# data[].attributes.headline
When Firearm Safety and Safe Storage is Your Goal

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When Firearm Safety and Safe Storage is Your Goal

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4 Simple Steps to a Medication Safe Home

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4 Simple Steps to a Medication Safe Home

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Communicating With Children After a Suicide - Sesame Street

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Communicating With Children After a Suicide - Sesame Street

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Navigating life after a loss is never easy. You might find that you are left with unanswered questions and an array of complex emotions that can be difficult to understand. It's important to remember that your questions, feelings, and experiences are valid. You are never alone.

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Suicide Prevention: A Resource for Parents

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Suicide Prevention: A Resource for Parents

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Suicide Prevention: A Resource for Parents

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As a parent, it's important to recognize warning signs that your child may be struggling. Once you've identified the signs, navigating what comes next can be overwhelming.

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How to Launch a Local Outreach to Suicide Survivors (LOSS) Team

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How to Launch a Local Outreach to Suicide Survivors (LOSS) Team

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Attention A T users. To access the menus on this page please perform the following steps. 1. Please switch auto forms mode to off. 2. Hit enter to expand a main menu option (Health, Benefits, etc). 3. To enter and activate the submenu links, hit the down arrow. You will now be able to tab or arrow up or down through the submenu options to access/activate the submenu links.

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Apply for and manage the VA benefits and services you've earned as a Veteran, Servicemember, or family member-like health care, disability, education, and more.

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TAPS Postvention Toolkit for a Military Suicide Loss

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TAPS Postvention Toolkit for a Military Suicide Loss

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This bilingual kit uses the power of Elmo and Sesame Street Muppets to support grieving families. It includes a DVD of TV special with Katie Couric, the Muppets and stories of families coping with the death of a parent, a parent/caregiver guide, and a kid's storybook.

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This toolkit reflects consensus recommendations developed in consultation with national experts, including schoolbased administrators and staff, clinicians, researchers, and crisis response professionals. It provides guidance and tools for postvention, a term used to describe activities that help people cope with the e

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Model School District Policy on Suicide Prevention: Model Language, Commentary, and Resources

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Model School District Policy on Suicide Prevention: Model Language, Commentary, and Resources

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Model School District Policy on Suicide Prevention: Model Language, Co

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This document outlines model policies and best practices for school districts to follow to protect the health and safety of all students.

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Addressing the Intersection of Suicide, Overdose, and AdverseChildhood Experiences

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Addressing the Intersection of Suicide, Overdose, and AdverseChildhood Experiences

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Who is exposed, affected and bereaved after suicide? - Dr Julie Cerel (2013)

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When a Friend Dies: Guidelines for Students

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When a Friend Dies: Guidelines for Students

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Idaho School Response Guidelines for Suicide and Sudden Death

Suicide crisis response and postvention are critical as they:

Maintain student and staff safety.

Provide support to grieving or traumatized victims.

Screen or refer and follow-up with those who may need more support.

Reduce the likelihood of imitation for suicide, other self-harm, and violent crises.

Idaho Code §33-136(3)(a) states "Each public school district shall adopt a policy on student suicide prevention. Such policy shall, at a minimum, address procedures relating to suicide prevention, intervention and postvention. As used in this paragraph, "postvention" means counseling or other social care given to students after another student's suicide or attempted suicide."

Responsibilities of School Principal or Designee

Verify the death with law enforcement, coroner's office, hospital, or family of the deceased. IMPORTANT: The death may be labeled a suicide ONLY AFTER it has been officially determined by the coroner. This determination may take weeks. See the note below if family does not want the death labeled as suicide.

Convene Crisis Response Team immediately.

Contact the family of the deceased to express condolences, offer support, ask what students should be told and inquire about funeral arrangements.

Inform 1) your school district office, 2) the Idaho Department of Education at (208) 332-6960, and 3) administrators of schools where siblings are enrolled or where the deceased recently attended. In tribal communities, the Bureau of Indian Education may notify main offices that notify principals.

Notify staff. If news of the death is received before the start of the school day, ensure all staff have been contacted via phone tree before start of school and are advised how the school response will proceed. Set up a staff planning session before the school day. Be sure to consider staff who are not regularly part of the school but who may need to know, such as regular substitutes, after-school coaches, leaders of off-campus groups, relevant bus drivers, etc. If news is received during the school day, use your Crisis Response Team procedures for proper handling of staff notification.

Act as the media spokesperson. Direct all staff to refer all media requests to principal or designee. A prompt response to the media is critical to help mitigate rumors. When speaking with media, focus on the positive steps of the school's postvention plan to help students through the immediate crisis. Offer warning signs (if coroner has ruled a suicide or confirmed that the death is being investigated as such) and resources where parents and students can get help (See Media Sample Statement). Remind media of safe messaging guidelines (See Recommendations for Reporting on Suicide).

Ensure office personnel are prepared to deal with calls and in-person visitors concerned with the death (See Office Personnel Phone and Visitor Protocol).

Schedule a time and place for an after school de-briefing for school personnel to provide emotional support and review next steps.

Provide information about the death and funeral arrangements to parents of other students when the information becomes available. If the coroner has ruled a suicide or confirmed the death is being investigated, refer to it as such. Include information about support services available to students at school, signs of grief, ideas to help (See What Helps) and other community resources, including the hotline number and warning signs if the death is a suicide (See Parent Sample Letter).

Only refer to the death as a suicide if 1) the coroner has made the official certification and 2) the family of the deceased does not object. Otherwise, refer to it as a sudden death. If the family objects, it may be helpful to have someone from school administration or counseling who has a good relationship with the family contact them and explain that students are already talking, texting, or using social media to discuss the death and that talking with the students about suicide can help keep students safe. If they still object, schools can state, "The family has requested that information about the cause of death not be shared at this time." The school may then go on with suicide postvention activities without referring to this death as a suicide. Let the family know that the school will be sending out an email with general support and resources to all students' parents so that they can watch for signs of concern in their own children. A school's main responsibility is to keep all youth safe.

Keep the school open and as close to normal as possible. For safety purposes, permit students to leave school early only with parental permission and documentation and ask parents to pick up their children in person. If parents are unable to pick up and stay with their children, the students should remain at school to ensure safety. Implement an enhanced system of tracking student attendance. Follow regular school routines to the extent possible.

DO NOT announce news of the death over the loudspeaker or in school assembly. Refer to Crisis Response Team protocols below for proper handling of student notification.

DO NOT empty the deceased's locker without first contacting the family. The family of the deceased may prefer to do this in privacy or to have school personnel do it for them. Provide quiet time and support to meet their wishes. If the locker becomes a memorial, let students know that items outside will be collected and shared with the family up until the time of the funeral. After the funeral, the school will no longer keep memorials.

Responsibilities of School Crisis Response Team

The school Crisis Response Team manages the emotional fallout within the school community to decrease the potential for imitation (copycat behavior). The team will likely meet several times during the first day.

Contact law enforcement to verify the facts of the case, if not already obtained in the call by the principal.

Implement counseling support plan to:

Assess what resources are needed. Consider requesting resources from neighboring school districts, pre-screening available mental health services, and contacting clergy, if appropriate.

Clarify responsibilities for support of school personnel, students, and parents with regard to grief counseling, debriefing, etc.

Designate rooms and personnel for students in crisis. Do not allow bereaved students to congregate in halls or allow large groups in the designated rooms.

Coordinate with district or community mental health services for additional resources.

Implement communication plan, which should include:

Write or review existing scripts for office personnel or other designee - not students - for answering the phone, a staff announcement, a student announcement (by classroom), and parent letter/email. Scripts should be honest and direct (See Classroom Announcements Scripts and Staff Instructions).

Notify staff. If news of the event happens before the start of the school day, conduct a staff planning session (See Guidelines for Staff Session). If news of the event happens during the school day, or if phone tree notifications were not implemented before the start of school, assign team members to first notify staff who taught the deceased student or other staff who might have had extensive contact. The team member should be accompanied by another adult in case the staff member is unable to continue their duties. Substitutes may be needed.

Notify closest friends of deceased, if known. Keep in mind the family of the deceased may have the best information about which students were friends and might be at risk. Individually notify any students who may be particularly at risk. Student services staff should provide support immediately and ongoing.

