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United States Air Force Suicide Prevention Program

The United States Air Force Suicide Prevention Program (AFSPP) is a population-oriented approach to reducing the risk of suicide. The Air Force has implemented 11 initiatives aimed at strengthening social support, promoting development of social skills, and changing policies and norms to encourage effective help-seeking behaviors. AFSPP's 11 initiatives include:

  • Leadership Involvement
  • Suicide Prevention in Professional Military Education
  • Guidelines for Use of Mental Health Services
  • Community Preventive Services
  • Community Education and Training
  • Investigative Interview Policy
  • Critical Incident Stress Management
  • Integrated Delivery System (IDS)
  • Limited Privilege Suicide Prevention Program
  • Behavioral Health Survey
  • Suicide Event Surveillance System

Descriptive Information

Areas of Interest Mental health promotion
Outcomes Review Date: July 2006
1: Suicide prevention
Outcome Categories Suicide
Ages 18-25 (Young adult)
26-55 (Adult)
Genders Male
Female
Races/Ethnicities Data were not reported/available.
Settings Workplace
Geographic Locations No geographic locations were identified by the developer.
Implementation History The U.S. Air Force first implemented the program with active-duty personnel in late 1996. Reported results are based on data from the exposed cohort (1997-2002) and an unexposed cohort (1990-1996). A follow-up study examined data through 2007.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: No
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects Relative risk for mild family violence, defined as exposure to potentially harmful behavior with no readily apparent physical or emotional harm, increased 18% in the AFSPP study. This may have been related to increased identification due to an emphasis on outreach and earlier identification of distress.
IOM Prevention Categories Universal

Quality of Research
Review Date: July 2006

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Knox, K. L., Litts, D. A., Talcott, G. W., Feig, J. C., & Caine, E. D. (2003). Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the U.S. Air Force: Cohort study. British Medical Journal, 327, 1376-1381.  Pub Med icon

Supplementary Materials

Air Force Suicide Prevention Program. (2001). The Air Force Suicide Prevention Program: A description of program initiatives and outcomes. [AFPAM 44-160]. Washington, DC.

Air Force Suicide Prevention Program: 11 initiatives [Handout]

Air Force Suicide Prevention Program Web site, http://afspp.afms.mil/

Litts, D. A. (2002). Air Force Suicide Prevention Program: A population-based, community approach. U.S. Department of Health and Human Services Best Practice Initiative.

New Freedom Commission on Mental Health (2003). Achieving the Promise: Transforming Mental Health Care in America.

Pflanz, S. (n.d.). Air Force Suicide Prevention Program. Unpublished manuscript.

Pflanz, S. (n.d.). Air Force Suicide Prevention Program (AFSPP) Overview. Unpublished manuscript.

Taylor, G. P. (2003). Air Force Instruction 44-154: Suicide and violence prevention education and training.

Outcomes

Outcome 1: Suicide prevention
Description of Measures Suicide prevention was indicated by epidemiological surveillance. Relative risk was assessed using mortality data routinely collected for other purposes.
Key Findings Personnel exposed to the program experienced a 33% reduction of risk of committing suicide compared with personnel prior to implementation (p < .001). Compared with Air Force personnel during the 1990-1996 time period, personnel exposed to the program in 1997-2002 also experienced:

  • A 54% reduction of risk for severe family violence (p < .0001)
  • A 51% reduction of risk for homicide (p = .05)
  • A 30% reduction of risk for moderate family violence (p < .0001)
  • An 18% reduction of risk for accidental death (p = .05)
Studies Measuring Outcome Study 1
Study Designs Quasi-experimental
Quality of Research Rating 2.8 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 18-25 (Young adult)
26-55 (Adult) 		84% Male
16% Female 		Data not reported/available

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures 		Validity
of Measures 		Fidelity Missing
Data/Attrition 		Confounding
Variables 		Data
Analysis 		Overall
Rating
1: Suicide prevention 1.5 2.5 2.5 4.0 3.0 3.5 2.8

Study Strengths

The quasi-experimental design is probably the most logical and practical approach for studying suicide prevention. The cohort study eliminates potential problems with attrition and missing data. Interpretations of possible confounds were conservative. The design and methods were strong enough to support results showing that the intervention decreases the relative risk of suicide.

Study Weaknesses

There is limited documentation on the reliability and validity of data on cause of death. In a quasi-experimental design, researchers have limited control over potential confounds.
Readiness for Dissemination
Review Date: July 2006

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Air Force Suicide Prevention Program Web site, http://afspp.afms.mil/

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials 		Training and Support
Resources 		Quality Assurance
Procedures 		Overall
Rating
2.7 1.5 1.0 1.7

Dissemination Strengths

Implementation materials are clear and easily accessible through the program Web site. The Leader's Guide to Managing Personnel in Distress provides extensive information on behavioral signs of specific problems that may be affecting personnel, the "do's and don'ts" of early intervention, and community resources for referral. One slide presentation outlines the steps for becoming an instructor; the program's "Integrated Service Delivery" approach gives guidance to leaders on moving concerns through the chain of command, understanding policy that serves as supervisory direction, and consulting community agencies to get supervision or consultation on specific issues. Quality assurance is supported by information on the reasonable steps for demonstrating proficiency as an instructor.

Dissemination Weaknesses

Most of the implementation materials provided discuss the program and the need; very little focus is placed on how implementers can make use of this intervention. No information is provided on how instructors or coaches/supervisors are selected, trained, and coached to become effective trainers and coaches for new instructors. No information is presented about how outcome data is collected to measure the impact of briefings and early interventions. No clear process is described for ensuring implementation fidelity.
Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Implementation materials, instructions, and published guidance Free Yes
Training material examples Free Yes
Technical assistance Free No
Program checklist Free Yes
Program inspection Free No

Additional Information

The Air Force employs one full-time suicide prevention program manager for a population of roughly 330,000 Airmen. At each of 81 installations, an individual is assigned oversight of the base suicide prevention program as part of his or her duties (per base, an estimated 100 hours per year). Leadership time is spent at all levels of command reviewing data, policy, and programs related to suicide prevention. Lastly, every employee participates in 15 minutes of suicide prevention education every year, representing another important cost.
Replications

No replications were identified by the developer.
Contact Information

To learn more about implementation or research, contact:
Michael D. McCarthy, Maj.
(703) 681-7603
Michael.McCarthy@pentagon.af.mil

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.