(p. 497) Universal Approaches to Youth Suicide Prevention
(p. 498) In this chapter, we focus on suicide prevention programs that have taken a universal approach, targeting whole populations of youth regardless of individual risk factors. The aim of universal suicide prevention programs is to reduce risk factors or enhance protective factors across the entire population. One particularly widespread approach targets youth where they are most accessible—in the schools.
There are four types of universal prevention programs that are especially common and continue to be the most widely used approach in schools:
• School-based screening programs
• Adult and peer gatekeeper training programs
• Skills training programs
• Comprehensive or “whole school” programs
Over the past 10 years, the number of school-based suicide programs has expanded considerably. Because of the seriousness and pervasiveness of the problem of youth suicide, and given that youth spend much of their time in schools, school personnel have been asked to take an increasingly prominent role in suicide prevention (Gould & Kramer, 2001; Kalafat, 2003; Miller, Eckert, & Mazza, 2009). Schools have transitioned into an obvious and accepted environment for implementing suicide prevention initiatives for young people. The increase in the number of school-based programs is also due to federal and state policies that call for increased school mental health and the use of evidence-based programs and practices for suicide prevention (George et al., 2013).
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.
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. Universal screening programs as a youth suicide prevention strategy are designed to identify young people who should receive treatment because they are at risk for suicide. 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.
The first widely used screening program was the Columbia TeenScreen Program (CTSP), which was used in high schools between 2003 and 2012. In one variant of the CTSP, students completed a brief, self-report questionnaire, the Columbia Suicide Screen. Those who screened positive on this measure were 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 was regarded as particularly important for avoiding overidentification of students at risk. In the final stage, youth who had been identified through Voice DISC 2.3 as meeting specific diagnostic criteria for a psychiatric disorder were evaluated by a clinician, who determined whether the student needed to be referred for treatment or further evaluation. Ideally, the program also included a case manager who contacted the parents of students who were referred and established 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 (p. 499) received prior treatment. About half of the students referred for treatment attended at least one treatment visit, however. A study by Husky et al. (2011) found that students that participated in TeenScreen had greater odds of making contact with a student assistance mental health professional and of establishing contact with community-based services. This increase in the rate of referral reflects the superiority of mental health screening over traditional methods for identifying adolescents at risk for clinically significant problems (Brown, Goldstein, & Grumet, 2009; Husky et al., 2011; Scott et al., 2009).
TeenScreen was endorsed by a number of organizations, including the National Alliance for Mental Illness (NAMI), and received federal grant funding and support from the Substance Abuse and Mental Health Services Administration (SAMHSA). TeenScreen became the model for other school-based screening programs that are still used today, including use of the Columbia Suicide Screen in primary care settings (Kreipe, 2013).
Two screening programs used in college and universities are the CollegeResponse program, developed by Screening for Mental Health, and the Interactive Screening Program, developed by the American Foundation for Suicide Prevention. Formerly known as the Comprehensive College Initiative, the CollegeResponse program promotes the prevention, early detection, and treatment of prevalent, often underdiagnosed and treatable mental health disorders and alcohol problems through in-person and online screening. The CollegeResponse program offers kits to host in-person events for National Depression Screening Day, the National Eating Disorders Screening Program, and National Alcohol Screening Day. In addition, CollegeResponse provides access to unlimited, anonymous online screenings and/or confidential screenings at in-person events; tools for help seeking; and immediate results and referrals to on-campus counseling and the health center following the completion of the screening questionnaire.
The second program, the Interactive Screening Program, provides an anonymous, web-based method of outreach that starts with a brief, confidential Stress & Depression Questionnaire. As currently applied, the primary focus of the program is connecting people at risk for suicide to a counselor who provides information and support for help seeking (Garlow, 2008; Haas et al., 2008). This program, which is currently in place at over 100 colleges and universities nationwide, is based on the following principles: anonymity for the user, personalized contact with real counselors, interactive engagement between user and counselor, and identifying and resolving the user’s personal barriers to treatment. The program provides a brief online questionnaire to help the user to identify depression or other mental health problems. The 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 et al., 1999, 2000). In addition to depression, the questionnaire includes items dealing with current suicidal ideation, past suicide attempts, anxiety and other affective disorders, use of drugs and alcohol, and eating disorders. The questionnaire is housed on a secure website, which is customized for each participating college and university. Students are typically invited to participate via email, and use a self-assigned user ID and password to log in to the website. Those who complete and submit the questionnaire receive a personalized written response from a counselor and are encouraged to exchange follow-up messages online with the counselor without having to identify themselves. The dialogs with the counselor play a critical role in the process of encouraging the student to seek help by facilitating the resolution of barriers to treatment. Students who agree to meet with the counselor in person are further evaluated, and treatment options are discussed.