Notify all staff and students. Read announcement from a written message, class by class. Notify as many classes simultaneously as possible (as resources allow). Provide special support in classes of the deceased student including a student support person to sit in the deceased's desk throughout the day, or for any teacher or student needing assistance. Pay close attention to students who have attempted suicide or have previously experienced any loss, either by suicide or a recent loss (See Youth Suicide: Helping Your Student).

Ensure notification of other schools where there are siblings or others who may be affected, including schools where the deceased student was engaged in extracurricular activities or schools where they recently attended.

Only refer to the death as a suicide if 1) the coroner has made the official determination and 2) the family of the deceased does not object. Always stick to the known facts of the case only.

Manner of Death: If the coroner has not officially determined the death to be a suicide, refer to the event as a sudden death. (See guidelines for actions when the family objects under the DO NOT section for the school principal above.)

Squelch Rumors: Rumors create more anxiety and trauma. If the coroner has not yet made a ruling, and there are students or anyone sharing undocumented information, take them aside and ask them to keep other vulnerable students safe by sharing only what is determined to be fact.

If the Family Objects: If the coroner HAS determined the death to be a suicide, but the family objects to that determination being shared, honor the family's wishes. For the announcements, use "sudden death" and state what the family has requested be shared. However, if students ask or talk about this death as a suicide, tell them that since the topic of suicide has come up, we can discuss it. Be sure to provide students with the hotline number and warning signs and ask them what trusted adult they will talk to if they are concerned about a friend or themselves. Let the family know that the school is sending an email for families to watch for suicide warning signs in their own students.

EXERCISE DISCRETION about the kind of information shared.

AVOID EXCESSIVE DETAIL, e.g., discussion of method of death.

HONOR THE VICTIM BUT DO NOT GLORIFY THE DEATH.

DO NOT VILIFY THE SUICIDE VICTIM.

Staff to Follow Schedule: Assign a staff member to follow the deceased student's schedule, even sit in the deceased's chair, to observe reactions and comments of students and follow-up as necessary. Let students know that seating assignments will be re-arranged after the funeral.

Watch for Others at Risk: Identify, monitor, and assist students who are considered at risk for suicide. Follow-up with these individuals and their families, and the school should continue checking in for as long as necessary. All school staff should be especially sensitive to students who are particularly affected by the death such as the deceased's close friends, peer groups, teams, clubs, etc., including activities at other schools. These students may need to talk about their reactions. Attention to these students may prevent future suicidal behavior. Keep in mind that in small schools, this may mean every student (See Youth Suicide: Helping Your Students).

Deceased's Siblings Re-entry: Consider and provide accommodations for reintegration of the deceased student's siblings. Ensure this is addressed if siblings attend a different school.

Keep Staff Updated: Conduct daily debriefing with faculty and staff during the crisis and postvention periods.

Documentation: Document activities as dictated by school protocols. Document social media memorial pages by taking pictures of them before they are taken down, usually 30-60 days after death. Documentation is important as each crisis presents an opportunity to improve the process for handling the next crisis and can help keep schools safe from liability.

Memorial Activities

Help students find a way to grieve without allowing inappropriate memorial activities. Avoid any activities that glorify, glamorize, or sensationalize the death. "Schools can play an important role in channeling the energy and passion of the students (and greater community) in a positive direction, balancing the community's need to grieve with the impact that the proposed activity will likely have on students, particularly on those who might be vulnerable to imitation. The school should prioritize protecting students who might be vulnerable to imitation over what might comfort students who want to remember the deceased student ( After a Suicide: A Toolkit for Schools)."

Please note: Memorials should be the same for any student death regardless of cause. Administration should carefully consider the establishment of any permanent marker for any student death. School staff are advised to make assertive, proactive efforts to guide students in the direction of safe activities for grieving and honoring the student who died. Ideas that safely honor the deceased are below.

AVOID that which other vulnerable youth may see as a way to receive recognition for considering suicide.

ALLOW that which honors the student who died and can help the living.

Do not allow memorial services within the school building.

Assign support staff to attend the funeral service to help monitor students during the service.

Do not send all students to the funeral or cancelling classes for the funeral.

Allow donations collected for the bereaved family, charities, suicide prevention efforts or youth support programs.

Do not fly the flag at half-mast.

Suggest positive notes or memories written by those students and staff who wish to be given to the family.

Do not allow large student assemblies about the victim or a moment of silence at assemblies.

Allow students to leave memorials at the deceased's locker up to five days or until the day of the funeral, whichever comes first.

Do not allow permanent memorials of any kind, e.g. plaques, trees, benches, retirement of a sports jersey, photos of the deceased on school walls or in display cases, etc.

Allow pages in school newspapers or yearbooks that treat the dedication equally with that of any other death. Common guidelines suggest a small photograph, name, birth and death dates and something positive about what they did while living.

Do not allow visual displays of the deceased's image, name, death date, etc., on posters, bracelets, t-shirts, or other attire. If this occurs, tell students of the dangers it poses to other vulnerable youth.

Do not dedicate of sports events or other events to the deceased.

Other Important Postvention Elements

Social Media: DO assign an appropriate school official to monitor social media related to the deceased student such as TikTok, Facebook, Instagram, and Twitter pages. In some cases, the site many need to be taken down particularly if posts or comments are unsafe or traumatizing.

Self-Care: DO remember self-care during this process! Be aware of your own emotional response to these events and take care of yourself ( See Self Care for Adults).

Students at the Funeral: DO suggest to the family, if possible, to hold the funeral after-school hours so staff and students might attend. When emailing parents, remind them that attending the funeral with their children will greatly support and help keep students safe.

These guidelines are meant as a basic list of critical functions for school postvention. For a complete postvention guide, see After a Suicide: A Toolkit for Schools published by SAMSHA.

Also see Children, Teens and Suicide Loss Flip Book published by the American Foundation for Suicide Prevention.
For immediate or ongoing questions or concerns, contact the Idaho Department of Education at (208) 332-6960. If you feel any student or staff poses an immediate threat to self or others, contact the Idaho Crisis & Suicide Hotline at 988, or call 911 if the person has lethal means.
For more information on school-related suicide prevention, intervention and postvention, visit www.sprc.org.

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Idaho State Department of Education (SDE)

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Comprehensive postvention support is available year-round to any school community that experiences a sudden death.

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Is Suicide Really Contagious? - Ep 2 | DavidWCovington.com

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Is Suicide Really a Choice? - Ep 1 | DavidWCovington.com

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An Overview of Idaho's Violent Death Reporting System

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An Overview of Idaho's Violent Death Reporting System

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An Overview of Idaho's Violent Death Reporting System

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Hope Lives - Film Screening & Panel Discussion

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Hope Lives - Film Screening & Panel Discussion

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Hope Lives: Preventing Teen Suicide - Virtual Film Screening & Discussion Panel

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Idaho's data landscape, an interview with Dr. Anna Radin

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Idaho's data landscape, an interview with Dr. Anna Radin

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Dr. Anna Radin, Suicide Prevention Research Interview - Nov. 13, 2023

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Suicide in Schools: A Practitioner's Guide to Multi-level Prevention, Assessment, Intervention, and Postvention 1st Edition

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Suicide in Schools: A Practitioner's Guide to Multi-level Prevention, Assessment, Intervention, and Postvention 1st Edition

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Suicide in Schools provides school-based professionals with practical, easy-to-use guidance on developing and implementing effective suicide prevention, assessment, intervention and postvention strategies. The authors include detailed case examples, innovative approaches for professional practice, usable handouts, and internet resources on the best practice approaches to effectively work with youth who are experiencing a suicidal crisis as well as those students, families, school staff, and community members who have suffered the loss of a loved one to suicide. Readers will come away from this book with clear, step-by-step guidelines on how to work proactively with school personnel and community professionals, think about suicide prevention from a three-tiered systems approach, how to identify those who might be at risk, and how to support survivors after a traumatic event--all in a practical, user-friendly format geared especially for the needs of school-based professionals.

Over 40 e-resources are available here:
routledge.com/books/details/9780415857024/#eresources.

