Factors that increased the trend 

The root causes of suicide are complex in nature and difficult to understand. This project has identified several root causes that are believed to be foundational in contributing to suicide and subsequently, promising in helping to reduce and prevent suicide. 
The four primary root causes this Project has identified are:

(1) Mental Health Stigma -

Mental health stigma isnegative, harmful or prejudice attitudes, values or beliefs about mental illness including those related with suicide. Mental health stigma can be seen at the societal and individual level.  Stigma is correlated with isolation, low self-esteem, low social support and poor quality of life. Perceived or self-stigma is when an individual internalizes negative attitudes and perceptions of discrimination (Graham, 2013).
Stigmatizing beliefs about suicide are held by a broad range of individuals within society in the form of unwarranted assumptions, avoidance, friendship-loss and social rejection.  The low value placed on mental health by mainstream society nurtures attitudes and discriminatory behaviors that foster the stigma associated with suicide.  Stigma and other contributing factors create barriers to preventative services and diminish self-help seeking behaviors, which can significantly impact treatment outcomes.  At both the societal and individual level, there is a lack of mental health awareness and education.  Media regularly plays a role in perpetuating stereotypes and stigma associated with suicide.  Mental health stigma is also widespread in the medical profession, in part because it is given low priority during the training of doctors and providers (Graham, 2013).

California Assembly Bill 2273, noted on the bottom right, was written to ensure that any active duty military member who attempts to take his/her own life, cannot be punished or Court Martialed under Article 134 of the Manual for Court Martial. Previously, attempted suicides were criminalized, and completed suicides were not.  This type of action increased the stigmatization of mental illness among military personnel.  Assembly Bill 2273 also ensures that individuals attempting suicide in the armed forces will be referred to the appropriate resources for treatment and care, not a jail cell.

Contributing Factors

• Substance Use and Abuse
• Uninformed/Inexperienced Providers
• Uninformed/Uneducated Clients
• Untreated/Undiagnosed Mental Illness

Compound Cause

• Barriers to Access
• Cultural and Religious Values
• Isolation
• Lack of Mental Health Awareness and/or Education
• Social Norm to Place Low Value on Mental Health

First Level Cause

• Insufficient Protective Factors

(2) Decline in Connectedness

Decline in Connectedness Connectedness is defined by theamount of social closeness among individuals or groups of people and can refer to Connectedness among individuals, families, community sectors or society. It can also be measured by the amount of community assets shared with one another.  Related to connectedness, social capital refers to the level of trust a person has in his/her "community." Social capital denotes the level of social integration and availability of social organizations or community activities.   A decline in connectedness is among the root causes of suicide in Stanislaus County.
Overall, studies show that connectedness is an important attribute for suicide prevention and is a protective factor. Connectedness protects against suicidal behaviors by decreasing isolation and increasing coping, problem-solving and self-help seeking skills.  If risk factors or life stresses, whether acute or chronic, outweigh protective factors or coping skills the risk of suicide increases.  For example, economic hardship or financial strain, such as unemployment, earning a non-livable wage, difficulty covering medical, food and housing costs may increase the risk of suicide (Stone, et al., 2017).  Additionally, without living wages, people must meet basic needs by working longer hours, sometimes at multiple workplaces, which leaves little time for family, faith, civic or community activities (Konigsburg, 2017). Earning a livable wage and escaping poverty then sustains livelihoods, restores human dignity and builds connectedness. With financial security, individuals can participate in family and community activities, therefore increasing the amount of connectedness as a protective factor (Konigsburg, 2017).

California Assembly Bill 2845, noted on the bottom right, seeks to improve the connectedness and social supports of youth negatively impacted by discrimination, harassment, intimidation and bullying in the school setting.  The bill connects youth to resources and fosters healthy relationships with faculty and family, and helps bolster protective factors and increase connectedness.
Substantially higher risk for suicide and suicidal behaviors has been found among lesbian, gay and bisexual youth.  A lack of connectedness can hinder help-seeking behavior and consequently put the individual at more risk.  The Youth Risk Behavior Surveillance System (YRBSS) survey reports on a number of youth behaviors and health indicators.  During the reporting period of September 2014 through December 2015, questions regarding sexual identity and sexual orientation were added to the survey, yielding valuable data on LGB youth that had previously been unavailable.

The national survey found that 42.8% of LGB respondents had seriously considered attempting suicide; 38.2% had made a plan on how to attempt; and 29.4% attempted suicide.  Additionally, the survey found that 9.4% of LGB respondents who attempted suicide were subsequently treated by a doctor or nurse for self-inflicted injuries.(L. Kann, et al.,2016)  Furthermore, the U.S. Dept. of Health and Human Services (2012) cited that suicide attempt rates for LGB youth were 3 to 4 times higher than heterosexual youth, and 8 to 10 times higher for transgender adults compared to other adults.

