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Universal Approaches to Youth Suicide Prevention 

Universal Approaches to Youth Suicide Prevention
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Universal Approaches to Youth Suicide Prevention
DOI:
10.1093/9780195173642.003.0023
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date: 14 December 2018

In this chapter, we focus on suicide prevention programs that have taken a universal approach, targeting youth in specific settings regardless of individual risk factors. One particularly widespread approach targets youth where they are most accessible—in the schools. Although the ultimate goal of all suicide prevention programs is to reduce death by suicide, school-based programs typically focus on more proximal outcomes.

Two broad types of universal prevention programs have been especially common. The first includes educational programs that aim to increase students' knowledge and awareness about suicidal behavior, encourage troubled students to seek help, and improve recognition of at-risk students by teachers, counselors, and other “gatekeepers” within the school or community settings. In the second category are screen-ing programs that seek to identify and refer to treatment youth who are at risk for suicidal behavior.

In each category, suicide prevention efforts have been separately designed for high school and college students. In the following pages, we summarize these universal programs, identifying for each broad type the underlying assumptions and specific program examples, and providing a summary critique of the approach.

SUICIDE AWARENESS AND EDUCATION PROGRAMS

Assumptions

A wide range of suicide education and awareness programs have been developed; these are summarized in Table 22.1 The key assumptions underlying such programs are that the conditions that contribute to suicide risk in adolescents and young adults often go unrecognized, undiagnosed, and untreated, and that educating students and gatekeepers about the warning signs for suicide and appropriate responses will result in better identification of at-risk youth, and an increase in help seeking and referrals for treatment.

Table 22.1 Suicide Education Programs

Reference

Intervention

Study Design

Program Length

Sample Size

Comments

Spirito et al., 1988

Samaritan-based program

Nonrandom pre–postcontrol group design

8 hr

Experimental: 291 high school students

Control: 182 high school students

Program-exposed group demonstrated increase in knowledge

Females increased knowledge more than males

Overholser et al., 1989

Samaritan-based program with didactics, handouts, discussion, and role-playing

Nonrandom pre–postcontrol group design

5 health classes

Experimental: 215 ninth-grade students from two schools

Control: 256 ninth-grade students from one school

53% male from suburban middle class

Gender and personal experience related to students' knowledge and attitudes at baseline and after the program

More positive effect of program for females and slightly negative in some aspects for males

Students who knew suicidal peer were more likely to increase knowledge

All students except males with personal experience with suicidal behavior had decreased negative attitudes

No comparisons with controls presented

Shaffer et al., 1990

Didactics and discussion led by trained, regular education classroom teachers

Nonequivalent control group with 2×2 (attempt yes/no×program yes/no) pre–post design

1–3 hr, depending on school

Initial sample: N = 1,551 ninth graders

Final sample:

N = 63 suicide attempters (35 program/28 control)

N = 910 nonattempters (489 program/421 Control)

Majority felt others should participate in program

Changes in knowledge and attitudes tended to be in intended direction

Male attempters more likely than nonattempters to feel uncomfortable dealing with friends' problems, to know someone upset by program, and to discourage participation

Shaffer et al., 1991

Vieland et al., 1991

Didactic instruction and discussion

Pretest–posttest design with comparison group

Follow-ups at 1 month and of a subsample at 18 months

3 different suicide-awareness programs, each lasting 3–4 hr, focusing on symptom identification and help seeking; differences between programs in use of teachers and focus on help seeking, problem solving, or mobilizing networks

11 schools

n = 758 from 6 program schools (2 for each program)

n = 680 from 5 control schools

9th and 10th graders

5 urban

2 suburban

4 rural/suburban

Reaction to program was good

Females and nonwhite ethnic groups rated programs more highly

Base knowledge high; exposure increased controversial beliefs supported by the programs

Programs increased knowledge about where to get help but did not improve help-seeking behavior

Kalafat & Elias, 1994

Adolescent Suicide Awareness Program (ASAP)

Didactics and discussion program

Solomon four-group design

3 health class periods

253 suburban 10th graders

Increased knowledge about warning signs

Improved attitudes about help seeking

More likely to talk about a friend's suicidal behavior and refer for help

Kalafat & Gagliano, 1996

ASAP

Didactics, discussion, and simulated encounters with suicidal peers

Stratified random sample

Pre–post control group

5 health class periods

109 eighth graders (whole grade)

White

n = 52 experimental

n = 57 controls

Experimental group was more likely to tell an adult about suicidal peers

Less likely to report suicidal behavior to an adult when ambiguous

Zenere & Lazarus, 1997

Didactics and discussion

Epidemiological comparison

No control group

One class in 5-year program

Reports from department of crisis management

Decreased rate of suicide completions and suicide attempts

No change in suicidal ideation

Aseltine et al., 2003

Signs of Suicide (SOS)

