public health approach utilizes tools such as surveillance, epidemiological analysis, intervention design, and evaluation. These tools are then used to focus on recognizing the underlying risk and protective factors for suicide, identifying strategies to address these factors, and evaluating the impact that those strategies have made to reduce the biosocial disease burden of suicide.

The science of injury control and prevention builds on the public health model and is based on the understanding that injury is a disease rather than the result of fate or random occurrences [21, 22]. The fundamentals of injury control and prevention are constructed from the public health triad of host (individual), agent/vector (e.g., kinetic energy from a car or gun), and environment (physical or socioeconomic). Injury control and prevention is the scientific discipline of understanding what prevents or attenuates the transfer of energy to the host, which can happen by separating the host from the agent through modification of the environment, equipping the host with protections against the agent, or eliminating or modifying the vector that transmits the energy [23–26]. William Haddon developed a two-dimensional approach to injury analysis by dividing the public health triad of agent, host, and environment into three phases: preinjury, injury, and postinjury [27]. This phase-factor matrix has become the scientific underpinning of injury control and prevention. Suicidal behavior can then be broken down into the component factors of Haddon’s matrix, allowing specific interventions to target specific factors and phases [28]. The World Health Organization [29] report on violence and health describes violent behaviors as resulting from a combination of biological, social, cultural, economic, and political risk factors. WHO uses an ecological model for understanding the risk factors for violence at different scales of organization, and how they overlap to influence an individual’s behavior. The ecological levels include individual, relationship, community, and societal. From the public health perspective, suicide can be viewed as a subset of violent behaviors—selfinflicted violence. Suicide can be understood as a public health problem which can be addressed via public health approaches to intervention. According to the public health perspective, suicide prevention interventions can be classified as universal, selective, or indicated [29]. Universal interventions have been defined as broad, population-based prevention strategies targeted at communities. These include both media and educational campaigns and environmental prevention strategies that focus on physical changes to reduce risk, such as reducing access to lethal means through barriers on high places, changes to car exhaust systems and gun control. Selective interventions include screening and interventions targeted at high-risk groups. Indicated interventions are those targeting the treatment of individuals with existing suicidal ideation and behavior.

Public Health Strategies for Reducing Suicides The following is not an exhaustive review of suicide prevention strategies, but rather, an overview of those public health approaches with some degree of empirical support, and which most clearly broaden the scope of suicide prevention as

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traditionally conceptualized by psychiatrists and other mental health professionals. Pharmacological Interventions Pharmacotherapy, specifically the prescription of psychotropic medication and the subsequent monitoring of patients prescribed such medication is first-line treatment for suicidal patients in the field of psychiatry. Psychiatric patients with suicidal ideation also have the potential to overdose on their psychotropic medications, the most frequent method of suicide attempt in many health care settings. For both of these reasons, the effectiveness of pharmacotherapy, although certainly a more traditional approach to suicide risk management, will be addressed briefly here. Psychological autopsy studies have suggested that approximately 90 % of suicide victims possess a psychiatric diagnosis at the time of their death [30], and that mood disorders are among the most prevalent of diagnoses among suicide decedents. Higher antidepressant prescription rates have been shown to be associated with lower suicide rates [31, 32] in both adolescents and adults [33–35]. In countries with the greatest increase in SSRI prescriptions, suicide rates have dropped most significantly [36]. Lithium has been associated with decreased risk for suicide and suicide attempts among patients with both unipolar and bipolar depressive disorders [37–40]. Given the overdose potential associated with lithium due to its toxicity, however, it is recommended that patients prescribed the drug be monitored carefully. Follow-Up Contact Interventions Some research has demonstrated that follow-up contact by healthcare facilities may be protective with respect to future suicide risk. For examples, Motto [41, 42] explored this question in a sample of more than 3,000 patients admitted to psychiatric inpatient units secondary to depressive symptoms or suicidal ideation. Of those who do not follow through with their post-discharge treatment plans, those who received follow-up contact via phone or letter expressing general concern for the well-being (via phone or letter), were less vulnerable to death by suicide than both those who did not receive such contact, and those who had followed through with postdischarge treatment. This difference held over 5 years, but gradually dissipated over the course of the 15-year follow-up period. In a related study of those admitted to a hospital for a first-time episode of self-directed violence (suicidal intent versus non-suicidal intent not differentiated), patients in an experimental group were offered quick, easy access to on-call psychiatry residents via a “green card,” which indicated telephone or face to face contact with a psychiatry trainee was available 24/7, and encouraged patients to seek help at an early stage [43]. One-year follow-up data revealed reduced risk for actual and seriously threatened self-directed

