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Research Agenda for Youth Suicide Prevention 

Research Agenda for Youth Suicide Prevention
Chapter:
Research Agenda for Youth Suicide Prevention
DOI:
10.1093/9780195173642.003.0026
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date: 14 December 2018

In the preceding chapters, we have reviewed what is currently known about youth suicide, how it can be prevented, and how the problems associated with suicidal behavior can be treated. We begin this last chapter with a summary of what we currently know.

WHAT WE KNOW

About Youth Suicide

  • Between the mid-1950s and the late 1970s, the suicide rate among U.S. males aged 15–24 more than tripled. Among females aged 15–24, the rate more than doubled during this period. The youth suicide rate generally leveled off during the 1980s and early 1990s, and since the mid-1990s, it has been steadily decreasing.

  • About 4,000 people aged 15–24 die by suicide each year in the United States.

  • In the United States suicide is currently the third leading cause of death among all youth ages 15–24.

  • Among young people aged 15–24, males die by suicide almost six times more frequently than females.

  • Youth suicide rates vary widely among different racial and ethnic groups. The rate for African-American, Hispanic, and Asian-American youth are currently less than that of white youth; the highest suicide rate is seen among American Indian and Alaskan Native youth.

  • Over eight percent of American high school students make a suicide attempt. Seventeen percent of high school students report having seriously considered suicide during the previous 12 months.

  • The vast majority of youth (70%–90%) who die by suicide had at least one psychiatric illness at the time of death. The most common diagnoses among youth are depression, substance abuse, and conduct disorders.

  • Other factors associated with youth suicide include physical abuse, sexual abuse, serious conflict with parents, interpersonal loss, not being in school or not working, knowing someone who has attempted suicide or died by suicide, and access to firearms.

  • Suicide and suicide attempts are increased in families in which a parent has died by suicide or attempted suicide.

  • Among youth (and adults), a prior suicide attempt is a strong predictor of subsequent attempts and suicide death.

About Youth Suicide Prevention Programs

  • Under adequate conditions of implementation, programs that educate high school students about suicide can increase students' knowledge of mental illness and suicide, encourage more adaptive attitudes about these problems, encourage help-seeking behaviors, and increase referrals of at-risk students to treatment.

  • Programs that train teachers, counselors, and community gatekeepers about suicide intervention can increase participants' knowledge about suicide and suicide prevention, increase self-confidence and willingness to intervene, and increase referrals to treatment.

  • Programs that screen high school and college students to identify those at risk for suicide and refer them for treatment can identify some high-risk individuals who were not previously recognized or treated. Most at-risk students who are identified, however, do not adhere to recommendations regarding treatment.

About Treatment of Suicidality and Underlying Disorders Among Youth

  • Under adequate conditions of implementation, intensive school-based programs for students at risk of dropping out of school can reduce depression and suicidality in students who exhibit these problems.

  • Programs that engage young suicide attempters and their families while they are in the emergency department can increase adherence to outpatient treatment and de crease immediate and subsequent hospitalizations.

  • Cognitive behavior therapy can improve social functioning and reduce suicidal ideation and self-harm behaviors among suicidal youth.

  • There appears to be increasing evidence that treatment with fluoxetine (Prozac) can reduce depression, alcohol dependence, and suicidal ideation in youth.

  • Combination treatment involving Prozac and psychotherapy appears to result in the most positive outcomes for depressed, suicidal youth.

  • There is some evidence that posthospitalization programs for suicidal youth can reduce subsequent suicidal ideation and mood impairment among female participants.

In spite of considerable research and program development focusing on youth suicide, there is much we do not yet know about the factors that cause or significantly influence suicidal behavior among youth and the interventions that must be made if this behavior is to be prevented or treated. Listed below are the key knowledge needs our review has identified that constitute a future research agenda for youth suicide. Clearly, the task that lies ahead for researchers and program developers is formidable.

WHAT WE DON'T KNOW

About Youth Suicide

  • Although the problem of youth suicide is disproportionately due to its prevalence in young males, explanations for this phenomenon are currently lacking.

  • Also not well understood is the impact of race and ethnicity on suicide vulnerability among youth. What particular risk or protective factors are conferred by membership in particular racial or ethnic groups?