Video, didactics, discussion, school kit with materials for screening and parents

One group posttest only, 1-and 3-month follow-up

1–2 class periods

376 high schools postscreen

233/376 schools at 1 month

64% white

12% African American

10% Latino

27% urban

33% suburban

41% rural

21% school lunch eligible

177/376 schools at 3 months

63% completed program and evaluation

Schools reported increased help-seeking behavior of students, increased help-seeking on behalf of friend, low cost

1% of teachers thought program might have had adverse effect

Thompson, 2003a

YSPP

Needs assessment and school-based student-led campaign program

Single group(s) qualitative design

Ongoing program

Gatekeepers, crisis teams, community groups, and high school students willing to participate

Increased awareness, knowledge, and number of students advising peers to get help

Direct involvement of students in antisuicide campaign development

National Mental Health Association

Booklets and offers of help to develop mental health programs

Not yet evaluated

Booklet

Distributed to college students, administrators, and student leaders, and on Web site

Not yet evaluated

Aseltine & DeMartine, 2004

SOS

Video and discussion guide

Columbia Depression Screen (CDS)

Posttest only

Stratified random assignment with delayed-treatment comparison group

2 health or social studies classes

N = 2,100

n = 1,435

3 classes from Hartford, CT High School

grades 9–12, “economically disadvantaged”

47% male

59% Hispanic

20% non-Hispanic black

20% in remedial English or ESL

n = 665 from two Columbus, GA high schools

ninth graders

52% male “working class”

39% white

37% African American

15% remedial English or ESL

SOS vs. Comparison

3.6 vs. 5.4 suicide attempts

SOS had higher posttest knowledge and more positive attitudes than comparison

No difference in suicidal ideation or treatment seeking

Combined schools without comparing

Don't know about pretest differences

ESL, English as a second language.

Program Examples

Most suicide awareness and education programs described in the literature have been implemented at the high school level and share a core of common programmatic features, centering on a suicide education curriculum, supplemented in some cases with training directed toward teachers and other gatekeepers. Such programs are exemplified by those developed by Kalafat and colleagues (Kalafat & Elias, 1992, 1994; Kalafat & Gagliano, 1996; Kalafat & Ryerson, 1999), which incorporate education about the warning signs of suicide and appropriate help-seeking behaviors into the regular physical education or related curricula. Such education has been reported by the program developers to result in students' increased knowledge about suicidal behavior, more positive attitudes about talking to friends they believe to be suicidal, and seeking of help from adults. In its most fully developed form, the Adolescent Suicide Awareness Program (ASAP) includes education for teachers, school staff, and parents, as well as students. Although no controlled evaluations have been reported, the developers cited anecdotal reports of increased referrals of at-risk youth, following implementation of ASAP in a number of schools (Kalafat & Ryerson, 1999).

Another widely applied curriculum-based prevention effort is the Signs of Suicide (SOS) program, developed by Jacobs and colleagues. The SOS program delivers the core message that suicidal behavior is directly related to mental illness, particularly depression, and needs to be responded to as a mental health emergency. The instructional component, which occurs over one to two class periods, may be augmented with screening and parent-awareness activities. Schools in which the program has been implemented have reported substantial increases in students' help-seeking behavior and high satisfaction with the program among school officials (Aseltine, Jacobs, Kopans, & Bloom, 2003). In a recent posttest-only evaluation involving five high schools in Columbus, Georgia, and Hartford, Connecticut, 2,100 students were randomly assigned to intervention and control groups. In self-administered questionnaires 3 months after program implementation, students who had participated in the SOS intervention reported significantly lower rates of suicide attempts and greater knowledge and more adaptive attitudes about depression and suicide (Aseltine & DeMartino, 2004).

Educational efforts in the Dade County, Florida, Public School System provide an example of universal programs applied on a community-wide level. This program, which began in 1989, included related curricula across kindergarten through 12th grade, although only 10th graders received direct discussion of suicide and suicide prevention. In addition to the instructional components, it also included intervention and postvention activities by school-based crisis teams.

A 5-year longitudinal study of the Dade County program examined rates of suicide deaths and suicide attempts by youth in the county in the years during which the program was operative (1989–1994), comparing them to comparable rates over the 8-year period preceding the program (Zenere & Lazarus, 1997). The annual suicide rate was reported to have decreased from an average of 12.9 deaths per 100,000 youth prior to the program to 4.6 per 100,000 during the 5 years of program operation. Known suicide attempts were reported to have dropped from 87 to 37 per 100,000 youth. No significant change was reported in rates of suicidal ideation.