violence, as well as reduced utilization of medical and psychiatric services in the experimental group. Other studies involving follow-up interventions have shown no difference in subsequent rates of suicide attempts or ideation [44, 45]. Means Restriction Interventions Reducing firearm-related suicides is an important strategy for reducing the overall burden of suicide. Several studies assessing case fatality rates indicate that acts of self-directed violence in which a firearm was used are much more likely to end in death compared to other mechanisms such as poisoning or suffocation [46, 47]. One study looking at case fatality rates in the Northeast found that 91 % of all suicide acts in which a firearm was used resulted in death compared to 2 % of poisonings by drugs [47]. Conwell et al. [48] determined that storing a firearm unlocked and loaded was found to increase suicide risk. The combined results of these and related studies have led to a number of public health strategies focused on reducing firearm-related suicides and suicide attempts. There are a number of prevention opportunities where change can be accomplished by focusing on the vehicle, such as a firearm. Researchers (e.g., [48, 49]) have suggested that healthcare providers assess for whether or not distressed patients have access to firearms. The Department of Veterans Affairs has implemented a gunlock program called Project Child Safe (developed by the National Shooting Sports Foundation in 2003), named as such in order to destigmatize use of gun locks and to encourage use by focusing on protecting families and children among those who are resistant to use them for the purpose of their own suicide risk reduction. In addition, several studies have demonstrated a reduction in firearm-related suicides following the introduction of gun control legislation [50–52]. A community-based program targeting the agent involves reduced package sizes of pain medications [53]. In response to an increasing number of self-poisonings with pain medications (acetaminophens and salicylates), Great Britain implemented legislation in 1998 limiting the package sizes and number of tablets allowed per sale of these drugs, which had previously been unlimited. In addition to packaging limits, printed warnings about the dangers of overdose were included with all sales. Suicide deaths from acetaminophens and salicylates decreased by 22 % in the year after the change in legislation involving blister packaging and reduced package sizes; this reduction was maintained at 2-year follow-up. Liver unit admissions and liver transplants for acetaminophen-induced hepatotoxicity decreased by approximately 30 % in the 4 years after the change in legislation. Numbers of acetaminophen and salicylate tablets in non-fatal overdoses decreased in the 3 years after the legislation. Other medication-related means restriction interventions include restrictions on access to barbiturates via changes in prescription practices [54–56] and the development of

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safer, less toxic antidepressants [31, 57]. Restrictions on access to alcohol have also been associated with declines in overall suicide rates [57, 58]. Anecdotally, physicians often prescribe potentially toxic medications in smaller amounts in order to minimize the possibility of overdose in those experiencing depression, suicide risk, or with a history of suicide attempts. Other effective means restriction approaches to suicide prevention include construction of bridge barriers [59, 60], detoxification of domestic gas [61–63], mandating catalytic converters in motor vehicles [64–66], and restrictions on the utilization of pesticides [67, 13]. Although some research has pointed to method substitution in the cases of domestic gas detoxification and pesticide restrictions, most research supports the effectiveness of means restriction interventions can be effective. Ongoing research is exploring the possibility that railroad fences or other barriers, targeted in specific locations, might also be effective in reducing numbers of suicides by railroad [68, 69]. Media-Based Interventions Another public health approach to suicide prevention is that of responsible media reporting of suicide. Some research has suggested that media blackouts and campaigns to limit media coverage of suicides have been associated with decreases in suicides [70, 71]. However, the effectiveness of establishing media guidelines and educating journalists with respect to responsible reporting of suicide has been mixed [72].