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Suicide in Schools: A Practitioner's Guide to Multi-level Prevention, Assessment, Intervention, and Postvention (School-Based Practice in Action)

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Suicide in Schools: A Practitioner's Guide to Multi-level Prevention, Assessment, Intervention, and Postvention (School-Based Practice in Action) [Erbacher, Terri A.] on Amazon.com. *FREE* shipping on qualifying offers. Suicide in Schools: A Practitioner's Guide to Multi-level Prevention, Assessment, Intervention, and Postvention (School-Based Practice in Action)

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Longterm Effects of Losing Someone to Suicide

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Longterm Effects of Losing Someone to Suicide

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Tahoe Truckee Suicide Prevention Coalition

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Dr. Julie Cerel on the Longterm Effects of Losing Someone to Suicide

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Madelyn S. Gould, Ph.D., M.P.H.

Columbia University and New York State Psychiatric Institute

and

Alison M. Lake, M.A.

New York State Psychiatric Institute

Introduction

Evidence has accumulated to support the idea that suicidal behavior is "contagious" in that it can be transmitted, directly or indirectly, from one person to another ( Gould, 1990). This evidence is derived from three bodies of research: studies of the impact of media reporting on suicide, studies of suicide clusters, and studies of the impact on adolescents of exposure to a suicidal peer. In each case, suicide contagion can be viewed within the larger context of behavioral contagion or social learning theory. While research has also addressed the distinct but related topic of the contagion of nonsuicidal self-injurious behavior (Jacobson and Gould, 2009; Hawton et al., 2010; Whitlock, 2010), the current review focuses specifically on attempted and completed suicide.

Impact of Media Reporting on Suicide

Research into the impact of media stories about suicide has demonstrated an increase in suicide rates after both nonfictional and fictional stories about suicide. Most research in this area has addressed nonfictional reporting, which has been shown to have a more powerful effect ( Stack, 2003). More than 50 studies on nonfictional stories reported in newspapers, on television, and more recently on the Internet, have yielded consistent findings. Suicide rates go up following an increase in the frequency of stories about suicide (e.g., Hagihara et al., 2007). Moreover, suicide rates go down following a decrease in the frequency of stories about suicide (e.g., Motto, 1970). A dose-response relationship between the quantity of reporting on completed suicide and subsequent suicide rates has consistently been demonstrated (e.g., Phillips, 1974; Phillips and Carstensen, 1986; Pirkis et al., 2006). Changes in suicide rates following media reports are more pronounced in regions where a higher proportion of the population is exposed ( Etzersdorfer et al., 2004). The prevalence of Internet users, with access to Internet stories about suicide, has been associated with general population suicide rates in males, but not females ( Hagihara et al., 2007; Shah, 2010).

The way suicide is reported is a significant factor in media-related suicide contagion, with more dramatic headlines and more prominently placed (i.e., front page) stories associated with greater increases in subsequent suicide rates ( Phillips, 1974, 1979; Kuess and Hatzinger, 1986; Michel et al., 1995). Repetitive reporting on the same suicide and definitive labeling of the death as a suicide have also been associated with greater increases in subsequent suicide rates ( Niederkrotenthaler et al., 2009, 2010). Content analyses of suicide newspaper reports from six countries with different suicide rates (Austria, Finland, Germany, Hungary, Japan, and the United States) found that attitudes toward suicide in newspaper reports varied by country, and that national suicide rates were higher in countries where media attitudes toward suicide were more accepting (Hungary) and suicide completers were more positively portrayed (Japan) ( Fekete et al., 2001). Conversely, national suicide rates were lower in countries (Finland, Germany, and the United States) where reporting tended to portray the suicide victim and act of suicide in terms of psychopathology and abnormality, and to describe the negative consequences of the suicide. Moreover, media stories about individuals with suicidal ideation who used adaptive coping strategies to handle adverse events and did not attempt suicide have been negatively associated with subsequent suicide rates ( Niederkrotenthaler et al., 2010).

The impact of media reporting on subsequent suicides is not monolithic, but interacts with characteristics of the reported suicide and characteristics of the media audience, as well as with characteristics of the media portrayal, as noted above. For example, celebrity suicides are more likely and the suicides of criminals are less likely to be followed by increased suicide rates ( Stack, 2003; Niederkrotenthaler et al., 2009); individuals with a recent history of suicide attempt and/or a concurrent severe depression are more likely to attempt suicide in the wake of a media report ( Cheng et al., 2007a, b).

Ecological studies of the impact of media on suicide rates, like those described above, meet four of Hill's five criteria for demonstrating causality (namely, consistency, temporality, strength of association, and coherence), but provide less convincing evidence of specificity ( Hill, 1965; Gould, 1990; Insel and Gould, 2008). A handful of extant individual-level studies, however, have examined whether individuals who attempted suicide following a media story were exposed to and influenced by the media report, and have contributed evidence to support the specificity of the media effect. Hawton and colleagues (1999) conducted a study in emergency departments in the United Kingdom, examining the pattern of suicide attempts before and after a fictional Royal Air Force pilot took an overdose of paracetamol (i.e., acetaminophen) in an episode of a popular weekly TV drama. Presentations for self-poisoning increased by 17 percent in the week after the broadcast and 9 percent in the second week. Increases in overdoses using the specific drug used by the model were more marked than increases in other types of overdoses. The most compelling evidence of modeling from this study was that use of the specific drug for overdose among overdose patients who were viewers of the drama doubled after the episode in question, compared with overdose patients who were viewers of the drama prior to that episode. Twenty percent of the interviewed patients reported that the model had influenced their behavior. In a more recent study, 63 individuals who attempted suicide in Taipei, Taiwan, following the suicide of a young female pop singer were assessed for exposure to media reporting about her death. Forty-three (68 percent) respondents had been exposed to the media reporting, of whom 37 percent reported that the media stories influenced their suicide attempts ( Chen et al., 2010). This study also demonstrated a positive modeling effect on the chosen method of suicide (burning charcoal inside a closed car), with an adjusted odds ratio of 7:3 (for additional evidence of a modeling effect based on choice of suicide method, see also Etzersdorfer et al., 2004; Cheng et al., 2007b; Chen et al., 2012).

Suicide Clusters

A suicide cluster is an excessive number of suicides occurring in close temporal and/or geographical proximity ( Gould et al., 1989). Clusters occur primarily among teenagers and young adults, with between 1 percent and 5 percent of teen suicides occurring in clusters ( Gould, 1990; Gould et al., 1990; Hazell, 1993). A case-control study of two teen suicide clusters in Texas indicated that the clusters included teens who had close personal relationships with others in the cluster, as well as teens from the same community who were not directly acquainted with one another ( Davidson et al., 1989). When compared with matched living controls, suicide completers were more likely to have preexisting vulnerabilities (e.g., emotional illness, substance abuse problems, frequent changes of residence, recent or anticipated relationship break-up) that may have increased their susceptibility to suicide contagion.

It has been suggested that teen suicide clusters may result from the combination of assortative relating, the tendency for similar individuals (in this case, teens at high risk of suicide) to preferentially associate with one another, with shared life stress ( Joiner, 2003). According to this argument, which should apply only to those teens within a suicide cluster who were directly acquainted with one another, teen suicides may cluster within a peer group because of high levels of preexisting vulnerability across the peer group, not because of suicide contagion. A recent study used agent-based computer simulation modeling to test this hypothesis and to explore the possible mechanisms behind suicide clustering ( Mesoudi, 2009). As programmed in the simulation model, social learning was sufficient to generate suicide clusters localized both in time and space. The simulation model further found that assortative relating, also known as homophily, was likely to generate spatially localized suicide clusters among high-risk peer groups, but less likely to generate spatiotemporal suicide clusters and unlikely to generate purely temporal clustering of suicides. As the study's author notes, homophily seems to provide no reason why suicides should be clustered in time. Finally, the model confirmed that media effects, in combination with the effects of prestige and similarity biases, were capable of generating suicide clusters localized in time, but not space.

Even within spatiotemporal suicide clusters, where decedents are more likely to have direct contact with one another, media reporting on suicide can play a role. A recent analysis of the Foxconn suicides in China found support for a temporal clustering effect ( Cheng et al., 2011). National (but not local) newspaper reporting on the suicides and the occurrence of a Foxconn suicide or suicide attempt were each associated with elevated chances of a subsequent suicide 3 days later, demonstrating the impact of both media-related contagion and direct contagion within the Foxconn company.