  • Studies of the relationship of sexual orientation to youth suicidality have to date produced equivocal findings. Better understanding is needed of the interrelationships among sexual orientation and other risk factors, including psychopathology, substance abuse, and family and peer conflicts, and of what appears to be an increased number of suicide attempts (but not suicide deaths) among homosexual and bisexual youth.

  • What external environments increase or decrease youth vulnerability and susceptibility to suicide? How can these be improved?

  • Although psychopathology has been well documented to be the most potent factor underlying suicide among all age groups, relatively little is known about the specific clinical pathways to youth suicide. In particular, much more needs to be known about the contribution of bipolar disorder, panic attacks, and posttraumatic stress disorder (PTSD) to suicide deaths among youth. The impact of race and ethnicity on diagnostic profiles and clinical pathways to suicide likewise needs greater scrutiny. Longitudinal studies of young suicide ideators and attempters are particularly needed. In addition, because most people with psychopathology do not engage in suicidal behavior and suicidal behavior crosses many different psychopathologies, the interactions among specific forms of psychopathology, other suicide risk factors less associated with mental disorders, and factors that protect against suicide need greater research attention.

  • Much more needs to be known about the role of neurobiological abnormalities that contribute to youth suicidal behavior, and the degree to which these may be inherited. Family studies of adults and adolescents who have attempted suicide or died by suicide can provide important information about inherited characteristics, and it is essential that youth be included in such research.

  • The extent to which parental and familial psychopathology influences suicide ideation, attempts, and completions among youth, over and above genetic influences, needs to be examined. Specifically, what is the effect of exposure to parental suicide attempts and completion, and suicide risk among youth? Does childhood physical and sexual abuse confer suicide risk independent of other effects of family psychopathology?

  • Although suicide clusters have been identified among youth, the characteristics of those most vulnerable to “contagion” and the mechanisms through which contagion occurs have not been precisely identified.

  • Much more needs to be understood about the role of personal and social skills in protecting youth from suicidal behavior. Do strong problem-solving skills, decision-making abilities, and support from family and schools actually protect young people from developing suicidal impulses, or is the absence of such skills a manifestation of psychopathology that is more directly related to suicidal thoughts or behavior? What is the role of culture, identity, and religious beliefs in reducing suicide risk?

  • Both theoretically and in practical programmatic terms, it is essential to have better understanding of which combinations of risk and protective factors have the greatest predictive value for youth suicide. Current research points to the identification and treatment of psychopathology among adolescents as a priority suicide prevention strategy, but better understanding is needed of the wide range of interpersonal, cultural, and environmental factors that may exacerbate or mitigate the impact of psychopathology among particular groups of high-risk youth. In addition, some treatments have been found to reduce suicidality without significantly affecting psychopathology. Research to date has focused almost exclusively on looking at relationships between single risk or protective factors and adolescent suicidal behavior. Comprehensive analyses that simultaneously consider a number of individual variables are essential.

About Youth Suicide Prevention Programs

  • Most suicide education programs have not identified the active ingredients responsible for the outcomes they produce.

  • Most suicide education programs target outcomes whose relationship to youth suicide has not been precisely identified. Many, for example, have reported increased knowledge of mental illness and suicide among students, although the impact of this outcome on suicidal behavior is not known. Greater attention needs to be given identifying long-term behavioral outcomes among students who have received such education, particularly those with particular risk factors.

  • Although increasing the number of referrals to treatment is a key goal of screening programs, there is no clear evidence of a direct linkage between increased referrals and decreased suicidal behavior among youth.

  • Screening programs have generally not identified effective mechanisms for encouraging larger numbers of youth identified as at risk for suicide into treatment.

  • Little data are currently available about the cost-effectiveness of school-based screening programs.

  • Although popular in recent years, the effects of postvention programs, both positive and adverse, on youth exposed to a suicide death have not been clearly documented.

  • Despite limited evidence that educational programs directed at parents, particularly fathers, can decrease youth access to firearms, the impact of means restriction programs on decreasing suicide attempts and suicide deaths among youth has not been documented.

About Treatment of Suicidality and Underlying Disorders Among Youth

  • The active ingredients of comprehensive high school–based programs for treating students at risk of dropping out, including some who are depressed and suicidal, have not been clearly identified.