The lack of a contemporaneous local control group in this study makes it difficult to determine the linkage between the educational program and the reported decline in suicide rates. Although this report concludes that the comprehensive educational program contributed to the declines, it should be noted that youth suicide rates were declining nationally during the 5-year period of the program's implementation, although not as sharply as were reported in this particular county. In addition, the county under study was quite small (330,000 students), so that relatively large fluctuations in suicide rates are not as meaningful as they would be for the national population.

Many states are currently implementing universal youth suicide prevention programs that, in addition to student education, frequently include parent and gatekeeper training. Like other programs of this type, controlled evaluation studies have not yet been reported. In an internally published report (Eggert, Karovsky, & Pike, 1999), positive results have been reported for one of the most fully developed such programs, the Youth Suicide Prevention Program (YSPP) in Washington State.

Some efforts to address suicide prevention on a universal level have concentrated specifically on gatekeeper training. These programs are summarized in Table 22.2. The Suicide Options, Awareness and Relief (SOAR) program, for example, trains school counselors to identify students at risk of suicide and increase the likelihood and effectiveness of their interventions. This program has been reported to result in improved knowledge and increased comfort and confidence in dealing with at-risk students. More positive results were found among the most recently trained counselors, suggesting the need for ongoing training (King & Smith, 2000).

Table 22.2 Gatekeeper Training Programs

References

Intervention

Study Design

Program Length

Sample Size

Comments

Turley & Tanney, 1998

Suicide Aware Program (SA)

Interventions Workshop (IW)

Pre–post

No control or comparison group

1–3 hr presentation (SA)

2-day IW

N = 3,972 participants in SA across 3 sites (4 groups per site)

N = 2,870 participants in IW across 4 sites, 1996–1998

Participants were from all areas of school, mental health and administrative programs

89% of trainers plan to continue program

Most trainers continue to meet 3 trainings/year requirement after 2 years

Most participants reported increased comfort, competence, and confidence immediately after training and 4 months later

Knowledge increased

Willingness to intervene with suicidal youth increased

Most attrition was from rural areas

Fendrich et al., 2000

Team Up to Save Lives: what your school should know about preventing suicide

CD-ROM mailed to schools with written instructions

Posttest only

No comparison or control group

CD-ROM available for viewing

CD-ROM was sent by mass mailing to every high school, K–12 school, or junior high school in the U.S. in January 1997

n = 301 Chicago-area schools were contacted in 1998

Public and private schools

n = 202/301 responded to survey

n = 79/202 participated in the evaluation

The majority of schools did not know that they had received the CD-ROM (only 20% knew about CD-ROM)

Only 39% of schools contacted participated in review of CD-ROM

Lack of time, computer equipment, and training were cited as factors preventing review of CD-ROM

Those who reviewed CD-ROM had positive evaluations and negative reactions were rare

Most respondents said either they had made use of the information (40%) or planned to (87%)

King & Smith, 2000

Project SOAR: Suicide Opinions, Awareness and Relief

Program for school counselors

Posttest only

No comparison or control group

8-hr training course

All school counselors in Independent School District of Dallas, TX

N = 186/247

60% counselors ≤ 10 years

48% received SOAR training 3 years ago

88% had assessed a suicidal student

More than half of school counselors had adequate knowledge in most areas

Almost all knew risk signs for suicide including depression, previous attempt, low self esteem, recent break-up of relationship, child abuse

There were gaps in knowledge related to drug use and gun accessibility

Most had good knowledge of appropriate interventions

Almost two-thirds thought they could effectively offer support for suicidal student

Turley, 2000

ASIST: Applied Suicide Intervention Skills Training

Posttest only

No ASIST comparison group

2-day workshop

n = 91 ASIST 75% female

n = 40 No ASIST 63% female

Participants include school, mental health, and medical personal

Increased readiness to make suicide intervention

Increased knowledge, especially relative to control group

Comparison group did not change in readiness to intervene

Pfaff et al., 2001

Youth suicide prevention workshop for general practitioners, focused on recognizing and responding to distress and suicidal ideation in adolescents

Pre–post case reviews

1 training session

N = 23 general practitioners

N = 423 patients ages 15–24

N = 203 cases preworkshop

N = 220 cases post-workshop

48% increase in identifying psychological distress

40% increase in identification of depression

33% increase in inquiry about suicidal ideation

130% increase in recognition of suicidal patients

No change in patient management strategy

Maine et al., 2001

Youth Suicide: Recognizing the Signs

Video for parents with booklet

Pretest–posttest

No comparison or control group

1 session with 1–20 people

N = 112 parents with no experience of suicide within the family from South Australia

