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The CDC has issued new guidance -- -- on and to clusters of suicide, as tens of thousands of lives are lost to suicide each year in the U.S.

Though suicide clusters are rare, they "can have unique characteristics and challenges," and "are often highly publicized and can have considerable negative effects on the community, including prolonged grief and elevated fear and anxiety about further deaths," Michael Ballesteros, PhD, of CDC's National Center for Injury Prevention and Control (NCIPC), and colleagues wrote in (MMWR).

In response, the CDC has outlined steps an agency or community can take to assess and investigate suspected suicide clusters as well as a new set of recommendations for responding to them.

For investigating suspected suicide clusters, three primary steps were detailed by Eva Trinh, PhD, of the NCIPC, and colleagues in . These included conducting a preliminary assessment to determine if a formal assessment is warranted; a formal assessment of the suspected cluster to determine whether it meets the definition of a cluster; and an investigation to identify similarities in cases that can guide community response.

Initial information to be collected includes types of cases (suicide attempts or deaths); geographic and physical locations of cases; relation of cases to each other; demographic characteristics; and risk factors or precipitating circumstances, such as mental health condition or exposure to other suicide attempts or deaths. A committee of experts should then be convened to investigate the suspected cluster to determine whether to conduct a formal assessment.

Formal assessment includes developing a case definition, determining the time frame of cases, identifying data sources, and ultimately determining whether to conduct further investigation.

The third step consists of developing and implementing an investigation plan, which may include reviewing the literature on suicide clusters, gathering qualitative data through in-depth interviews or focus groups of people directly connected to cases, determining a comparison group, and comparing distributions of epidemiologic characteristics between recent and previous cases.

Ultimately, a final report should be developed describing procedures, findings, and recommendations that "reflect the community's culture and environment and decisions made each step of the way," Trinh and colleagues wrote. "These findings can inform a community response plan to prevent further suicides."

In responding to suicide clusters once they're identified, it was noted that CDC's 1988 guidance remains relevant. However, new guidance in "reorganizes, updates, and expands on that information to include new insights based on current science and public health practice attained using strategies from the original guidance," according to Asha Ivey-Stephenson, PhD, of the NCIPC, and colleagues.

The new report "provides lead agencies, in conjunction with community leaders, with information on how to best respond to a confirmed or suspected suicide cluster, including strategically tailoring a response plan based on resources, cultural context, and health equity needs of the community," they wrote.

Preparing for and responding to a suicide cluster should include reviewing guidance and developing a community-specific response plan, engaging partners in a suicide cluster coordinating committee, identifying relevant community resources, and determining the conditions under which a response plan should be implemented.

In directly responding to the suicide cluster, staff members who have integral roles in crisis response should be notified immediately. Then those who are at high risk -- including people close to decedents; those who have attempted or thought about suicide; those who are known to isolate or who lack social support; and those with a history of depression, mental illness, or other known for suicide -- should be identified, screened, and referred to support services.

It is also important to avoid glorifying suicide decedents, minimize sensationalism, and provide timely, accurate, and appropriate information to the media.

Responders should also consider the relevance and respond to the impact of social media. Since 1988, when the original guidance on suicide clusters was issued, "these technological advances have served as both a suicide cluster response tool and a potential risk to the response; however, applicability will vary by community," Ivey-Stephenson and colleagues noted.

The final step is taking action to prevent the next suicide cluster, including identifying and changing elements in the environment that might increase the likelihood of further suicides or attempts, addressing long-term issues suggested by the nature of the cluster, and considering evaluating overall response to the cluster.

Changing elements in the environment might include reducing access to lethal means among people at risk for suicide, such as through safe storage of firearms and medications, as well as policies that increase the time between thoughts of suicide and the decision to act. It might also include creating protective environments like interventions at bridges and tall buildings where people are known to die by suicide, as well as community-based policies like those that seek to reduce excessive alcohol and substance use by reducing the number of places that sell alcohol in an area.

Regarding long-term issues, "[o]ne long-term issue that often plagues communities at the societal level of the social ecological model is the stigma surrounding suicide," Ivey-Stephenson and colleagues noted.

Finally, "[w]hen feasible, conducting a post-response evaluation, similar to a disaster response after action report, could be considered to build best practices to support future responses," they wrote. "Evaluation will be important for growing the literature on responding to suicide clusters while simultaneously helping communities to be better prepared for future clusters."