Impact on Adolescents of Exposure to a Suicidal Peer

Of 16 studies reviewed by Insel and Gould (2008) on the impact on adolescents of exposure to a suicidal peer, the majority found a significant association between exposure to the suicidal behavior of an adolescent peer and a subsequent adolescent suicide attempt. Odds ratios ranged from 2.8 to 11.0 for attempted suicide. Analysis of data on a nationally representative sample of U.S. high school students from the National Longitudinal Study of Adolescent Health (ADD Health) found that "teens who know friends or family members who have attempted suicide are about three times more likely to attempt suicide than are teens who do not know someone who attempted suicide" ( Cutler et al., 2001). Girls were more likely to attempt suicide if they knew someone who had survived a suicide attempt, while boys were more likely to attempt suicide if they knew someone who had died by suicide. Teens who had not made a suicide attempt in wave one of the study were more likely to have attempted suicide in wave two if they knew someone who had attempted suicide in the interim; this temporal sequencing lends support for the role of contagion alongside the possible effect of assortative relationships among high-risk teens. In the context of exposure to the suicidal behavior of an intimate, contagion may operate via the impact on a vulnerable teen of stress or grief at the loss of a loved one, as well as via social learning about suicide.

Strategies to Prevent Suicide Contagion

A number of evidence-based interventions capable of combating suicide contagion have been developed. Studies have shown that it is possible to intervene to mitigate media-driven suicide contagion by implementing media guidelines for suicide reporting ( Gould, 2001; Pirkis and Nordentoft, 2011). Media guidelines can interrupt the transmission of suicidality by identifying the types of media reporting through which suicidality is likely to be transmitted, and by modifying the volume and content of media reporting, with resultant decreases in suicide rates. For example, suicides in the Vienna subway system decreased by approximately 75 percent in 1987 following implementation of media guidelines for reporting on subway system suicides ( Etzersdorfer et al., 1992). Applying media guidelines to new electronic media, including social networking websites, presents a new challenge to the suicide prevention community ( Pirkis and Nordentoft, 2011; Robertson et al., 2012).

Screening for suicide risk can also interrupt the transmission of suicidality by identifying in advance individuals who may be susceptible to suicide contagion ( Gould et al., 2009). In addition, suicide screening works to alleviate that susceptibility by enabling services to be directed to at-risk individuals identified by the screen. Key settings for suicide screening include schools and primary care practices. A range of school- and community-based psychosocial programs may also work to alleviate susceptibility to suicide contagion by, for example, changing adolescent peer norms through positive messaging ( Wyman et al., 2010), or educating and empowering parents to communicate with teens ( Toumbourou and Gregg, 2002). Finally, research suggests that coordinated postvention/crisis intervention efforts following a death by suicide may minimize and contain the effects of suicide contagion ( Poijula et al., 2001; Hacker et al., 2008).

Conclusion

While the complex etiology of suicidal behavior is recognized ( Gould et al., 2003), it has become increasingly apparent that suicide contagion exists and contributes to suicide risk along with psychopathology, biological vulnerability, family characteristics, and stressful life events. Strategies to prevent suicide contagion are essential and require ongoing evaluation.

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What is a suicide cluster?

Suicide clusters are defined as a greater-than-expected number of suicides or nonfatal events such as suicide attempts and self-harm occurring close in time or geography. Clusters can also imply relatedness on some other level than just statistical (for example, when vulnerable individuals from diverse locations are exposed to a highly publicized suicide and imitate the method of that suicide).

Reference:

Niedzwiedz C, Haw C, Hawton K, Platt S. The Definition and Epidemiology of Clusters of Suicidal Behavior: A Systematic Review. Suicide Life Threat Behav; 2014; 44: 569-581. https://doi.org/10.1111/sltb.12091

Is there a way to statistically prove whether or not a cluster occurred?

It may be difficult to prove that a cluster occurred because of small numbers. There are statistical methods available that can be applied, such as geographic information systems, Knox, Poisson, or Scan tests.

References:

What does suicide contagion mean?

Suicide contagion is the process by which suicide or suicidal behavior influences an increase in the suicidal behaviors of others.

References:

O'Carroll P. Suicide prevention: Clusters and contagion. In: Berman AL, editor. Suicide Prevention: Case Consultations. New York: Springer, 1990.

Cheng Q, Li H, Silenzio V, Caine ED. Suicide contagion: A systematic review of definitions and research utility. PLoS One. 2014; 9(9): e108724. doi: 10.1371/journal.pone.0108724.

Does media attention (such as social media, news reports, and entertainment media) affect suicidal behavior?

Risk of suicide can increase when media reports fail to follow best practices, including:

Dramatic or graphic headlines or images

Repeatedly reporting on the same suicide

Explicitly describing the suicide method or showing pictures of it

Dramatizing the suicide death through romanticized or sensational headlines

Showing the site of the suicide and pictures of those who are grieving

Media can play an important role in preventing suicide risk or deaths by following Best Practices and Recommendations for Reporting on Suicide. For example, media can:

Provide information on warning signs of suicide risk

Provide resources for how to get help, including local or national hotlines

Share messages of hope and resilience

Engage experts to provide facts about suicide and how to prevent it

References:

Where are suicide clusters more likely to occur?

There is no one place where clusters are more likely to occur. Published investigations of suicide clusters have shown that they occur in a variety of locations and settings such as schools, correctional facilities, military institutions, and hospitals.

References:

What are the risk factors associated with suicide clusters?

Risk factors for individuals involved in suicide clusters include male sex, being an adolescent or young adult, excessive alcohol use, drug misuse, and past history of self-harm.

Reference:

Haw C, Hawton K, Niedzwiedz C, Platt S. . Suicide Life Threat Behav. 2013; 43(1): 97-108.

What age group has more clusters?

Among published reports, adolescents and young adults seem to experience clusters more frequently than middle-aged or older adults. In the United States, approximately 1% to 5% of teen suicides occur as part of a cluster.

References:

How can a community respond when a suicide cluster occurs?

CDC recommends three general phases of action to prevent and respond to clusters: preparedness, intervention/postvention, and follow-up. These phases are briefly discussed below.
Preparedness

A community should review recommendations and develop a response before the onset of a suicide cluster.

A crisis plan and response should involve all concerned sectors of the community and should be coordinated by:

a coordinating committee which manages the day-to-day crisis response, and

a host agency whose responsibilities would include "housing" the plan, monitoring the incidence of suicide, and calling meetings of the coordinating committee when necessary.

The relevant community resources should be identified.

Intervention

The response plan should be implemented under either of the following two conditions:

when a suicide cluster occurs in the community, or

when one or more deaths from trauma occur in the community, especially among adolescents or young adults, which may potentially influence others to attempt or complete suicide.

The first step of a response plan should be to contact and prepare those groups who will play key roles in the first days of the response.

The response should avoid glorification of the suicide victims and minimize sensationalism.

People who may be at high risk of suicide should be identified and have at least one screening interview with a trained counselor. These people should be referred for further counseling or other services as needed.

The media should have a timely flow of accurate, appropriate information.

Follow up

Elements in the environment that might increase the likelihood of further suicides or suicide attempts should be identified and changed.

Long-term issues suggested by the nature of the suicide should be addressed.

References:

# data[].attributes.attachment_link.title
Suicide, Suicide Attempt, or Self-Harm Clusters

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CDC Epi-Aids provide technical assistances to public health authorities responding to suicide, suicide attempt, and self-harm clusters.

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The goal of Coping with Loss at School is to prepare school communities for dealing with a loss and build resiliency among students and staff.
Learning objectives:

Take the next steps to establish a crisis response plan which includes identifying a crisis response team, communicating clear and universal expectations, and collaborating with community mental health services

Understand the extra considerations for postvention when dealing with a death by suicide

Support students impacted by a death by spotting signs of distress, affirming and normalizing their emotions, and connecting them with support, if needed

Identify signs of compassion fatigue in colleagues and advocate for their self-care and support

# data[].attributes.attachment_link.description
Coping with Loss at School is an interactive role-play simulation to prepare schools for responding to a death in the school community.