Parents with a child ≥ 15 years old

84% females

No indigent parents

Knowledge of suicidal signs increased

Improved ability to choose a more appropriate response to suicidal statements

Parents became more rejecting of suicide

Parents indicated higher intention to help

Toumbourou & Gregg, 2002

Parenting Adolescents: A Creative Experience (PACE)

Didactic training for parents, focused on improving communication and relationships with adolescents

Discussion, pamphlets, booklets, and behavioral homework for reinforcing program

Pretest–posttest

Random assignment to program or control group

7 sessions for groups of 10 parents at a time

N = 577 eighth-grade students from 28 school campuses in Melbourne, Australia

n = 305 parents from 14 schools in PACE

n = 272 parents from 14 control schools

Private and public schools

PACE schools had reduced elevation of substance use but this did not lead to cessation

Delinquent behavior decreased in PACE schools and increased in control schools

Suicidal behavior and depressive symptoms were stable in both groups

Family conflict and parental care increased in PACE schools relative to control schools

The broadest and most frequently applied gatekeeper training program, the Applied Suicide Intervention Skills Training (ASIST), has been developed by LivingWorks Education for application in a wider community setting (Ramsay, Cooke, & Lang, 1990; Rothman, 1980). Developed over the last 20 years, ASIST is a 2-day workshop for teachers, counselors, youth leaders, and other community caregivers that seeks to increase their awareness and understanding of suicide, address the associated stigma and taboos, develop their readiness and ability to use “first-aid” actions to prevent suicidal behavior, and network with other gatekeepers to improve communication and continuity of care. An estimated 25,000 caregivers participate in the program each year, and to date more than 300,000 have been trained worldwide.

Pre-to postevaluations of participants suggest increased knowledge about suicidal behavior, greater willingness to intervene, and improved competence in dealing with suicidal individuals (Eggert et al., 1999; Tierney, 1994). In one evaluation report of training programs in Australia, more than three quarters of ASIST workshop participants reported using their knowledge and intervention skills directly during the 4 months following their participation in the program (Turley & Tanney, 1998). There is some evidence of an increase in referral to treatment as a result of gatekeeper training (Turley, 2000; Walsh & Perry, 2000).

A second component of LivingWorks' efforts is the Training for Trainers (T4T) program. This 5-day course, offered worldwide, trains and certifies gatekeepers to provide the ASIST training in their local communities. A CD-ROM program has recently been developed by LivingWorks to provide posttraining retention and reinforcement of intervention skills through virtual simulation of interactions with suicidal individuals.

Less proactive training strategies for school personnel and parents have used audiovisual materials to enhance suicide awareness and encourage early identification of youth at risk. Preliminary evaluations of two such efforts (Fendrich, Mackesy-Amiti, & Kruesi, 2000; Maine, Shute, & Martin, 2001) suggest that while most of those who view CD-ROMs and films about suicide prevention react positively, lack of time and inaccessibility of computer equipment may limit the effectiveness of such efforts, particularly within schools.

Another approach to gatekeeper training has involved educating general practitioners to more effectively identify suicidal patients. One such intervention was a youth suicide prevention workshop for general practitioners in Australia, which sought to encourage screening of young patients for psychological distress, depression, and suicidal behavior. The workshop was reported to have resulted in increased identification of distressed, depressed, and suicidal adolescents; no changes were reported, however, in physicians' management of such patients (McKelvey, Davies, Pfaff, Acres, & Edwards, 1998; McKelvey, Pfaff, & Acres, 2001).

In comparison with programs addressed to high school students and the adults who have frequent contact with them, suicide awareness and education programs for college students are far less cohesive and identifiable (Haas, Hendin, & Mann, 2003). One of the few programs that involve more than a single campus is Finding Hope and Help, developed by the National Mental Health Association in 2001. This program facilitates partnerships between a local mental health association and a university to develop and implement campus educational programs on suicide and related mental health problems. These “campus coalitions” typically work with residence hall advisers, campus counseling centers, relevant academic departments, campus ministries, and other student affairs personnel to design trainings for students and staff, peer counseling programs, and other activities to increase knowledge and awareness of mental health concerns (National Mental Health Association, 2005).

Another effort that targets colleges and universities is the recently produced film developed by the American Foundation for Suicide Prevention (AFSP), “The Truth About Suicide: Real Stories of Depression in College.” The film is accompanied by a Facilitator's Guide that includes recommendations for its use in classrooms, orientation sessions, and dorm meetings and at other student activities, as well as educational materials to assist faculty and other facilitators in guiding student discussions and answering specific questions about suicide. Although no formal evaluation of the film's effectiveness is currently planned, AFSP is gathering feedback data from viewers and facilitators.