Two additional publications on the Interactive Screening Program describe its effectiveness in graduate and medical school populations (Moffit et al., 2014; Moutier et al., 2012). The expansion of this program, along with other efforts such as those funded by the SAMHSA Campus Suicide Prevention Grants, should lead to improved knowledge about interventions to increase identification of mental illness and help seeking (Hunt et al., 2010).
(p. 500) Critique
Screening programs as implemented within both high school and college settings closely conform to scientifically validated premises regarding the causes of suicide—that is, 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. Even with acceptable sensitivity and specificity, screening measures 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 or decrease the likelihood of identifying students in need of referral.
Both high school and college 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 skills training programs, gatekeeper training programs, and screening programs may be helpful.
Although it is intuitive that contextual factors such as peer support, residential settings, and the supportiveness of academic personnel would affect student mental health, researchers have yet to examine these relationships rigorously. 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. Most colleges and universities 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) do not have adequate coverage 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 screening programs on 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 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 engage in suicidal behavior.
Parental and community opposition to school-based screening efforts has also been an issue, contributing to the demise of some programs, as in the case of Columbia TeenScreen. Finally, an additional limitation to screening programs is their inability to reach youth who are not in school, and most screening programs directed at young adults are designed specifically for college students. Although screening programs can be expensive to administer and monitor, creative strategies are needed for integrating and supporting screening into existing healthcare settings that reach all youth.
Gatekeeper Training Programs
Gatekeeper training is designed to give teens and adults in the school environment the (p. 501) knowledge and skills needed to identify at-risk youth and to take appropriate action (Garland & Zigler, 1993; Gould et al., 2003; Kalafat & Elias, 1995; Lake & Gould, 2011). A common goal of gatekeeper training programs is to increase participants’ general knowledge of youth suicide and suicide-related behavior, risk factors, and warning signs, as well as changing attitudes toward suicide intervention to enhance referrals to treatment. Another common theme is to increase gatekeepers’ confidence and self-efficacy in relation to working with suicidal students and to apply what they have learned to help someone else (Robinson et al., 2013).
Many states are currently implementing universal youth suicide prevention programs that frequently include gatekeeper training for parents, teachers, and other school personnel, or follow a peer-to-peer model by training youth as gatekeepers. One widely applied program is the Signs of Suicide (SOS) program, developed by Screening for Mental Health, Inc. Although the SOS program contains a screening component, the primary goals are to educate students about mental illness, particularly depression, and teach them to identify symptoms of depression, suicidality, and self-injury in themselves and their peers using the SOS technique. Through video and group discussions, SOS teaches students to ACT: Acknowledge the signs of depression or suicidal thoughts in a friend; let the friend know you Care and want to help; and Tell a responsible adult. 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). The results of the post-only evaluation involving nine high schools in three states implementing the SOS program confirms and expands the first-year results that demonstrated the program’s efficacy in an urban, economically disadvantaged sample of youth. The Aseltine et al. (2007) analysis of 4,133 students, based on a more socially, economically, and geographically diverse group of high school students, found the SOS program to be associated with significantly greater knowledge, more adaptive attitudes about depression and suicide, and significantly fewer suicide attempts reported by intervention youths relative to untreated controls 3 months after the intervention. The impact of the SOS program on knowledge, attitudes, and suicidal behavior was not associated with increased help seeking among emotionally troubled youth.