# data[].attributes.attachment_link.description
A personal safety plan is an evidence-based intervention for individuals with suicidal ideation or after a suicide attempt has been made.

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Postvention- A Guide for Response to Suicide on College Campuses

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This resource is intended for use by colleges and universities that are affected by and/or want to be prepared for campus crises and campus deaths. Suicide postvention efforts address the need for predetermined strategies to effectively and sensitively respond to campus deaths after they occur.

# data[].attributes.headline
Responding to Grief, Trauma, and Distress After a Suicide: US National Guidelines

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Responding to Grief, Trauma, and Distress After a Suicide: US National Guidelines

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Helping a Child Cope with Loss and Grief

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Helping a Child Cope with Loss and Grief

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Talking to Your Teenager About a Suicide Attempt in Your Family

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Talking to Your Teenager About a Suicide Attempt in Your Family

# data[].attributes.headline
Talking to Your School Age Child About a Suicide Attempt in Your Family

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Talking to Your School Age Child About a Suicide Attempt in Your Family

# data[].attributes.headline
Talking to Your Preschool Child About a Suicide Attempt in Your Family

# data[].attributes.subject
Talking to Your Preschool Child About a Suicide Attempt in Your Family

# data[].attributes.headline
Preventing & Responding to Suicide Clusters in American Indian and Alaska Native Communities 

# data[].attributes.subject
Preventing & Responding to Suicide Clusters in American Indian and Alaska Native Communities 

# data[].attributes.headline
After a Rural Suicide: A Guide for Coordinated Community Postvention Response

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After a Rural Suicide: A Guide for Coordinated Community Postvention Response

# data[].attributes.headline
After a Suicide: Social Media Best Practices

# data[].attributes.subject
After a Suicide: Social Media Best Practices

# data[].attributes.headline
After a Suicide - A Postvention Primer for Providers

# data[].attributes.subject
After a Suicide - A Postvention Primer for Providers

# data[].attributes.headline
What do first responders need to know about suicide loss

# data[].attributes.subject
What do first responders need to know about suicide loss

# data[].attributes.headline
After a Suicide - Best Practices for Remembering a Young Person

# data[].attributes.subject
After a Suicide - Best Practices for Remembering a Young Person

# data[].attributes.headline
LIFE - Developing a Community Plan for Suicide Clusters (AUS)

# data[].attributes.subject
LIFE - Developing a Community Plan for Suicide Clusters (AUS)

# data[].attributes.headline
Responding to Suicide Clusters in the Community

# data[].attributes.subject
Responding to Suicide Clusters in the Community

# data[].attributes.headline
CDC Recommendations for a Community Plan for the Prevention and Containment of Suicide Clusters

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CDC Recommendations for a Community Plan for the Prevention and Containment of Suicide Clusters

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Publication date: 08/19/1988

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This online archive of the CDC Prevention Guidelines Database is being maintained for historical purposes, and has had no new entries since October 1998. To find more recent guidelines, please visit the following:

I. A community should review these recommendations and develop

II. The response to the crisis should involve all concerned

III. The relevant community resources should be identified.

IV. The response plan should be implemented under either of the

V. If the response plan is to be implemented, the first step

VI. The crisis response should be conducted in a manner that

VII. Persons who may be at high risk should be identified and

VIII. A timely flow of accurate, appropriate information should be provided to the media.

IX. Elements in the environment that might increase the

X. Long-term issues suggested by the nature of the suicide

POINT OF CONTACT FOR THIS DOCUMENT:

Article
OUTLINE
I. A community should review these recommendations and develop its own response before the onset of a suicide cluster.
II. The response to the crisis should involve all concerned sectors of the community and should be coordinated by:
A. Coordinating Committee, which manages the day-to-day response to the crisis, and
B. Host Agency, whose responsibilities would include "housing" the plan, monitoring the incidence of suicide, and calling meetings of the Coordinating Committee when necessary.
III.The relevant community resources should be identified.
IV. The response plan should be implemented under either of the following two conditions:
A. When a suicide cluster occurs in the community, or
B. When one or more deaths from trauma occur in the community, especially among adolescents or young adults, which may potentially influence others to attempt or complete suicide.
V. If the response plan is to be implemented, the first step should be to contact and prepare those groups who will play key roles in the first days of the response.
VI. The response should be conducted in a manner that avoids glorification of the suicide victims and minimizes sensationalism.
VII. Persons who may be at high risk of suicide should be identified and have at least one screening interview with a trained counselor; these persons should be referred for further counseling or other services as needed.
VIII. A timely flow of accurate, appropriate information should be provided to the media.
IX. Elements in the environment that might increase the likelihood of further suicides or suicide attempts should be identified and changed.
X. Long-term issues suggested by the nature of the suicide cluster should be addressed.
INTRODUCTION
Recent suicide clusters among teenagers and young adults have received national attention, and public concern about this issue is growing. Unfortunately, our understanding of the causes and means of preventing suicide clusters is far from complete. A suicide cluster may be defined as a group of suicides or suicide attempts, or both, that occur closer together in time and space than would normally be expected in a given community. A statistical analysis of national mortality data indicates that clusters of completed suicide occur predominantly among adolescents and young adults, and that such clusters account for approximately 1%-5% of all suicides in this age group (1). Suicide clusters are thought by many to occur through a process of "contagion," but this hypothesis has not yet been formally tested (2,3). Nevertheless, a great deal of anecdotal evidence suggests that, in any given suicide cluster, suicides occurring later in the cluster often appear to have been influenced by suicides occurring earlier in the cluster. Ecologic evidence also suggests that exposure of the general population to suicide through television may increase the risk of suicide for certain susceptible individuals (4,5), although this effect has not been found in all studies (6,7).
The Centers for Disease Control (CDC) has assisted several state and local health departments in investigating and responding to apparent clusters of suicide and suicide attempts. These clusters created a crisis atmosphere in the communities in which they occurred and engendered intense concern on the part of parents, students, school officials, and others. In the midst of these clusters of suicides or suicide attempts, community leaders were faced with the simultaneous tasks of trying to prevent the cluster from expanding and trying to manage the crisis that already existed. Potential opportunities for prevention were often missed during the early stages of response as community leaders searched for information on how best to respond to suicide clusters.

The recommendations contained in this report were developed to assist community leaders in public health, mental health, education, and other fields to develop a community response plan for suicide clusters or for situations that might develop into suicide clusters. A workshop for developing these recommendations was jointly sponsored by the New Jersey State Department of Health and CDC on November 16-17, 1987, in Newark, New Jersey.* Participants in that workshop included persons who had played key roles in community responses to nine different suicide clusters. They were from a variety of different sectors including education, medicine, local government, community mental health, local crisis centers, and state public health and mental health. Also participating in this workshop were representatives from the National Institute of Mental Health (NIMH), the Indian Health Service (IHS), the American Association of Suicidology (AAS), and the Association of State and Territorial Health Officials (ASTHO).

These recommendations should not be considered explicit instructions to be followed by every community in the event of a suicide cluster. Rather, they are meant to provide community leaders with a conceptual framework for developing their own suicide-cluster-response plans, adapted to the particular needs, resources, and cultural characteristics of their communities. These recommendations will be revised periodically to reflect new knowledge in the field of suicide prevention and experience acquired in using this plan.

Certain elements of the proposed plan for the prevention and containment of suicide clusters are quite different from those of crisis-response plans for other community emergencies. These differences are primarily attributable to the potentially contagious nature of suicidal behavior and to the stigma and guilt often associated with suicide. Other elements of the proposed plan, however, are germane to crisis-response plans in general. Therefore, state and local health planners might consider whether the plan they develop from these recommendations should be integrated into existing guidelines for managing other emergencies or mental health crises.

I. A community should review these recommendations and develop its own response plan before the onset of a suicide cluster.