Critique

Most suicide awareness and suicide education programs involve one or a limited number of relatively brief sessions focused on suicidal behavior, frequently as part of a larger curricular effort aimed at reducing multiple high-risk behaviors. Although pre-to postevidence suggests that such programs can increase students' knowledge and awareness of suicide risk and improve their help-seeking behaviors, little attention has been paid to determining the scientific accuracy of program content. Examination of curricular materials used by some of these programs reveals considerable variation in regard to their portrayal of suicide risk factors, in particular, the relationship between suicide and mental illness, as well as suicide demographics.

Generalizable conclusions about the efficacy and effectiveness of suicide education programs for both high school and college students are further limited by the lack of control or comparison groups that would make it possible to differen tiate program impact from broader co-occurring trends. In the case of the comprehensive, multilevel educational programs, insufficient attention has been paid to documenting which program components are responsible for the reported outcomes.

An additional limitation of currently available data on the impact of universal education programs is their short-term focus. It is not clear if ongoing interventions might serve as “booster shots” to enhance and reinforce a program's impact. In addition, follow-up evaluations of these programs have been rare, and thus little is currently known about their impact on reducing suicidal behavior among the targeted group. Longitudinal controlled studies that look at youth several years after participating in educational programs are needed to address the question of long-term behavioral change. This will require addressing the fact that neither high schools nor colleges currently have a reliable system for reporting suicidal behaviors among students, thus hampering collection of reliable data to determine an educational program's impact. Also, students graduate and leave the school environment, making follow-up difficult.

Long-term controlled studies of gatekeeper training programs are likewise needed to determine the frequency or the effectiveness of participants' direct interventions during the years following the training. Because little is known about particular approaches that make referral efforts safe and effective, further evaluation is needed of the impact of such programs on referral processes, adequate treatment, and, in turn, the reduction of suicide risk factors and suicidal behavior among youth.

Some concerns have been voiced by high school personnel and parents that overt discussion of suicide in the school curriculum may increase suicidal thoughts and behavior, and adequate attention has generally not been given by evaluators to documenting adverse effects. One study found statistically significant increases in hopelessness and maladaptive coping resources among some male students after exposure to a suicide awareness curriculum (Overholser, Hemstreet, Spirito, & Vyse, 1989). Studies by Shaffer and colleagues (1990, 1991) and Vieland and colleagues (1991) found that students who had previously made a suicide attempt were less likely to recommend suicide awareness programs in the schools, and were more likely to feel that talking about suicide in the classroom would increase suicidal behavior among some students. While the small number of students reporting past suicidal behavior limit generalization of these findings, they point to the need for evaluations of school-based suicide education programs to include better assessment of potential harmful effects and identification of adolescents who may be vulnerable to adverse effects. Educational programs should also include a plan for clinical assessment and referral for students who are identified to be at risk for suicidal behavior. It is essential that school personnel be made aware of referral sources in the community and for the school to have in place a plan of action for identified students that includes a debriefing component for peers and faculty who are involved in making referrals.

In the case of college-based programs, concerns about effects on the institution's legal liability, reputation, and student enrollment sometimes encourages campus officials to avoid or minimize the problem of student suicide, which appears to have limited the development of educational programs directed to this population. In addition, providing suicide education to college students poses unique issues. In contrast to high school students, who follow a tightly prescribed core curriculum that typically includes at least a minimal amount of health education, college students are not generally required to take any courses in which education about depression and suicide may be appropriately incorporated. Other than a limited number of mandatory orientation sessions, few opportunities exist to reach large numbers of college students with information about mental health issues and services. Involvement of parents in educational programs on such issues is also extremely limited in most college settings.

Finally, it should be noted that most suicide prevention programs directed to young adults are designed specifically for college students, who represent less than half of all persons aged 18–24 in the United States. Although few research studies have examined suicide risk among young adults not in college, this population may have particular risk factors, including more involvement with substance use, as well as less access to mental health resources.

One effort that may have applicability to youth in noncollege settings is the U.S. Air Force suicide prevention program, which has focused on removing the stigma of seeking help for mental health and psychosocial problems, enhancing understanding of mental health, and changing policies and social norms within the service. Introduced in 1996–97, the Air Force program has been described as highly effective in reducing suicide and other adverse outcomes, including family violence and homicide, among its five million members. A recent evaluation that compared 5-year cohorts before and after program implementation reported a 33% relative risk reduction for suicide and reductions ranging between 18% and 54% for other outcomes (Knox, Litts, Talcott, Feig, & Caine, 2003). The impact of the program on young servicemen in particular has not been reported, and thus the program is not listed as a youth suicide prevention program in the current review.