The broadest and most frequently applied gatekeeper training program is the Applied Suicide Intervention Skills Training (ASIST), developed by LivingWorks Education for application in community settings (Ramsay, Cooke, & Lang, 1990; Rothman, 1980). Although not specifically targeting young people, ASIST provides a model that has been applied to helping teens and young adults, and school personnel have been increasingly targeted by ASIST. Developed in 1983, ASIST is a 2-day gatekeeper training workshop that seeks to develop participants’ readiness and ability to use “first-aid” actions to prevent suicidal behavior, and to network with other gatekeepers to improve communication and continuity of care. Evaluations of participants before and after the workshop suggest that it enhances caregivers’ sense of readiness for suicide intervention, increases their knowledge about suicidal behavior, increases their willingness to intervene, and improves competence in dealing with suicidal individuals (Eggert et al., 1999; Smith et al., 2013; 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).
Another commonly used gatekeeper training program is Question Persuade Refer (QPR). QPR is a 1- to 2-hour training program delivered by certified instructors in person or online. This brief program is designed to teach parents, teachers, coaches, and other gatekeepers the warning signs of a suicide crisis and how to respond by Questioning the individual’s desire or intent regarding suicide, Persuading the (p. 502) person to seek and accept help, and Referring the person to appropriate resources.
Computer-assisted self-study training strategies for school personnel and parents have used audiovisual materials to train school-based gatekeepers. Recent advancements in technology have expanded such strategies and are changing the way that many gatekeepers are being trained. One program getting a lot of attention is At-Risk, developed by Kognito Interactive. The At-Risk program was adapted to meet criteria for use by educators in a variety of settings, including middle schools, high schools, and colleges. The 45-minute to 1-hour online gatekeeper training program seeks to teach school personnel how to identify students exhibiting signs of distress, including depression and thoughts of suicide; approach students to discuss their concern; and make a referral to school support services. Unlike in-person gatekeeper training, participants are guided through virtual conversations with student avatars to learn strategies for broaching the topic of psychological distress to motivate students to seek help.
Recently, At-Risk, QPR, and other gatekeeper programs have gained a lot of attention in colleges.
Gatekeeper training in schools is one widely used strategy designed to improve early identification of students at risk for suicide and to facilitate timely mental health referrals, responding to the fact that suicidal youth are underidentified and few are using services. Despite their widespread use, gatekeeper training has been largely untested in rigorous evaluations (Wyman et al., 2008). Long-term controlled studies of gatekeeper training programs are needed to determine the frequency and effectiveness of participants’ direct interventions during the years following the training. In addition, further evaluation is needed to determine the types of referrals being made, the connection to treatment, and the impact that it may have on the reduction of suicide risk factors and suicidal behavior among youth.
There is some evidence of an increase in referral of youth to treatment through ASIST (Walsh & Perry, 2000); however, evidence of the program’s success in preventing suicidal behavior has not been established. School personnel in Washington state, for example, demonstrated increased knowledge about suicide and intervention skills after the ASIST training, showed a mix of intervention behaviors 6 months after training, and showed decreased intervention behaviors 9 and 12 months after training (Guttormsen et al., 2003).
A study by Wyman et al., (2008) used a randomized trial designed to assess the impact of QPR training on school staff members’ knowledge, appraisals of willingness to assume a gatekeeper role, and self-reported suicide identification behaviors with students. In addition to assessing overall impact, they tested whether QPR training had a differential effect on gatekeeper surveillance and gatekeeper communication. Researchers found that while the training increased self-reported knowledge, appraisals of efficacy, and service access, the follow-up showed that staff members’ increased knowledge and appraisals were not sufficient to increase suicide identification behaviors; when such behaviors did increase, it was mostly for staff members who were already communicating with students about suicide and distress.
Skills training programs are designed to enhance protective factors and reduce risk factors for youth suicide through the development of cognitive and social skills (Lake & Gould, 2011). Skills training curricula may be presented universally or may be targeted at a specific population known to be at higher risk for suicide (Lake & Gould, 2011). This section will focus on skills training programs with a universal approach to suicide prevention.
Skills training programs aim to prevent suicide by enhancing problem-solving, coping, (p. 503) and cognitive skills, which have been found to be impaired in suicidal youth (Lake & Gould, 2011). The key assumptions underlying skills training programs are that developing and enhancing these skills may mitigate suicide risk factors such as depression, hopelessness, and drug abuse.