Comment. When a suicide cluster is occurring in a community--or when such a cluster seems about to occur--several steps in our recommended response plan should be taken right away. If such a timely reaction is to be possible, the response plan must necessarily already be developed, agreed upon, and understood by all the participants at the onset of the crisis. The recommended response requires a great deal of coordination among various sectors of the community. Such coordination is sometimes difficult to establish at the best of times and may be even more difficult to establish in the face of a crisis.
In the early days of an evolving suicide cluster there has typically been a great deal of confusion. There is often a sense of urgency in the community that something needs to be done to prevent additional suicides, but there has usually been little initial coordination of effort in this regard. Moreover, community members often disagree about precisely what should be done to prevent a cluster from expanding. In almost every case, communities ultimately develop some sort of plan for responding to the crisis in a coordinated manner, but opportunities for prevention are often missed in the crucial first hours of the response.

II. The response to the crisis should involve all concerned
sectors of the community and should be coordinated as follows:
A. Individuals from concerned agencies--education, public health, mental health, local government, suicide crisis centers, and other appropriate agencies-- should be designated to serve on a coordinating committee, which would be responsible for deciding when the response plan should be implemented and coordinating its implementation.
B. One agency should be designated as the "host" agency for the plan. The individual representing that agency would have the following responsibilities:

Call the initial meeting of the coordinating committee before any crisis occurs so that these recommendations can be incorporated into a plan that reflects the particular resources and needs of the community (see Section III, below).

Establish a notification mechanism by which the agency would be made aware of a potentially evolving suicide cluster (see Comment, below).

Convene the coordinating committee when it appears that a suicide cluster is occurring, or when it is suspected that a cluster may occur due to the influence of one or more recent suicides or other traumatic deaths (see Section IV, below). At this initial meeting, the members of the coordinating committee could decide whether to implement the community response plan and how extensive the response needs to be.

Maintain the suicide-cluster-response plan. The coordinating committee should meet periodically to assure that the plan remains operational.

Revise the community plan periodically to reflect new knowledge in the field of suicide prevention, the community's experiences in using the plan, and changes in the community itself.

Comment. Every effort should be made to promote and implement the proposed plan as a community endeavor. During past suicide clusters, a single agency has often found itself "in the hot seat," that is, as the focal point of demands that something be done to contain the suicide cluster. No single agency, however, has the resources or expertise to adequately respond to an evolving suicide cluster. Moreover, the emergence of one agency as the sole focus for responding to an apparent suicide cluster has several unfortunate consequences. The agency and its representatives run the danger of becoming scapegoats for a community's fear and anger over the apparent cluster. Such a focus can potentially blind a community to other valuable resources for responding to the crisis and to basic community problems that may have engendered the crisis.
The concept of a "host" agency was developed because--even though the response will involve a variety of different agencies and community groups--one person must necessarily take responsibility for establishing a notification mechanism, maintaining the response plan, and calling meetings of the coordinating committee as outlined above. Which agency should serve as the host agency should be decided by each community. In past clusters, for example, a school district, a municipal government, a mental health association, and even a private, nonprofit mental health center have taken the lead in organizing their community's response. State or local public health or mental health agencies might also serve as host agencies for the plan. The role of host agency might also be rotated among the various agencies represented on the coordinating committee.

The notification mechanism by which the host agency would be made aware of a potentially evolving suicide cluster would vary from community to community. In small communities, one death of a teenager by suicide might be unusual, and information about the death would be quickly transmitted to a county-level host agency. In some large communities, however, there are many suicides each year among young persons. Clearly, a more formal system would be needed in such a county to notify the host agency when an unusual number of suicides had occurred in a particular high school or municipality.

Determining whether to implement the response plan is not an all-or-nothing decision. Indeed, an important function of the coordinating committee is to decide to what extent the plan will be implemented. In situations in which it is feared that a cluster of suicides may be about to start, for example, the implementation of the plan might be quite subtle and limited, whereas in the event of a full-blown community crisis the implementation should be more extensive.

III. The relevant community resources should be identified.
In addition to the agencies represented on the coordinating committee, the community should also seek to identify and enlist help from other community resources, including (but not limited to):
a) hospitals and emergency departments
b) emergency medical services
c) local academic resources
d) clergy
e) parents groups (e.g., PTA)
f) suicide crisis centers/hotlines
g) survivor groups
h) students
i) police
j) media
k) representatives of education, public health, mental health, and local government, if not already represented on the coordinating committee

Comment. The roles of each of the above groups should be defined as clearly as possible in the response plan before any crisis occurs. These roles should be agreed upon and reviewed by persons representing those groups. Most of those involved in the response will already know how to perform their particular duties. However, appropriate training for the staff of these groups should be provided as necessary (8). For example, if it is deemed desirable to conduct surveillance for suicide attempts through hospital emergency departments, officials at the state or local public health department might help design the system and train the emergency department staff. Other potential resources for training and counseling include state and local mental health agencies, mental health and other professional associations, and suicide crisis centers.

It is particularly important that representatives of the local media be included in developing the plan. In at least one community faced with a suicide cluster, the media collaborated in preparing voluntary guidelines for reporting suicide clusters. Although frequently perceived to be part of the problem, the media can be part of the solution. If representatives of the media are included in developing the plan, it is far more likely that their legitimate need for information can be satisfied without the sensationalism and confusion that has often been associated with suicide clusters.

The following example representing a composite of several actual suicide clusters illustrates the need for inclusion of and cooperation among many community organizations. Suppose that two high school students from the same school commit suicide in separate incidents on a weekend during the regular school year. The coordinating committee decides that these two deaths may increase the risk of suicide or attempted suicide among other students. The responsibilities of some of the relevant community resources might be as follows: School officials might be responsible for announcing the deaths to the students in an appropriate manner (discussed below, Section VI). School counselors and teachers might assist in identifying any students whom they think are at high risk; students in the school might also help in this regard. The local mental health agency might provide counselors to work with troubled students, as well as supply training and support for the teachers. Emergency departments of community hospitals might set up a suicide-attempt surveillance system that would increase the sensitivity with which suicide attempters were identified and would ensure proper referral of the attempters for counseling. Hotlines might help identify potential suicide attempters, and police might assist in locating such persons when appropriate. Police may also help by identifying and maintaining contact with such high-risk persons as high school dropouts and those with a history of delinquency. Local government or public health authorities might help coordinate these various efforts, if so designated by the coordinating committee.

IV. The response plan should be implemented under either of the following two conditions:

A. When a suicide cluster occurs in the community; that is, when suicides or attempted suicides occur closer together in space and time than is considered by members of the coordinating committee to be usual for their community; B. When one or more deaths from trauma occur in the community (especially among adolescents or young adults) which the members of the coordinating committee think may potentially influence others to attempt or complete suicide.
Comment. It is difficult to define a "suicide cluster" explicitly. Clearly, both the number and the degree of "closeness" of cases of suicide in time and space that would constitute a suicide cluster vary depending on the size of the community and on its background incidence of suicide. But when a community considers that it is facing a cluster of suicides, it is essentially irrelevant whether the incident cases of suicide meet some predefined statistical test of significance. With the suddenly heightened awareness of and concern about suicide in such a community, steps should be taken to prevent further suicides that may be caused in part by the atmosphere, or "contagion," of the crisis.

In several clusters of suicides or suicide attempts, the crisis situation was preceded by one or more traumatic deaths--intentional or unintentional--among the youth of the community. For example, in the 9 months preceding one cluster of four suicides and two suicide attempts among persons 15-24 years of age, there were four traumatic deaths among persons in the same age group and community--two from unintentional injuries, one from suicide, and one of undetermined intentionality. One of the unintentional-injury deaths was caused by a fall from a cliff. Two of the persons who later committed suicide in the cluster had been close friends of this fall victim; one of the two had witnessed the fall.

The hypothesis that a traumatic death can kindle a suicide cluster regardless of whether it is caused by intentional or unintentional injuries has not yet been tested. Nevertheless, the available anecdotal evidence suggests that some degree of implementation of the response plan be considered when a potentially influential traumatic death occurs in the community--especially if the person who dies is an adolescent or young adult.

We should emphasize that the fear of a contagious effect of suicide is not the only reason to implement this plan. For example, suppose that in the wake of some local economic downturn a community noted an excess of suicide deaths among persons who had been laid off from work. This would be a suicide cluster, and it would be entirely appropriate for the coordinating committee to implement the response plan. It is irrelevant that the suicides are not apparently related to contagion from previous suicides but to a "common-source" problem, since there is an identified population (laid-off workers) potentially at a suddenly increased risk of suicide.