SCREENING PROGRAMS

Assumptions

Screening for depression in adults has been demonstrated to increase the likelihood of depressed adults seeking mental health treatment (Greenfield et al., 1997, 2000). Universal screening programs as a youth suicide prevention strategy (listed in Table 22.3) are designed to identify young people at risk for suicidal behavior and refer them to treatment. Some programs focus specifically on identifying symptoms of psychopathology known to be related to adolescent and young adult suicidal behavior, while others assess specifically for signs of suicidality.

Table 22.3 Screening Programs

Reference

Intervention

Study Design

Study Length

Sample Size

Comments

Reynolds 1991

2-stage depression and suicide screening

No comparison or control group

Stage 1: Suicide

Ideation

Questionnaire

Stage 2: Suicide

Behavior Interview

N = 121

General high school

Used 90% as cutoff for adequate sensitivity and specificity

Lowering cutoff improves sensitivity but decreases specificity below acceptable levels

Lewinsohn et al., 1996

Baseline assessment with 1-year follow-up, no intervention

No comparison or control group

Baseline comprehensive diagnostic assessment with K-SADS repeated at 1 year

N = 1,709 at baseline

N = 1,507 at follow-up

14-to 18-year-olds in community

Poor to excellent sensitivity and specificity

80% false-positive rate

Thompson & Eggert, 1999

Suicide Risk Screen (SRS) and Measure for Adolescent Potential for Suicide (MAPS)

No comparison or control group

1. Identify potential dropouts

2. Screen with SRS

3. Comprehensive assessment with MAPS

4. Validity measures of depression and suicide

N = 581 potential high school dropouts, ages 14–20

58% male

43% minority

63% did not live with both biological parents

Excellent specificity

Poor specificity

No false negatives

Validity supported by expected associations with measures of risk and protective factors

Aseltine et al., 2003

Signs of Suicide (SOS) anonymous depression and suicide screening

No comparison or control group

1 class period complete Columbia Depression Scale and item about suicide risk

N = 233 high schools

64% white

12% African American

10% Latino

27% urban

33% suburban

41% rural

21% eligible for free/reduced price lunch

(Age and number screened varies by school)

Not evaluated

Shaffer et al., 2004

Columbia Suicide Screen

Group matched sample of youths who did not endorse risk items

5 phases with attrition at each phase:

1. Self-report questionnaire (1 class period)

2. DISC (2 hr)

3. Clinical evaluation (1 hr)

4. Case manager

5. Treatment

N = 1,729 high school students from 7 metropolitan schools

57% female

56% white

18% African American

13% Hispanic

35% scored positively on screen

High sensitivity, specificity, and negative predictive value (.75–.99)

Low positive predictive value (.16)

Jacobs, 2003

The Comprehensive College Initiative

451 colleges used in-person events

215 colleges used on-line screening tool

N = 9,964 in-person screens

N = 12,351 on-line screens for depression

N = 3,858 on-line screens for bipolar disorder

35% of in-person and 65% of on-line screens scored positive for depression

19% in-person and 25% on-line screens scored positive for bipolar disorder

89% of those with on-line positive risk reported intent to seek further evaluation

Based on on-line evaluation:

Seniors and freshman had highest rates of suicidal ideation (2.0% and 5.6%, respectively)

On-campus students had higher rates of suicidal ideation than off-campus students

Jed Foundation, 2003

ULifeLine Program

No comparison or control groups

Compares student screening questionnaire with computer-generated values to identify students at risk

Provides recommendations for treatment as indicated

Anonymous

No information available

No follow-up information or evaluation

Haas, 2003

American Foundation for Suicide Prevention College Screening Project

No comparison or control groups

1. Anonymous on-line questionnaire, using ID and password after e-mail invitation

2. Student risk determined

3. Counselor assesses responses and provides assessment and access to treatment info via e-mail

4. Student reviews feedback and can access referral

Sample from one college based on response to anonymous on-line questionnaire

No sample information available

8% of target students responded

15% of identified students sought evaluation and referral as needed

DISC, Diagnostic Interview for Children; K-SADS, Kiddie Schizophrenia and Affective Disorders Schedule; SRS

The primary assumption underlying screening programs is that because anxiety, depression, substance abuse, and suicidal preoccupation among youth often go unnoticed and untreated, a systematic, universally applied effort is needed to improve identification of at-risk individuals. Although not always explicitly stated, screening programs also rest on the assumptions that identification of youth with psychiatric disorders will substantially increase the number receiving treatment, the treatment will be sufficiently effective, and effective treatment will decrease suicides.