Contributing Factors

• Domestic Violence
• Fatherlessness
• Lack of Affordable Housing
• Limited Livable Wage
• Non-Nuclear Family Environment
• Substance Use and Abuse

Compound Cause

• Breakdown of Family and Community
• Cultural and Religious Values
• Economic Hardship, Poverty, Impoverishment
• Isolation
• Lack of Mental Health Awareness and/or Education
• Social Norm to Place Low Value on Mental Health

First Level Cause

• Insufficient Protective Factors

(3) Challenges of Sharing Information Across Sectors

Challenges of Sharing Information Research suggests services are maximized when care systems and providers are set up to effectively and efficiently share information. Access to preventative services is a contributing factor related to the underuse of preventative services and can lead to untreated suicidal behaviors.  Improved access to timely, affordable and quality services is critical to suicide prevention (Stone, et.al, 2017).
Strong formal relationships among agencies, community organizations, service providers and systems of care can increase the access and delivery of services, as well as promote the value of mental health and wellness (CDC Connectedness ASAP, 2011).  Formal relationships also establish a pathway for information to be shared across agencies, organizations and providers.

The ability to provide coordinated care is rooted in the ability to share vital information in a timely and ethical manner (SPRC, 2013). Information sharing and coordination of care across all types of providers is paramount to effective suicide prevention.  However, agencies, service providers and systems of care face many challenges and barriers in their ability to share vital care information.  Service delivery systems are often complex and have limited ability to share information due to federal, state and/or other policies.  Additionally, there is a lack of resources available to address the complex challenges and barriers that impede the ability to share information across public and private sectors.

Contributing Factors

• Complex Service Systems
• Federal and State Policy Impacts on Local Service Delivery
• Uninformed/Inexperienced Providers
• Untreated/Undiagnosed Mental Illness

Compound Cause

• Barriers to Access
• Service Capacity Limitations

First Level Cause

• Underutilized Preventative Services

(4) Lack of Shared Best Practices and Standards

Lack of Shared Best Practices and Standards A best practice or standard of care is defined as a level and type of care that a reasonably competent and skilled professional, with a similar background and education would have provided. The continuity of care focuses on quality of care and ongoing cooperative care-management with a shared goal of high quality, cost-effective care.

The lack of a shared best practice or approach, as well as the lack of a standard or continuity of care for suicide prevention, intervention and after-attempt care is a root cause of suicide in Stanislaus County.  Shared best practices and standards of care  have been found to substantially reduce the number of suicide deaths and attempts (Suicide Prevention Resource Center, 2013).

California Assembly Bill 2246, noted on the right, mandates that all public and private schools adopt suicide prevention policies.   Specifically, the polices must address procedures relating to suicide prevention, intervention and postvention. Additionally, the bill requires faculty to be trained in suicide prevention.  This policy can act as a model best practice for suicide prevention that could be replicated in other community sectors.

California Assembly Bill 89 mandates that all new applicants seeking a licensure for psychologist must first complete a minimum of six hours of coursework or applied experience in suicide risk assessment and intervention.  This mandate, effective January 1, 2020, also applies to currently licensed psychologists and those who wish to reinstate or reactivate a license.  This policy establishes a standard best practice for suicide risk assessment and intervention among psychologists.

Contributing Factors

• Complex Service Systems
• Federal and State Policy Impacts on Local Service Delivery
• Uninformed/Inexperienced Providers
• Untreated/Undiagnosed Mental Illness

Compound Cause

• Cultural and Religious Values
• Barriers to Access
• Lack of Mental Health Awareness and/or Education

First Level Cause

• Insufficient Protective Factors 

Click on the link for a complete copy of the Stanislaus County Suicide Prevention Needs Assessment.  StanCoSuicidePreventionNeedsAssessment2ndEditionJUNE2018.pdf

Who are partners that could help decrease the trend? 

• Stanislaus County Behavioral Health and Recovery Services (Prevention and Early Intervention)
• Stanislaus County Office of Education
• City Schools and Local School Districts
• Modesto Junior College
• Stanislaus County High Schools
• Central Valley Pride Center
• Center for Human Services
• National Alliance on Mental Illness (NAMI)
• American Foundation Suicide Prevention (AFSP)
• Hospitals - Sutter Health, Kaiser, Golden Valley, Doctors Hospital, Behavioral Health Center
• Law Enforcement - Modesto Police Department (Crisis Intervention), Stanislaus Sherriff's Department, and Turlock Police Department, Ceres Police Department
• First Responders and Mental Health Clinicians
• Coroner Office - Death Review Team, David Lopez
• Faith Based Organizations - Clergy, Pastor Group - Patterson, Catholic Charities, Modesto Group - City Ministry Network, Turlock Evangelical Association of Minister "Team" Pastor Ken Van Vielt
• Community Hospice (Modesto)
• Covenant Care Hospice (Turlock)
• Jessica's House (Turlock)
• Family Resource Center
• Workforce Development Resources
• Veterans and Aging Services
• Employers, Labor/Unions, Civic Organizations, Workforce Development Offices
• Chamber of Commerce