Whether and when to implement the response plan should be determined by the coordinating committee. At this stage of our understanding of suicide clusters, we cannot specify that the response plan should be implemented only under a particular list of circumstances. Until further scientific investigation and experience with suicide clusters provides us with a more empirical basis for deciding when to implement the response plan, we must rely on prudent judgments by community leaders regarding the potential for further suicides in their communities.

V. If the response plan is to be implemented, the first step should be to contact and prepare the various groups identified above.

A. Immediately notify those who will play key roles in the crisis response of the deaths that prompted the implementation of the response plan (if they are not already aware of them).
B. Review the respective responsibilities and tasks with each of these key players.
C. Consider and prepare for the problems and stresses that these persons may encounter--burnout, feelings of guilt if new suicides occur, and the like--as they carry out their assigned tasks.

Comment. Timely preparation of the groups involved is critical. In a past cluster that began with a scenario similar to that described in Section III above, the teachers and the students both heard about the suicide deaths at the same time over the school loudspeaker. The teachers were entirely unprepared to deal with the emotional response of the students and did not know what to say to them or where to refer those who were most upset. It would have been far preferable to have called a pre-school meeting with the teachers to outline the problem, discuss the appropriate roles of the teachers, and announce the various resources that were available (9). Support staff at the school--secretaries, bus drivers, janitors, nurses, and others--might also have been included at the meeting. Such preparation could have been of enormous help in several past suicide clusters.

VI. The crisis response should be conducted in a manner that avoids glorifying the suicide victims and minimizes sensationalism.

A. Community spokespersons should present as accurate a picture as possible of the decedent(s) to students, parents, family, media, and others (see Section VIII, below).
B. If there are suicides among persons of school age, the deaths should be announced (if necessary) in a manner that will provide maximal support for the students while minimizing the likelihood of hysteria.

Comment. Community spokespersons should avoid glorifying decedents or sensationalizing their deaths in any way (9). To do so might increase the likelihood that someone who identifies with the decedents or who is having suicidal thoughts will also attempt suicide, so as to be similarly glorified or to receive similar positive attention. One community that had had several suicides among high school students installed a "memorial bench" on the school grounds, with the names of the suicide victims engraved on the bench. Although this gesture was undoubtedly intended to demonstrate sincere compassion, such a practice is potentially very dangerous.

Spokespersons should also avoid vilifying the decedents in an effort to decrease the degree to which others might identify with them. In addition to being needlessly cruel to the families of the decedents, such an approach may only serve to make those who do identify with the decedents feel isolated and friendless. If the suicide victims are of school age, the deaths should be announced privately to those students who are most likely to be deeply affected by the tragedy--close friends, girl friends, boy friends, and the like. After the teachers are briefed (see Section V), the suicide deaths might be announced to the rest of the students either by individual teachers or over the school loudspeaker when all the students are in homeroom or some other similarly small, supervised groups. Funeral services should not be allowed to unnecessarily disrupt the regular school schedule.

VII. Persons who may be at high risk should be identified and have at least one screening interview with a trained counselor; these persons should be referred for further counseling or other services as needed.

A. Active measures:

Identify relatives (siblings, parents, children) of the decedents and provide an opportunity for them to express their feelings and to discuss their own thoughts about suicide with a trained counselor.

Similarly, identify and provide counseling for boy friends/girl friends, close friends, and fellow employees who may be particularly affected by the deaths.
a) Strategies to identify associates of the decedents or others who may be at increased risk of suicide might include: identifying the pall bearers at the funeral services of the decedent(s); checking with the funeral director regarding visitors who seemed particularly troubled at the services; keeping a list of hospital visitors of suicide attempters; and verifying the status of school absentees in the days following the suicide of a student.

In the case of suicides among school-age persons, enlist the aid of teachers and students in identifying any students whom they think may be at increased risk of suicide.

Identify and refer past and present suicide attempters for counseling if these persons were substantially exposed to suicide (see below), regardless of whether they were close friends of the decedents. a) "Substantially exposed" persons would include, for example, students in the same high school or workers at the same job location as the suicide victims. In past suicide clusters, such persons have committed or attempted suicide even though they did not personally know the victims who had committed suicide earlier in the cluster.

Identify and refer persons with a history of depression or other mental illness or with concurrent mental illness who were substantially exposed to suicide (see Section VII.A.4.a, above).

Identify and refer persons whose social support may be weakest and who have been substantially exposed to suicide. Examples of such persons include: a) students who have recently moved into the school district
b) students who come from a troubled family c) persons who have been recently widowed or divorced, or who have recently lost their jobs.

B. Passive measures:

Consider establishing hotlines or walk-in suicide crisis centers--even temporarily--if they do not already exist in the community; announce the availability of such hotlines/centers.

Provide counselors at a particular site (such as school, church, community center) and announce their availability for anyone troubled by the recent deaths. a) If suicides have occurred among school-age persons, provide counselors in the schools if possible; announce their availability to the students.

Enlist the local media to publish sources of help--hotlines, walk-in centers, community meetings, and other similar sources.

Make counseling services available to persons involved in responding to the crisis as well.

Comment. The recommendations for active measures to identify persons at high risk of suicide are based largely on scientific evidence that certain factors increase the risk of suicide. For example, mental illness (especially depressive illness) (10) and a history of past suicide attempts (11) are both strong risk factors for suicide. Certain sociologic factors such as unemployment (12), being widowed or divorced (13,14), other bereavement (15,16), and mobility (17), also appear to be important risk factors for suicide.
The role of imitation or "contagion" is, as we noted above, less well-established than the risk factors listed above. Nevertheless, the anecdotal evidence from suicide clusters is quite compelling, and several of the specific suggestions made above regarding who should be considered for screening are based on such evidence. For example, in one high school-based cluster, two persons who committed suicide late in the cluster had been pall bearers at the funerals of suicide victims who had died earlier in the cluster. It is likely that persons who are exposed to one or more of the aforementioned risk factors--depression or recent loss, for example--may be more susceptible to a contagious effect of suicide.

VIII. A timely flow of accurate, appropriate information should beprovided to the media.
A. Make certain that a single account of the situation is presented by appointing one person as information coordinator. This person's duties would include:

meeting frequently with designated media spokespersons (see Section VIII-B, below) to share news and information, and to make certain that the spokespersons share a common understanding of the current situation

"directing traffic"--referring requests for particular types of information to selected media spokespersons or to others (e.g., academic resources)

maintaining a list of local and national resources for appropriate referral of media inquiries

scheduling and holding press conferences.

B. Appoint a single media spokesperson from each of the relevant community sectors--public health, education, mental health, local government, and the like.

Each sector represented on the coordinating committee should have a spokesperson. This person is not necessarily the same representative who serves on the coordinating committee.

Spokespersons from additional agencies or public groups may be designated as appropriate.

C. These spokespersons should provide frequent, timely access to the media and present a complete and honest picture of the pertinent events. When appropriate, regularly scheduled press conferences should be held.

Avoid "whitewashing"--that is, saying that everything is under control or giving other assurances that may later prove unwarranted. This practice would undermine the credibility of the community spokespersons.

Discuss the positive steps being taken, and try to get the media to help in the response by reporting where troubled persons can go for help.

D. The precise nature of the methods used by decedent(s) in committing suicide should not be disclosed. For example, it is accurate to state that an individual committed suicide by carbon monoxide poisoning. But it is not necessary--and is potentially very dangerous--to explain that the decedent acquired a hose from a hardware store, that s/he hooked it up to the tail pipe of a car, and then sat in a car with its engine running in a closed garage at a particular address. Such revelations can only make imitative suicides more likely and are unnecessary to a presentation of the manner of death.

E. Enlist the support of the community in referring all requests for information to these spokespersons. Comment. If some suicide clusters spread through "contagion," the vehicle for such contagion is information, perhaps sensationalized information, about the suicides that have occurred. The role of the media in causing or exacerbating a suicide cluster is controversial, but some investigators will no longer even discuss an evolving suicide cluster with media representatives for fear that newspaper or television accounts will lead to further suicides. Although a definitive understanding of this issue must be left to future research, it is prudent in the meantime to try to prevent needlessly sensationalized or distorted accounts of evolving suicide clusters.