  • It has not been demonstrated that students at risk of dropping out of school are representative of suicidal youth generally, and therefore that programs that address this population have wide applicability.

  • The replication of such programs, which require considerable personnel and financial resources, has not been established.

  • The impact of emergency department pro grams for young suicide attempters and their families on decreasing suicide deaths has not been established.

  • Although some promising outcomes have been reported, long-term effects of cognitive behavior therapy with suicidal youth are not yet known.

  • Although there is increasing evidence of the safety and efficacy of Prozac in treating depressed and suicidal youth, the safety and efficacy of the many other antidepressants currently being used have not been established.

  • Much more needs to be known about the combinations of psychotherapeutic and pharmacological treatment that produce the most positive short-and long-term outcomes for depressed, suicidal youth.

  • Long-term effects of posthospitalization programs for suicidal youth have not been documented.

RESEARCH NEEDS

In order to effectively address the knowledge needs that have been identified, youth suicide research must expand beyond its present relatively narrow focus to incorporate standards of research design and program evaluation that are routinely used in other prevention fields. Our review has made clear the extent to which scientifically valid evaluation of youth suicide prevention programs has lagged far behind their development and implementation. As a result, many efforts show considerable promise but very few have been established with reasonable certainty to be effective in preventing suicidal ideation, suicide attempts, or suicide deaths among youth.

Evaluation strategies that have been employed have relied largely on pre–post designs that do not adequately link outcomes to program components. Prospective controlled studies are needed to determine the effectiveness, safety, and active ingredients of universal and targeted suicide prevention programs, including school-based education, screening, and skills development programs; and school and com-munity interventions for at-risk populations, including firearms restriction programs and gatekeeper training programs.

A development that is expected to encourage and support the use of scientifically valid evaluation designs by suicide prevention programs is the recent decision of the Substance Abuse and Mental Health Administration (SAMHSA) to expand its National Registry of Effective Programs and Practices (NREPP) from its original focus on substance abuse prevention programs to include mental health promotion and treatment programs, including those associated with suicide prevention. NREPP is currently in the process of developing a unified set of evaluation criteria for all prevention programs that would define precise standards regarding research design, sampling, measurement, statistical analysis, and other methodological aspects. These criteria will then be used to systematically evaluate programs and classify then into one of five categories: (1) Insufficient Data to Make a Determination, (2) Program or Practice of Interest, (3) Promising Program or Practice, (4) Conditionally Effective, or (5) Effective Program or Practice. Beginning in May 2005, suicide prevention programs that are determined to be evidence-based will be included in NREPP's online registry (SAMHSA Model Programs, 2005).

To meet the NREPP criteria, suicide prevention programs will need to give particular attention to several issues that have been particularly problematic.

Theoretical Justification of Expected Outcomes

As has been noted earlier in this chapter, some suicide prevention programs, in particular universal education programs, have targeted outcome variables whose relationship to youth suicide has not been precisely identified. Evaluation of program outcomes must include careful consideration of the theoretical relevance of program goals and expected outcomes.

Theory-driven prevention strategies, programs, and treatments are most likely to inform the field in a cumulative manner. Specific variables believed to contribute to youth suicidal behavior (e.g., impaired problem-solving) need to be justified theoretically and addressed in the prevention strategy. Following the intervention, change in the variable must be specifically measured to determine if it functions, in fact, as a mediator of suicide-related outcomes. Without a theoretical base, findings from many studies are difficult to integrate, leaving the field with an absence of information as to what actually worked, and what directions (and theoretical models) are worthy of further investigation.

Sampling Strategies

Relatively few suicide prevention programs have systematically studied adequate numbers of representative at-risk youth to allow meaningful conclusions to be reached about program effectiveness, and only rarely have appropriate comparison groups been simultaneously studied. Further, most outcome studies have had access to program participants for a short period of time, which precludes attention to long-term effects of the program, including adverse effects.

Use of Third-Party vs. Internal Evaluator

Evaluation reports on the outcomes of youth suicide prevention programs have most frequently been issued by the program developers themselves. Third-party evaluation, rare in this field, may provide a more objective assessment of program accomplishments.