development of social skills, and change policies and norms to encourage help-seeking behaviors. The intervention, which targets both individuals and the environment, is comprised of 11 elements including leadership involvement; suicide prevention in professional military education; guidelines (geared toward commanders) for the use of mental health services; community preventative services; community education and training; investigative interview hand-off policy; post-suicide response; management and monitoring of the program by the Integrated Delivery System (IDS; Air Force-wide helping agencies) and Community Action Information Board (provides oversight to the IDS); limited privilege suicide prevention program; Commander Consultation tools; and the Department of Defense Suicide Event Report (the DoD-wide surveillance system). School-based interventions involving screening/referral and gatekeeper training are a subcategory of communitybased interventions. Of note, reviews of the effectiveness of school-based interventions have been mixed with some gains identified in terms of knowledge and attitudes [76, 77]. One review identified both positive and negative effects on attitudes, help-seeking, and peer support [77]. One controlled study demonstrated a decrease in suicide attempts [78], while other studies examining the effect on suicidal ideation and behavior have been mixed and/or unevaluated [76, 78, 79].

Role of Psychiatrists Emergency Room Interventions Emergency department based-interventions with demonstrated effectiveness include ED Means Restriction Education for Parents [73] and Emergency Room Intervention for Adolescent Females [74]. The former includes informing parents of the reasons why their child is at increased suicide risk, educating them about reducing risk by limiting access to lethal means (e.g., firearms, medications, and alcohol), and problem solving with them about how to effectively limit and safely dispose of available means. The latter seeks to improve the emergency room experience of suicidal adolescents and their families by the training staff to effectively work with these individuals, showing a 20-min video that portrays the emergency room experience of two other adolescents who have attempted suicide, and utilizing a crisis therapist to deliver a brief family treatment in the emergency room. Community-Based Interventions The United States Air Force Suicide Prevention Program (AFSPP), which was among the first community-based suicide prevention programs to garner empirical support [75], was developed to strengthen social support, promote

Research suggests that 33 % of patients visit a mental health professional prior to ending their life by suicide [18]; thus, mental health professionals are an important group to which to target our suicide prevention educational efforts. Psychiatrists and psychiatry trainees may be especially well-positioned to address the burden of suicide, as a major frontline healthcare providers, addressing suicidal behavior in both inpatient and outpatient healthcare settings. In many facilities, psychiatrists are the sole providers with admitting privileges and are the primary providers involved in admission and discharge planning. Thus, it is critical that psychiatrists receive adequate training in suicide prevention. Psychiatrists may be especially likely to experience patient suicides during their residency training than at other points during their professional careers. Research suggests that 51 % of psychiatrists have experienced a patient suicide, and estimates suggest that 14 to 68 % of psychiatry residents have worked with a patient who suicided [8, 17]. Some of the reasons hypothesized to explain increased potential for patient suicide during residency training include: resident inexperience, the assignment of more severe/complex cases (who may also be underinsured or indigent) to residents, interruptions in patient care due to resident rotation, and especially relevant to

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this article, lack of suicide risk assessment training [8]. Thus, suicide prevention training for psychiatry residents is critical in reducing the burden of suicide. What role might psychiatrists play in reducing suicides, from a public health perspective? The World Health Organization has made the case that those in the healthcare field have a unique role to play in preventing suicide. Russell Gruen and colleagues [80] outline a model of physician responsibility that describes the domains of professional obligations that physicians have to promote the health of the community members they serve. These obligations stem from the social status physicians are granted by the society, as well as their perceived expertise in not only the biological aspects of disease, but also the social, environmental, and economic conditions that affect health. The primary and central domain is the physician’s responsibility to provide individual patient care. Beyond this, Gruen and colleagues argue that physicians are also obligated to promote access to care, including increased insurance coverage and availability of care for the uninsured, as these system characteristics have a direct impact on the health of the community. The third domain of professional obligation is the advocacy for socioeconomic influences for which there is a direct link between public policies and improved health outcomes, and where physician advocacy of such policies is likely to be feasible and effective. One example is taking a public stand on a gunlock or gun storage policy. Other examples of advocacy and community participation opportunities presented by Gruen and colleagues include working to improve systems of care within an institution; raising awareness of suicide by discussing with friends and family or participating in a public forum; participating in suicide prevention public advocacy (such as the Suicide Prevention Action Network (SPAN)) or lobbying; encouraging a medical society to act on a suicide-related public health issue, or serving in a local organization (e.g., a local suicide prevention organization chapter) or political group.

