The burden of suicide has shifted increasingly towards younger aged individuals over the last half century (WHO, 2004), and suicide accounts for more deaths among young people ages 10 – 24 in the U.S. (approximately 10/100,000) than all natural causes combined (NCHS, 2007). The public health significance of the problem is most apparent when the high rates of non-lethal suicidal behavior are taken into account. Each year, between 5-9% of adolescents attempt suicide and nearly 700,000 of them require medical attention (CDC, 2008; Grunbaum et al., 2002). Adolescents who make a suicide attempt are at markedly increased risk: a prior suicide attempt is a robust risk factor for suicide across sex, age, and race/ethnic groups (Joiner et al., 2005; Shaffer et al., 1996). Due to recognition of this public health problem, reducing youth suicide is a major focus of the U.S. suicide prevention agenda (National Strategy for Suicide Prevention; US Public Health Service, 2001), and youth suicide prevention programming has increased dramatically in the past decade. However, there is minimal evidence that youth suicides are declining, and the US Health People 2010 goals of cutting suicide rates by one-half and reducing the 12-month medically serious suicide attempt rate for adolescents from 2.6% to 1% (CDC, 2006) are not close to being met.
Current youth suicide prevention programming is unlikely to have a broad population impact needed to meet federal and state goals of reducing youth suicide deaths. Expanding programming to include interventions that modify ‘upstream’ risk and protective processes has the potential to enhance suicide prevention impact significantly. To achieve this goal, new partnerships are needed among suicide prevention advocates, practitioners, policy makers and researcher to identify promising interventions and build an evidence base needed to promote broad population dissemination of effective programs.
Current Status of Youth Suicide Prevention Programming
To date, nearly all widely used youth suicide prevention programs apply different ‘case identification’ methods to expand recognition and referral for treatment services of individuals who are already suicidal or at high risk for suicide. Training for adult gatekeepers and direct screening of youth populations for mood, substance abuse, or suicidal problems are the two most widely used approaches. These strategies respond to evidence that most suicidal youth have mental health and/or behavioral problems, most frequently depression and substance abuse, and few are receiving mental health services (Gould et al., 2005; Shaffer & Craft, 1999). With the passage in 2004 of the Garrett Lee Smith Memorial Act (GLSMA), federal funding became widely available for the first time for states, tribal groups and colleges across the U.S. to implement community-based youth suicide prevention programs. Gatekeeper training and screening are the most common approaches employed by GLSMA-funded groups; over 100,000 gatekeepers were trained and 30,000 youth screened in the first two GLSMA grantee cohorts from 2005 – 2008 (Goldston et al., 2010).
Research evaluating screening, gatekeeper training, education curriculum and hybrid programs combining those elements has accelerated, and a small number of studies have used rigorous designs that involve randomization and control groups. Although no evidence is available to determine if those strategies reduce suicide deaths, changes in behaviors targeted directly by these programs may contribute to decreased suicides. For example, in addition to supporting the safety of administering questions about suicide through school-based screening (Gould et al., 2005), nearly three-quarters of students referred will utilize some mental health services (at least one mental health contact) after screening and a high level of case management (Gould et al, 2010; Husky et al., 2011). Gatekeeper training increases knowledge of warning signs and attitudes; however, a recent completed randomized trial of a widely-used school-based gatekeeper training program found limited impact on changing adult staff-student communication about suicide, which is a key intended outcome of this training (Wyman et al., 2008), and no overall effect in secondary schools on increasing identification of suicidal students (Brown et al., 2011). Evaluations of a second generation, hybrid program (Signs of Suicide) combining an educational curricula with direct screening scored by students themselves, found decreased short-term rates of suicide attempts (3-months after starting the intervention) but not by increasing use of treatment services (Aseltine & DeMartino, 2004; Aseltine et al., 2007). At present, minimal evidence has been reported to determine if referrals to usual mental health treatment services reduces suicide risk, which is an assumption underlying each case identification approach.
Limitations of Current Approaches and Potential Benefits of Modifying Upstream Risk/Protective Processes
Identifying youth who are already suicidal or highly at risk for suicide to link them with treatment services may save lives and reduce other adverse consequences from suicidal behavior. However, the potential for ‘case identification and referral’ approaches to significantly reduce suicide rates in the population is limited by several factors, some described in the Institute of Medicine’s (2002) Reducing suicide: A national imperative. Several of these limiting factors are described below, along with the potential benefits from expanding the current suicide prevention agenda to include interventions that modify ‘upstream’ risk and protective processes:
- Relying on existing mental health and other services (e.g., substance abuse treatment) will not meet the needs of many suicidal youth. In communities with the highest rates of youth suicides, reliance on referrals to the mental health system to address the needs of suicidal youth may not suit those communities’ ability to provide accessible, effective services. In many rural areas, where youth suicide rates are above the national average (Brown et al., 2007), there is scarcity of, lack of acceptability and low accessibility to services (Hirsch, 2006). Suicides also disproportionately affect Native American and Alaska native youth, particularly males. Regarding services for Native American and Alaska Native youth, a recent U.S. Inspector General’s report (2011) documented significant gaps in both mental health and substance abuse services in native communities.