The media spokespersons should meet as a group and with the information coordinator regularly; under certain circumstances, they may need to check with each other several times a day. Gaining the cooperation of the community in referring requests to these spokespersons is a formidable task and will require early and ongoing efforts if it is to be accomplished. It may be helpful to assure community members that it is all right to say "no" to media phone calls or requests for interviews.

The cooperation of parents is especially essential in the context of a school-based suicide cluster. Interviews with students about the suicide of one or more of their peers can be very stressful. Parents who do not wish to have their children interviewed may be able to prevent such interviews by refusing to sign a release statement. A handout addressing how media requests should be handled might be prepared and distributed to parents, students, and other appropriate persons.

Gaining the cooperation of media representatives in this regard is also a formidable task. In the midst of a crisis, the frequent presentation of accurate and credible information is the best means of establishing such cooperation. It is preferable, however, to develop a working relationship with local media representatives before a crisis occurs.

IX. Elements in the environment that might increase the likelihood of further suicides or suicide attempts should be identified and changed.

Comment. If a particular method or site was used in previous suicides or suicide attempts, modification efforts should be addressed to these methods or sites first. For example, if the decedent(s) jumped off a particular building, bridge, or cliff, barriers might be erected to prevent other such attempts. If the decedent(s) committed suicide by carbon monoxide poisoning in a particular garage, access to that garage should be limited or monitored or both. If the decedent(s) committed suicide with a firearm or by taking an overdose of drugs, then restricting immediate access to firearms or to potentially lethal quantities of prescription drugs should be considered. In the case of suicides committed in jail, belts and other articles that may be used to commit suicide by hanging should be removed, and vigilance over the jail cells should be increased. Some of these modifications can be accomplished directly through the efforts of the coordinating committee, while others (limiting access to drugs or firearms) can only be suggested by the committee for others to consider.
Although immediate environmental modifications may be suggested by methods used in previous suicides, the modifications need not be limited only to those methods. If there is concern, for example, that the risk of suicide for particular adolescents may have been increased because of the influence of previous traumatic deaths, then common methods of suicide--firearm injury, carbon monoxide poisoning,overdose--should be made temporarily unavailable if possible. The coordinating committee should consider a variety of potentially relevant environmental factors in developing this element of the response strategy.

X. Long-term issues suggested by the nature of the suicide cluster should be addressed.

Comment. Common characteristics among the victims in a given suicide cluster may suggest that certain issues need to be addressed by the community. For example, if the decedent(s) in a particular suicide cluster tended to be adolescents or young adults who were outside the main stream of community life, efforts might be made to bring such persons back into the community. Or, if a large proportion of the suicide attempters or completers had not been suspected of having any problems, then a system should be developed (or the present system altered) so that troubled persons could receive help before they reached the stage of overt suicidal behavior.
Communities should consider establishing a surveillance system for suicide attempts as well as completed suicides. Suicide-attempt surveillance systems are almost nonexistent; yet the benefits of such systems are potentially great. In the context of a suicide cluster, such a system would allow persons who have attempted suicide in the past to be identified. Such persons are known to be at high risk of further suicide attempts. It would also allow for ongoing identification of high-risk persons during and after the current crisis. Communities should consider establishing suicide-attempt surveillance systems in their local emergency departments or wherever appropriate.

This plan should be modified according to the community's experience with its operation. Parts of the plan that have worked well in a given setting should be stressed in the updated plan, and parts that were inapplicable or that did not work should be excluded. Finally, the Centers for Disease Control requests that communities that use the plan notify us of their experiences with the plan to allow appropriate updating of this document. Please write to:

Chief, Intentional Injuries Section
Mailstop F-36
Centers for Disease Control
1600 Clifton Road NE
Atlanta, GA 30333

References

Gould MS, Wallenstein S, Kleinman M. A Study of time-space clusteing of suicide. Final report. Atlanta, Georgia: Centers for Disease Control, September 1987; (contract no. RFP 200-85-0834).

Robbins D, Conroy C. A cluster of adolescent suicide attempts: is suicide contagious? J Adolesc Health Care 1983;3:253-5.

Davidson L, Gould MS. Contagion as a risk factor for youth suicide. In: Report of the Secretary's Task Force on Youth Suicide, vol. II: Risk factors for youth suicide. Washington, DC: US Government Printing Office (in press).

Phillips DP, Carstensen LL. Clustering of teenage suicides after television news stories about suicide. N Engl J Med 1986;315:685-9.

Gould MS, Shaffer D. The impact of suicide in television movies: evidence of imitation. N Engl J Med 1986;315:690-4.

Phillips DP, Paight DJ. The impact of televised movies about suicide: a replicative study. N Engl J Med 1987;317:809-11.

Berman AL. Fictional suicide and imitative effects. Am J Psychiatry 1988 (in press).

Dunne EJ, McIntosh JL, Dunne-Maxim K, eds. Suicide and its aftermath: understanding and counseling the survivors. New York: WW Norton & Company, 1987:151-82.

Lamb F, Dunne-Maxim K. Postvention in schools: policy and process. In: Dunne EJ, McIntosh JL, Dunne-Maxim K, eds. Suicide and its aftermath: understanding and counseling the survivors. New York: WW Norton & Company, 1987:245-60, and 248.

Hagnell O, Lanke J, Rorsman B. Suicide rates in the Lundby study: mental illness as a risk factor for suicide. Neuropsychobiology 1981;7:248-53.

Paerregaard G. Suicide among attempted suicides: a 10-year follow-up. Suicide 1975;5:140-4.

Platt S. Suicidal behavior and unemployment: a literature review. In: Wescott G, Svensson P-G, Zollner HFK, eds. Health policy implications of unemployment. Copenhagen: World Health Organization, 1985:87-132.

Monk M. Epidemiology of suicide. Epidemiol Rev 1987;9:51-69.

Smith JC, Mercy JA, Conn JM. Marital status and the risk of suicide. Am J Public Health 1988;78:78-80.

MacMahon B, Pugh TF. Suicide in the widowed. Am J Epidemiol 1965;81:23-31.

Bunch J, Barraclough B, Nelson B, et al. Suicide following bereavement of parents. Soc Psychiatry 1971;6:193-9.

South SJ. Metropolitan migration and social problems. Social Science Quarterly 1987;68:3-18.

*Participants in the workshop included: Eugene Aronowitz, Ph.D., Department of Community Mental Health, Westchester County, N.Y.; Ines Assafi, M.S.W., Jefferson County Mental Health Center, Lakewood, CO; Dennis Blomquist, Guidance and Counseling for Mankato Public Schools, Mankato, MN; Ronald G. Burmood, Ph.D., Omaha Public Schools, Omaha, NE; Betsey S. Comstock, M.D., Baylor College of Medicine, Houston, TX; Karen Dunne-Maxim, R.N., M.S., New Jersey Youth Suicide Prevention Project, Princeton Junction, NJ; John W. Farrell, M.S.W., New Jersey State Department of Health, Trenton, NJ; Louis C. Goetting, IV, South Brunswick Township, Monmouth Junction, NJ; Madelyn S. Gould, Ph.D., New York State Psychiatric Institute/Columbia University, New York, NY; Myra Herbert, M.S.W., Fairfax Public Schools, Fairfax, VA; Karen Hymbaugh, Indian Health Service, Albuquerque, NM; Elizabeth N. Jones, Ed.S., American Association of Suicidology, Gainesville, FL; Alan J. Krumholz, M.D., Leominster Hospital Medical Center, Leominster, MA; James A. Mercy, Ph.D., CDC; Patrick W. O'Carroll, M.D., CDC; William Parkin, D.V.M., New Jersey State Department of Health, Trenton, NJ; Michael Petrone, M.D., New Jersey State Department of Health, Trenton, NJ; Julie Rayburn- Miller, M.S.W., Association of State and Territorial Health Officers, Jefferson City, MO; Jon Shaw, M.D., National Institute of Mental Health, Rockville, MD; Carole E. Steele, R.N., M.S., Crisis Center of Collin County, Plano, TX; and John A. Steward, M.P.H., CDC.
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Recommendations for a Community Plan/Prevention of Suicide Clusters

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CDC Recommendations for a Community Plan for the Prevention and Containment of Suicide Clusters