Suicide Prevention Training Curriculum Recommendations for Psychiatry Trainees While the APA Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors [10] focuses on the assessment, treatment, and risk management recommendations at the individual patient level, we have outlined the domains to be integrated into psychiatry training to ensure the psychiatrists have the skills, knowledge, and attitudes to apply a broader public health approach to the reduction of suicide. The examples below are the guidelines intended to expand the role of psychiatrists beyond the provision of individual patient care to interventions effecting a broader public health impact on suicide reduction.

Public Health Topics to be Addressed We recommend that psychiatry residency didactics incorporate a discussion of suicide risk and prevention in the context of Haddon’s matrix (across the pre, peri, and postinjury phases of the host, vector, and environment). Additionally, didactics need to encompass a variety of suicide care topics that include both how to care for the individual patient as well as how to expand care to the family, community, and societal levels, incorporating a broader public health perspective. See Fig. 1 for an adaptation of WHO’s ecological model [29], incorporating public health-oriented suicide prevention educational recommendations. It is recommended that the following domains also be addressed: suicide risk assessment, suicide prevention interventions (traditional settings), emergency room-based interventions, community-based interventions, pharmacological interventions, follow-up contact interventions, means restriction interventions (with respect to prescription practices, prescription medication disposal, firearm access, gun locks, and prescription medication packaging), postvention, and surveillance systems (root cause analyses and suicide event reporting systems). In addition to lectures, seminars, and skill-building workshops on suicide prevention/suicide care, it is also recommend that psychiatry residents be assigned readings on the public health approach to reducing suicide. See Table 2 for several recommended readings that cover a variety of public health-oriented suicide prevention topics. Venues for Application In addition to the more traditional approaches to evaluating psychiatry residence performance (e.g., exam performance and clinical skills demonstration), it is highly recommended that psychiatry residents be required to demonstrate their understanding, acquired skills, and ability to apply these skills in less traditional ways to include (1) teaching/supervision, (2) program evaluation/research, (3) collaboration/working in multidisciplinary teams, and (4) public policy/advocacy. With respect to clinical skills demonstration, a resident could demonstrate the breadth and depth of their empirically-based suicide risk assessment skills in the context of an outpatient psychiatry rotation, or could demonstrate their skills in managing suicide risk pharmacologically, perhaps in a patient with a bipolar spectrum disorder. Means restriction skills could be demonstrated via a means restriction counseling intervention (e.g., with a patient and his partner) to remove/limit access to a firearm, knife, or rope from a suicidal patient rope (Rudd and Bryan, Unpublished manual). Examples of teaching/supervision opportunities, incorporating a public health approach to suicide prevention, could include educating a group of community-based emergency

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Societal Education re: public policy/ advocacy Education re: how to facilitate collaboration w/ other helping agencies/ law enforcement

Community Providing opportunities for educating other mental health providers Providing opportunities for educating primary care and emergency department providers

Relationship Education re: means restriction

Individual Education re: means restriction Education re: evidence-based crisis intervention strategies and psychotherapies Education re: medication management, as related to suicide risk.

