Suicide Prevention in Diverse Populations: A Systems and Readiness Approach for Emergency Settings

Nov 03, 2014

In the US, suicide is a leading cause of death, ranking third among youths aged 15 to 24. Rates of suicide attempts and death are highest among US Pacific Island indigenous youths. Emergency departments play a key role in suicide prevention, especially in this and other minority populations.

Suicide is a serious, preventable public health problem. In the US, suicide is a leading cause of death, ranking third among youths aged 15 to 24.1 Rates of suicide attempts and death are highest among US Pacific Island indigenous youths-70% higher than their European American counterparts.2 Emergency departments (EDs) play a key role in suicide prevention. It has been well documented that EDs may be the primary or only source for health care, especially for those in rural areas and minority populations. A recent study found that youths in rural areas were nearly 4 times more likely to use an ED for mental health care than were youths in urban areas, and they have more frequent disposition to inpatient and outpatient care.3

ED providers are in a unique position to communicate with family and friends, facilitate engagement in outpatient care, and ultimately prevent future suicide attempts. Best practice recommendations for EDs include screening for depression and suicide risk, open communication with the patient and his or her family regarding the patient’s condition and treatment options, comprehensive discharge planning, referral to appropriate outpatient services, follow-up after discharge, and continuous enhancement of provider capacity.4

Training of ED staff on suicide and mental health can not only reduce stigma but also affect quality of service and increase detection of concealed mental health problems. With respect to diverse populations, it is essential that health care professionals be trained in providing culturally competent care as well as conduct outreach to enhance trust and readiness to seek care.3

Readiness and systems approaches

In clinical practice, the concept of readiness has referred to the precondition necessary to maximize the likelihood that an intervention with an individual patient will succeed (eg, transtheoretical model).5,6 Application of readiness assessments has since expanded to community-wide interventions. The community can be seen as a larger system with varying degrees of readiness to change; this variation can impact the likelihood that a program will be successfully planned and implemented and will have the desired effect.5

Effective suicide prevention requires a systems approach that integrates community and health care services.7 This approach focuses on interconnections across factors and sectors, and it can improve health by considering the multiple elements involved in caring for community members and the many factors influencing health. By understanding how these elements operate independently as well as how they depend on one another, a systems approach can integrate people, processes, policies, and organizations to promote well-being. Therefore, the ED is part of the larger community, and concepts such as readiness must be extended to all parts of the system.


Here we describe one example of how readiness and systems concepts were applied to suicide prevention work in multiple EDs across the state of Hawaii to positively impact the statewide mental health infrastructure. While Hawaii faces typical challenges in the provision of mental health services, unique factors include the state’s geographic expanse, the majority of the state being considered rural and medically underserved, and the ethno-culturally diverse population.

The Hawaii’s Caring Communities Initiative (HCCI) ED project aims to: (1) increase ED provider knowledge of youth suicide and prevention strategies, and increase confidence/preparedness/cultural sensitivity to communicate with at-risk youths and family members; and (2) establish protocols to identify at-risk youths, refer identified youths to services, and decrease the number of youths who make future attempts. Providers from each ED were certified as Connect trainers; they then trained others at their respective sites. Connect is a comprehensive, ecological, community-based training for suicide prevention and response.8

The training has modules specific to EDs, which served as a foundation for strengthening protocols and capacity for screening, identifying, and referring at-risk patients. Most important, Connect is adaptable to be culturally relevant and allows for the inclusion of local data, case examples, and terminology.

HCCI implemented the Communities that Care (CTC) rubric to assess readiness at project sites. CTC is a universal, community-wide prevention system that has been proved to increase the adoption of interventions.9 ED assessments included a two-stage data-driven process-chart review, and interviews with internal and external stakeholders who knew the organization and community’s culture. Qualitative questions covered existing “assets” and “social capital” within the organization, assets external to the organization, anticipated challenges, and potential solutions.