Program Examples

Reynolds (1991) described one of the first high school–based screening programs for youth at risk for suicide. The program involved a two-stage method, in which a general population of students was first screened using the Suicide Ideation Questionnaire (Reynolds, 1988). Students with scores above a defined cutoff value were subsequently evaluated clinically with the Suicide Behavior Interview, and those identified as being at risk were referred for treatment.

The program devoted particular attention to determining an appropriate cutoff score for identifying at-risk youth, comparing two different scores with regard to sensitivity (the ability to identify correctly those who have the problem, with few false negatives) and specificity (the ability to identify correctly those who do not have the problem, with few false positives). Reynolds found that increasing the cutoff score led to missing a disproportionate number of at-risk youth. The impact on suicidal behavior and the adherence to treatment recommendations were not reported.

Perhaps the most widely used high school screening program, the Columbia TeenScreen Program (CTSP), likewise employs a multistage procedure. In one variant of the CTSP, students complete a brief, self-report questionnaire, i.e., the Columbia Suicide Screen. Those who screen positive on this measure are given a computerized instrument, the Voice DISC 2.3, a version of the Diagnostic Interview Schedule for Children, which has been found to accurately identify a comprehensive range of psychiatric disorders in children and adolescents (Shaffer, Fisher, Lucas, Dulcan, & Schwab-Stone, 2000; Shaffer et al., 2004). This stage of the screen is regarded as particularly important for avoiding overidentification of students at risk. In the final stage, youth who have been identified through Voice DISC 2.3 as meeting specific diagnostic cri teria for a psychiatric disorder are evaluated by a clinician, who determines whether the student needs to be referred for treatment or further evaluation. Ideally, the program also includes a case manager who contacts the parents of students who are referred and establishes links with a clinic to facilitate treatment adherence.

Evaluation results indicate that most of the adolescents identified as being at high risk for suicide through the program were not previously recognized as such, and very few had received prior treatment. About half of the students referred for treatment attended at least one treatment visit, however. In addition, the program's requirements of a clinician and a case manager may be a resource burden for many schools.

The screening strategy developed by Thompson and Eggert (1999) as part of their comprehensive Reconnecting Youth program (discussed in detail in Chapter 24) is based on a public health prevention model that emphasizes the identification of at-risk students on the basis of observable behaviors. The first level of screening involves a review of high school attendance registers to identify students having high absenteeism. Teachers and guidance counselors are asked to recommend students they deem to be at risk. Identified youth are then assessed by means of the Suicide Risk Screen (SRS). Those with elevated risk for suicidal behaviors are given an appropriate intervention within the school setting or are referred for further evaluation and treatment (Thompson & Eggert, 1999).

Recent screening initiatives for college students include the Comprehensive College Initiative (CCI), developed by Jacobs (2003) to identify students at risk for depression and facilitate them to get treatment. The program has been offered at a large number of colleges in conjunction with National Depression Screening Day. In addition to the in-person screenings offered at this annual event, the program includes an on-line year-round screening component.

In campuses where it has been implemented, the CCI has been described by its developers as effective in identifying at-risk students and motivating them to seek treatment (Jacobs, 2003). Almost 20% of students taking the screening measure scored “very likely” to be suffering from depression and 5% reported persistent suicidal ideation. Both student participants and college officials were reported to have positive reactions to the in-person and on-line program components. No data have yet been reported, however, on treatment follow-up or outcomes, or on changes in suicidal behavior on the participating campuses.

Another recent program is the College Screening Project developed by the American Foundation for Suicide Prevention (Haas et al., 2003). This project, which is currently being pilot tested at selected colleges, uses the campus e-mail network to target students and encourage them to complete a Depression Screening Questionnaire, which is found on a project-developed Web site. This instrument is an adaptation of the Patient Health Questionnaire, which has been established to be an effective tool for identifying depression among community samples (Spitzer, Kroenke, Williams, & The Patient Health Questionnaire Study Group, 1999; Spitzer et al., 2000). In addition to depression, the screening questionnaire includes items dealing with current suicidal ideation, past suicide attempts, anxiety and other affects, drugs, alcohol, and eating disorders. Students use a self-assigned user name and password to log into the Web site; the user name is the sole identification on the submitted questionnaire.

Assisted by a computer program, a clinically trained counselor evaluates the responses and assigns the student into one of three tiers on the basis of their suicide risk. The counselor then writes a personalized reply that the student accesses on the Web site, using their user name and password. Students with significant problems as determined by a well-defined set of criteria are urged to come in for a face-to-face evaluation. The Web site also contains a “Dialogue” feature that allows students to communicate with the counselor on-line to discuss concerns they may have prior to an evaluation.