Fig. 1 Ecological model for understanding self-directed violence/suicidal behavior

room professionals on an emergency room-based intervention for suicidal patients (e.g., SafeVet, an emergency room-based intervention currently being evaluated; [81]). Another example might involve in providing an educational in-service for primary care physicians, psychiatrists, and pharmacists regarding the importance of limiting prescribed/dispensed quantities of potentially lethal medications in order to minimize the possibility of lethal overdose among patients experiencing suicidal ideation or with a history of suicide attempts. A third example may involve offering a presentation to a group of mental health providers on the use of gun locks, and how to implement their use, in both clinical practice and communitywide. Although fewer medical trainees tend to take advantage of program evaluation and research opportunities (relative to opportunities in teaching and clinical practice), there are

Table 2 Sample recommended readings incorporating a public health approach to suicide prevention Bryan CJ, Stone SL, Rudd, D: A practical, evidence-based approach for means-restriction counseling with suicidal patients. Professional Psychology: Research and Practice 2010, 42 (5): 339–346. Fang F, Kemp J, Jawandha A, et al.: Encountering patient suicide: a resident’s experience. Acad Psychiatr 2007; 31:340–344. Gruen RL, Pearson SD, Brennan TA: Physician citizens—public roles and professional obligations. JAMA 2004; 291 (1):94–98. Knox KL, Litts DA, Talcott GW, et al.: Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: cohort study. Brit Med J 2003; 327:1–5. Knox KL, Pflanz S, Talcott GW, Campise R, Lavigne JE, Bajorska A, Tu X, Caine, ED: The US Air Force suicide prevention program: Implications for public health policy. Research and Practice 2010; 100 (12): 2457–2463. Knox KL, Stanley B, Currier GW, Brenner L, Ghahramanlou-Holloway M, Brown G: An emergency department-based brief intervention for veterans at risk for suicide (SAFE VET). Am J of Pub Health 2012, 102 (S1):S33-S37. Mann JJ, Apter A, Bertolote J, et al.: Suicide prevention strategies: a systematic review. JAMA 2005; 294:2064–2074.

perhaps few other venues by which a resident would have the opportunity to develop a richer appreciation for empirically-supported public health approaches to suicide prevention. For example, a resident could participate in a research project examining the effectiveness of an emergency room-based intervention for suicide prevention. The public health perspective recognizes the contributions offered by individuals across disciplines and institutional departments, and emphasizes the value of collaboration. For a resident working within a medical center setting, for example, one example of intra-institutional collaboration might include participating on a committee with representatives from pharmacy, patient safety, and/or the facility suicide prevention committee to organize a medication disposal day, encouraging disposal of unused, potentially stockpiled prescription medications. Another example might involve participating in a pharmacy working group to educate pharmacy staff/ advocate for safer medication packaging, to include blister packaging of potentially lethal medications [53]. Examples of inter-institutional collaborations might include (1) collaboration with law enforcement agencies regarding the removal of guns from homes, gun safety education, and distribution of gun locks, or (2) actively contributing to data surveillance endeavors, as when asked to provide information to a medical examiner or coroner on a suicide or suicide attempt for which a resident may have been providing care. Regarding public policy/advocacy, residents might be required to shadow or support community stakeholders and policy-makers on policies which support construction of bridge barriers, or on policies/campaigns which support media blackouts and limitation of media coverage of suicides [70, 71]. Residents could also work with community stakeholders and policy-makers to develop policies which require acquisition certification of firearms, restrict the availability of some types of firearms to certain individuals, establish procedures for handling and storing firearms, require permits for those selling firearms, and/or increase the length of sentences for firearm offenses.

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Collaborating with community partners such as crisis agencies, law enforcement, and public health could also lead to the development of community coalitions designed to foster coordinated systems for managing individuals at-risk for suicide. It is believed that allowing for these additional roles during residency is imperative for the behaviors to extend into one’s professional practice once practicing independently. Through collaboration with colleagues and leadership both inside and outside of traditional mental health settings at the local, regional, and national levels, psychiatrists-in-training can begin to develop an appreciation for their potential roles as leaders within both the mental health and public health communities. Evaluation of Core Competencies To evaluate a resident’s understanding and competence with respect to public health approaches to suicide prevention, we recommend that training programs develop competencybased goals and objectives that can be measured throughout the resident’s training. Examples of a few public healthrelevant objectives are as follows: 1. Demonstrates an appreciation for a public health approach to reducing/preventing suicide as evidenced by educating medical staff or community members on one or more means restriction approaches to suicide prevention. 2. Demonstrates an appreciation for the surveillance aspect of the public health approach to reducing/preventing suicide by participating in facility individual and aggregate root cause analyses of suicides and suicide attempts. 3. Demonstrates an appreciation for a public health approach to reducing/preventing suicide by shadowing and/or supporting community stakeholders and policy-makers on a policy related to suicide (e.g., a policy addressing the availability and accessibility of firearms). We further recommend that each public health objective be evaluated utilizing a 5-point rating scale reflecting the following levels of mastery (Wilford Hall, Unpublished guide): (5) Exemplary autonomous practice, (4) Ready for entry-level practice, (3) Needs occasional supervision, (2) Needs regular supervision, and (1) Needs remedial work. More specific guidelines regarding the criteria for such ratings are provided in the reference noted. Supervision Supervision is an essential, overarching element of preparing psychiatry residents to practice independently; as with other aspects of psychiatry training, supervision should also incorporate a public health perspective. Falender and Shafranske [82] recommend incorporating vignettes, patient case

