Precedence for Integration of Clinical Services in Public Health Initiatives

Reduction of suicide is widely recognized as a public health priority, and reports of elevated rates among veteran and military populations have received considerable attention. Clinical services, including effective management of behavioral disorders, psychotherapy, and the use of pharmaceutical agents, have been identified as important elements in a comprehensive approach to the prevention of suicide.1 Nonetheless, the proper role of clinical services in suicide prevention programs remains unclear, with a perceived tension between diagnosis- or symptom-driven clinical management and more universal approaches. However, such tension is more likely a function of the many challenges to implementing effective clinical services to address suicide risk, including the relative lack of evidence-based clinical therapies to prevent suicide deaths, stigma associated with behavioral disorders (e.g., mood disorders, substance use disorders), and low service utilization and adherence to treatment, than inconsistencies between the missions of clinical science and population health. We view such challenges as a call to create systems of care that are more inclusive and effective in meeting the needs of individuals vulnerable to suicide than a justification for divorcing clinical services from a comprehensive public health approach to suicide. Many of the major public health achievements of the 20th century, such as the eradication of smallpox and global reductions in the incidence and consequence of paralytic poliomyelitis (polio), relied on clinical services to identify and protect vulnerable populations. For example, the eradication of smallpox would not have been possible without safe and effective strategies for vaccine delivery, and reductions in polio (while similarly related to safe and effective vaccine administration) resulted from enhanced clinical and laboratory surveillance to identify vulnerable populations and pockets of vaccine resistance.2