Funding for Evaluation Studies

Few youth suicide prevention programs have had the necessary personnel or financial resources to conduct independent program evaluations. If the field is to move forward, however, mechanisms need to be established that mandate and support comprehensive, well-designed outcome studies as a regular part of prevention programming. In regard to school-based programs in particular, effective evaluation requires follow-up of students who have participated in curricular or screening activities, to determine long-term outcomes. To date, sufficient resources for such research programs have not been available.

We have noted that much more attention also needs to be given to evaluating the outcome of treatment programs for suicidal youth. Since universal and selective suicide prevention programs focus heavily on encouraging help seeking and on identifying vulnerable youth and referring them to treatment, their impact on reducing youth suicide depends ultimately on the effectiveness of the treatments that are available to such young people. Thus, the single highest priority must be given to determining the relative efficacy and effectiveness of all currently employed treatments and indicated interventions for suicidal youth.

As has been noted, randomized controlled trials (RCT) of treatments used for suicidal youth are seriously lacking. These are clearly needed to determine the impact of brief interventions with young suicide attempters presenting to emergency departments; psychotherapeutic strategies for suicidal youth and pharmacological treatments for young suicide ideators and attempters; as well as hospitalization, partial hospitalization, and posthospitalization support programs for youth. In addition to studies focusing on individual treatments, simultaneous evaluations of multiple treatment approaches (e.g., psychotherapy and medication) are especially needed. Adverse effects of treatment, including the potential of certain antidepressant medications to induce suicidality among vulnerable youth, also need to be more closely evaluated. It is also important to encourage psychiatric treatment studies to include a systematic assessment of suicidal behavior, even if this is not their primary focus.

In addition to the general evaluation concerns noted above, treatment evaluations need to give particular attention to building appropriate safeguards into treatment trials involving high-risk youth populations. Maintaining troubled youth in treatment trials over an adequate period of time to observe both short-and long-term outcomes is a particular challenge. Time-limited treatments, while easier to evaluate, leave unresolved questions about long-term effectiveness. Although control or comparison groups are essential, the inclusion of such groups necessitates ethical consideration of appropriate “control” treatments. Few studies involving treatments for suicidality among youth have adequately defined or measured the therapeutic effects of treatment as usual.

The ultimate criteria for effectiveness in suicide prevention remain reduction in suicide attempts and suicide deaths, events for which the population base rate is low. The primary limitation of virtually all studies of the effectiveness of treatments for suicidal patients has been their relatively small size and thus their limited power to detect significant differences between or among alternative strategies (Hawton & Sinclair, 2003). Enrolling adequate numbers of appropriate participants into treatment trials can best be achieved through a number of centrally coordinated treatment research centers that can pursue common studies of treatment effectiveness. We know, for example, that antidepressant medication is effective against depression, and there is suggestive but not conclusive evidence that it reduces suicide in both adolescents and adults. Treatment research centers would make it possible to determine if this is so, to identify which medications are most effective, and to determine what degree their effectiveness is increased by combining them with various forms of psychotherapy. The formation of such centers was a primary recommendation of a recent Institute of Medicine report on suicide (Goldsmith, Pellmar, Kleinman, & Bunney, 2002).

Youth who engage in suicidal behavior vary considerably with respect to specific forms of psychopathology, substance abuse, and other psychosocial problems, and treatment trials must address this variability (Hawton & Sinclair, 2003). Particular protections must be developed to allow inclusion in such trials of suicidal youth with serious alcohol and drug problems, which confers considerable risk for subsequent attempts and suicide death.

In assessing the outcomes of treatment studies primary measures should focus on suicide-related outcomes, specifically suicidal ideation and behavior, and should also include as secondary outcomes measures of mood and social functioning. Based on their review of RCTs that have used repeated suicidal behavior as an outcome, Hawton and Sinclair (2003) have emphasized the importance of including measures of deliberate self-harm that did not lead to medical treatment. Their analysis also points to the importance of including measures of the costs of various intervention programs, and their cost-effectiveness, in assessing the impact of treatment strategies on reducing suicidality.

Finally, longitudinal studies are needed to follow up suicidal or at-risk youth through their young-adult, middle-adult, and later life years. It is clear that psychopathology can be lethal, and sustained attention to the problems evidenced by this vulnerable population is needed across the lifespan.