presentations, and group problem-solving and processing exercises into the supervision experience, particularly following a patient suicide or suicide attempt. Consistent with a public health perspective, vignettes and case presentations can be expanded to include an examination of environmental, social, and economic risk factors, and a discussion of strategies psychiatrists can use to address more systemic issues. Group problem-solving can be expanded to look at family and community-based interventions, as well as individual clinical approaches. Group processing exercises can be used to facilitate postvention efforts following a patient suicide or suicide attempt. It is also recommended that supervisors/training faculty take an active role in discussing the importance of a public health approach to suicide prevention with their supervisees. It is important for supervisors to discuss such topics as promoting access to care and serving as advocates for community-level suicide prevention efforts. As noted above, psychiatry residents can be encouraged to work with community stakeholders and policy-makers to develop policies which foster suicide prevention. It is critical for supervisors to facilitate their residents’ appreciation of their public role as change agents.

Summary Residency education in psychiatry typically requires 48 months. While the purpose of this paper was not to outline a specific year-by-year program, we do suggest that the above recommendations regarding public health topics to be addressed, venues for application, resident evaluation, and supervision be incorporated throughout psychiatry residency training. We emphasize that a public health approach to suicide prevention cannot be effectively taught via a one-time didactic seminar or workshop, but rather should reflect an integrated, progressive series of experiences taught and evaluated via numerous modalities over the course of the psychiatry residency training program. Suicide has characteristics of a disease with high-risk patients and environments, and with physical agents causing cellular and organ damage and death. We assert that suicide prevention training for psychiatry residents is critical in reducing the burden of suicide in homes, communities, schools, and the workplace, and propose incorporating the public health recommendations described above into a standardized curriculum for psychiatry residents. As discussed, the public health approach has merit in broadening the scope of potential suicide prevention strategies, the populations at which suicide prevention interventions are aimed, and ultimately in broadening the leadership of psychiatry beyond direct clinical care of patients, into settings to include emergency departments, primary care, schools, and communities. Psychiatrists and psychiatry residents are in an important and unique position, poised to have a very significant and increased impact on

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suicide prevention. Thus, ensuring that psychiatry residents obtain comprehensive suicide prevention and postvention training is an academic imperative. Implications for Educators & A review of the literature revealed that suicide prevention is currently inadequately addressed in psychiatry residency curricula. & Research suggests that psychiatrists are particular likely to experience patient suicides, and that residency training is a particularly high-risk period for patient loss to suicide. & Given the potential lethal consequences of suicidal behavior, and psychiatrists’ increased risk for experiencing a patient loss to suicide during their residencies, curricular recommendations for assessing, and addressing suicidal behavior deserve primary attention in psychiatry residency curricula. Development of a specific psychiatry training protocol for suicide prevention is recommended. & A comprehensive psychiatry residency curriculum needs to incorporate the public health perspective on suicide prevention.

Acknowledgments The authors would like to acknowledge Nicole M. Lindsay, B.S. and Shirley Duglin Kennedy, M.A. (LIS) for their contributions to the final editing and formatting of this manuscript. Disclosure On behalf of all the authors, the corresponding author states that there are no conflicts of interest to disclose.

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