Based on assessments and subsequent implementation with 17 partner hospitals, the most important elements were ascertained (Figure). Relationship-building is essential-not a process to be glossed over. This step is imperative to garner commitment from front-line staff and leadership. Relationships are also the cornerstone of engaging rural and minority communities. A purposeful assessment process goes hand in hand with relationship-building and should include a structured process for data collection.

Identification of assets allows for leveraging of resources from all levels of the social ecology and uses a cultural- and strengths-based approach that can systematically enhance prevention strategies in communities by facilitating a positive sense of belonging to a valued community.10 Resources can include assets that are tangible (eg, existing programming, funding) and intangible (eg, existing networks, partnerships). Finally, ongoing planning for sustainability requires purposeful strategies from the get-go. Sustainability is not always considered in systems and readiness approaches, but it is essential to the long-term viability of evidence-based programming.

Future directions

In both communities and health care settings, readiness needs to be addressed when starting any intervention. Here we described an innovative application of a systems and readiness framework in conjunction with an evidence-based mental health promotion program. Conducting this process with EDs can be challenging, but systematic and coordinated efforts can result in more sustainable organizational changes. Taking a systems approach, and considering the ED as part of the larger system, can also facilitate the role of the ED in promoting continuity of care. This is essential, given that the risk of suicide attempt and death are highest within 30 days after discharge.4 HCCI is looking to expand this approach into the primary care setting.

This article was originally posted on 8/14/2014 and has since been updated.


Dr Sugimoto-Matsuda is Assistant Professor of Psychiatry, University of Hawaii at Manoa, John A. Burns School of Medicine in Honolulu. Mr Rehuher is Assistant Program Manager, University of Hawaii at Manoa, John A. Burns School of Medicine in Honolulu. The above-mentioned study was supported, in part, by a grant from the Substance Abuse and Mental Health Services Administration (award number 1U79SM060394-01).


1. Centers for Disease Control and Prevention. Suicide Prevention: A Public Health Issue. Atlanta: Centers for Disease Control and Prevention, Division of Violence Prevention, National Center for Injury Prevention and Control; 2012. Accessed August 13, 2014.

2. Else IR, Andrade NN, Nahulu LB. Suicide and suicidal-related behaviors among indigenous Pacific Islanders in the United States. Death Stud. 2007;31:479-501.

3. Matsu CR, Goebert D, Chung-Do JJ, et al. Disparities in psychiatric emergency department visits among youth in Hawai’i, 2000-2010. J Pediatr. 2013;162:618-623.

4. Suicide Prevention Resource Center. Continuity of Care for Suicide Prevention: The Role of Emergency Departments. Waltham, MA: Education Development Center, Inc; 2013.

5. Parker RN, Alcaraz R, Payne PR. Community readiness for change and youth violence prevention: a tale of two cities. Am J Community Psychol. 2011;48:97-105.

6. Prochaska JO, Redding CA, Evers KE. The transtheoretical model and stages of change. In: Glanz K, Rimer BK, Viswanath K, eds. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San Francisco: Jossey-Bass; 2008:97-121.

7. National Action Alliance: Clinical Care and Intervention Task Force. Suicide Care in Systems Framework. Washington, DC: National Action Alliance; 2011.

8. Suicide Prevention Resource Center. Best Practices Registry Section III: Adherence to Standards. Connect Suicide Prevention/Intervention Training. Waltham, MA: Education Development Center, Inc; 2007.

9. Hawkins JD, Catalano FR, Arthur MW. Promoting science-based prevention in communities. Addict Behav. 2002;27:951-976.

10. Guerra NG, Bradshaw CP. Linking the prevention of problem behaviors and positive youth development: core competencies for positive youth development and risk prevention. In: Guerra NG, Bradshaw CP, eds. Core Competencies to Prevent Problem Behaviors and Promote Positive Youth Development: New Directions for Child and Adolescent Development. San Francisco: Jossey-Bass; 2008:1-17.