During the face-to-face meeting, treatment options, including medication and psychotherapy, are discussed and referrals are made to appropriate services on and off campus. In an effort to evaluate treatment effects, the project collects data on an ongoing basis from treatment provid ers on student adherence, treatment progress, and disposition.

Initial reports indicate that about 80% of the students who respond to the screening questionnaire indicate some mental health problems, with almost half of all respondents falling into the highest-risk tier. Fewer than 15% of identified students, however, comply with recommendations for evaluation, which suggests that recommendations need to be refined to make them more acceptable, or that innovative strategies need to be developed to encourage greater numbers of at-risk students to seek help. Almost all students who receive a clinical evaluation through the College Screening Project are referred for treatment. Over 90% of students coming for evaluation have reported that the screening questionnaire and the counselor's responses were critical factors in their decision to seek help (Haas, 2003).

One other Web-based screening program for college students, the ULifeLine program, has recently been developed by the Jed Foundation (2003). This program provides computer-generated results to students who complete the screening instrument. Although identified students are provided with recommendations regarding treatment possibilities, no follow-up is offered. It is not clear whether without a personal connection, such Web-based screenings will succeed in motivating students in need to seek treatment.

Critique

In their basic assumptions, screening programs as implemented within both high school and college settings closely conform to scientifically validated premises regarding the causes of suicide—i.e., that suicide risk is not randomly distributed, but rather is conferred by certain factors that are both identifiable and, to a considerable extent, alterable. At the same time, such programs face a number of challenges.

Screening measures with acceptable test characteristics (e.g., a sensitivity of 80% and a specificity of 70%, figures similar to screens for depression) will necessarily miss some in the population who will go on to make suicide attempts, while identifying many more as at risk when they are not. The often transient or episodic nature of suicidality among young people makes screening this population even more difficult. Given that costs are involved each time a segment of the target group is screened, most school-based screening programs assess students only once a year, and in some cases, only once during a several-year period. The timing of the screening may increase the likelihood of identifying students in need of referral (e.g., close to exams, at the beginning of high school or college, or during the senior year) or at other times may reduce this likelihood.

Both high school-and college-based screening programs report relatively low adherence with treatment recommendations among those identified through the screening instrument to be at risk. Although this is likely due to a range of problems that are beyond the scope of the screening effort (e.g., lack of parental support, perceived quality of available treatment, and attitudes of treatment providers), additional strategies appear to be needed to encourage students at risk to access and make effective use of needed treatment services. In this regard, better integration of suicide education, gatekeeper training programs, and screening programs may be helpful.

All school-based suicide screening programs need to be mindful of the availability and quality of mental health services for students who are identified as at risk. On college campuses, this is sometimes a formidable problem. It is estimated that only 38% of colleges provide mental health services (Gallagher, 2001), and most of those that do limit the number of sessions or offer only group therapy that may not be appropriate for students at risk for suicide. Although many colleges require students to have health insurance, most students (as well as most people in the general population) are not adequately covered for acute or long-term mental health services.

Even when implemented under ideal conditions, there is no clear evidence that screening for suicide in general populations improves rate reduction outcomes. In addition, as yet, no data have been reported on the effectiveness of high school-or college-based screening programs in reducing suicide risk factors, including depression and suicidal ideation, or suicidal behavior at the schools where screening programs are being implemented.

Within high schools, there is evidence that administrators prefer suicide education and awareness programs over screening programs (Miller, Eckert, DuPaul, & White, 1999). Many colleges and universities have also expressed reluctance about implementing depression and suicide screening programs. This appears to reflect, in part, concerns about the liability schools may assume in the event that students identified as at risk for suicide do not follow through with treatment recommendations and actually engage in suicidal behavior. Identification of at-risk students may also put universities into a difficult legal and ethical position with respect to parents. Because students over the age of 18 are considered adults, parents of students cannot typically be contacted without written permission from the student. Although confidentiality can be waived in situations in which threat to life is concerned, universities are reluctant to become embroiled in such matters. Further, monitoring students identified as in need of mental health services is difficult because of their diverse living arrangements and lack of supervision by other adults.

Although Web-based programs show promise as a tool for suicide screening with youth, one complication is the recent Health Insurance Portability and Accountability Act (HIPAA), which limits the use of electronic technology to transmit identifiable health information, because of the potential threats to patient confidentiality. This has been interpreted as requiring that a student's actual identity not be revealed on-line, making it impossible for the counselor to intervene to help a student believed to be suicidal unless he or she presents in person for evaluation.

Finally, as was earlier noted in discussing suicide prevention education, most screening programs directed at young adults are designed specifically for college students. Although screening programs are expensive to administer and monitor, creative strategies are needed for integrating and supporting screening into existing health-care settings that reach all youth.