Developed by Barrish et al., (1969) the Good Behavior Game (GBG) is a universal program directed at socializing children for the student role and reducing aggressive, disruptive behavior. In a classroom-based randomized trial examining the GBG intervention for young adult suicide ideation and attempts, Wilcox et al. (2008) found that first-grade students who were assigned to GBG classrooms experienced a lower incidence of suicidality through childhood, adolescence, and young adulthood compared to those who did not. In addition, this group reported half the amount of lifetime rates of suicidal ideation and attempts compared to the matched controls. While this program shows a reduction in suicidal ideation and attempts among the two groups, GBG’s effect on suicide attempts was less definitive once researchers controlled for gender and baseline depressive symptoms.
Most skills training programs continue to involve only 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 comparing evidence from before and after such programs suggests that they 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 the 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.
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 for those at risk. Indeed, 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). 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.
Generalizable conclusions about the efficacy and effectiveness of skills training programs are further limited by the lack of control or comparison groups that would make it possible to differentiate the impact of the program from broader co-occurring trends. For the comprehensive, multilevel skills training programs, insufficient attention has been paid to documenting which program components are responsible for the reported outcomes.
Ecological and Comprehensive Approaches
Comprehensive or “whole school” approaches to school-based youth suicide prevention seek to build a competent school community in which all members are aware of options and resources for preventing youth suicide (Kalafat & Elias, 1995; Lake & Gould, 2011). Comprehensive programs may include the specific goal of transforming the culture, climate, or social ecology of the school to ensure that the school environment is positive and health-promoting (Kalafat, 2003; Kalafat & Elias, 1995).
The key assumptions underlying comprehensive “whole school” programs are that (1) a cohesive and supportive school environment may be protective against suicide risk and (p. 504) (2) fostering a school climate of open communication may facilitate help seeking on the part of a student in crisis (Lake & Gould, 2011).
Suicide prevention efforts in the Dade County, Florida, public school system provide an example of universal programs applied on a community-wide level. The Youth Suicide Prevention and Intervention 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). One study (Zenere & Lazarus, 2009) was a longitudinal extension of the earlier work, examining the program effects from 1995 to the last data collection period in 2006. The 18-year longitudinal case study showed a significant decrease in the annual suicide rate from an average of 12.9 deaths per 100,000 youth prior to the program to 1.4 per 100,000 in 2006. Known suicide attempt data also showed a decrease from 88 per 100,000 in the program’s first year to 9.0 per 100,000 in 2006. This case study is among the first to suggest that comprehensive school-based suicide prevention programs can reduce youth suicidal behavior and sustain this reduction over time. A frequent criticism of many school-based suicide prevention programs is that most of them to date have been largely focused on changing knowledge and attitudes about suicide rather than actual rates of suicide and suicide attempts.
Similar to the first study, 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 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 populations.
In its most fully developed form, the Adolescent Suicide Awareness Program (ASAP) includes education for teachers, school staff members, 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). This program was one of the first of its kind and has laid the foundation for enhancements in curriculum-based suicide prevention and awareness efforts.
The Lifelines program developed by Hazelden is a comprehensive, schoolwide suicide prevention program for middle and high school students. The goal of the Lifelines program is to promote a caring, competent school community in which help seeking is encouraged and modeled and suicidal behavior is recognized as an issue that cannot be kept secret. A quasi-experimental study by Kalafat et al. (2007) found that the posttest results from the intervention group demonstrated a significantly greater increase in knowledge about suicide and more positive attitudes about seeking help compared to the control group.
Comprehensive, “whole school” approaches to school-based youth suicide prevention often group together multiple suicide prevention strategies. This presents a challenge for evaluation, and to date, insufficient attention has been paid to documenting which program components are responsible for the reported outcomes. Generalizable conclusions about the efficacy and effectiveness of such (p. 505) comprehensive 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 differentiate the program’s impact from broader co-occurring trends.
The universal suicide prevention programs addressed in this chapter aim to prevent youth suicide by establishing a school community in which all members play a role in supporting youth who may be suicidal or are at risk for suicidal behavior. These programs aim to establish a supportive school environment that promotes students’ resilience and well-being and in which all members are aware of options and resources for preventing youth suicide.
Follow-up evaluations on the impact of universal 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 the collection of reliable data to determine an educational program’s impact. Also, students graduate and leave the school environment, making follow-up difficult. (p. 506)