- The potential for large population reductions in suicide rates is greater for approaches that target more common, lower-risk conditions compared to approaches that target the highest risk conditions (IOM, 2002). Specifically, approaches targeting high-risk conditions will be limited in reducing suicides in the total population due to their relatively low occurrence (i.e., prevalence) (Brown, 2001). For example, although adolescents hospitalized for major depression are much more likely to die from suicide than non-hospitalized youth (i.e., a much higher relative risk), a prevention approach that reduces suicide risk in this group can only have a modest overall impact because hospitalization for major depression is relatively rare. In contrast, a much larger effect on reducing suicides is possible by reducing the occurrence of new instances of antisocial behavior problems or substance abuse, both of which increase risk for suicide at a lower level than hospitalization for depression but occur much more frequently in the population. To date, suicide prevention funding and policy has focused on reducing risk associated with the highest risk conditions, rather than conditions that have the potential for greatest population impact. Recent findings showing that the Good Behavior Game program implemented in 1st grade classrooms (Kellam et al., 2008) lowered suicidal behavior 15 years later in late adolescence (Watkins et al., 2008) demonstrates the potential suicide prevention impact from targeting early life aggressive-disruptive behaviors, which increase children’s risk for a variety of mental health and substance abuse problems later in development.
- The current focus on treatment of individual disorders also has limited potential for strengthening protective factors within social systems or promoting across large segments of the youth population individual strengths that promote effective coping for adolescents who experience mental health problems and acute stressors. Interventions that modify school settings and communities by increasing youth-adult connectedness (CDC, 2006) or that utilize peer opinion leaders to change coping norms among youth in their social networks (Wyman et al., 2010) are examples of interventions that may enhance the likelihood that depressed or distressed youth will seek and receive help and reduce the occurrence of new instance of suicidal behavior. Similarly, interventions that create positive school climate and reduce bullying (Olweus, 1996) may be cost effective in reducing suicidal behaviors. Among the approaches that can modify social settings and reach large groups are universal programs that target entire school communities or higher risk groups such as children in foster care. The potential impact of such interventions was underscored by a recent Institute of Medicine (2009) report on effective programs that prevent mental, emotional and behavioral disorders, which concluded that integration within natural settings such as schools increases the likelihood that programs will have enduring positive impact (O’Connell, Boat, et al., 2009). Changes in laws and policies that decrease children’s access to weapons may also be cost effective in reducing suicide deaths. In addition, youth development programs targeting young children designed to increase emotional competencies and ‘self-regulation’ (e.g., PATHS, Greenberg et al., 1995) have shown positive impact on reducing ‘distal’ risk factors for suicide (e.g., internalizing and externalizing problems in school), although their potential impact on reducing risk for suicide has not yet been systematically examined.
Identifying Priorities and Overcoming Obstacles to Upstream Suicide Prevention
Suicide prevention researchers, practitioners and policy makers, including the IOM’s (2002) report, have called for an expansion of youth suicide prevention approaches towards universal and selective strategies designed to move prevention ‘upstream’. However, with a few exceptions, progress has been minimal in identifying which prevention strategies hold the greatest promise in having broad population impact in lowering suicide rates or in expanding funding and partnerships for new youth suicide prevention strategies. The following questions are designed to stimulate discussion towards actionable solutions.
- How can partnerships be created from suicide prevention advocacy groups, prevention practitioners, researchers and policy makers to create a critical mass of interest in upstream youth suicide prevention?
- What are the primary barriers that reduce enthusiasm and commitment to upstream prevention by key opinion leaders and groups – such as long time lapses between early prevention programming and outcomes – and what strategies may overcome those barriers?
- How can partnerships be built between researchers and practitioners interested in suicide prevention and prevention scientists who have made progress in developing and disseminating programs in highly relevant areas such as antisocial behavior, depression, and substance abuse prevention,and in mental health promotion?
- How can priority areas be identified for upstream suicide prevention with consensus among key stakeholders including funders necessary to expand implementation and identify the most promising approaches?