A Community Based Suicide Prevention Planning Manual
Have launched a multimodal community-based suicide prevention program. The suicide prevention measures in accordance with the intervention manual. A statistician in the study group will determine the analysis plan, whereas a.
Warning: This online archive of the CDC Prevention Guidelines Database is being maintained for historical purposes, and has had no new entries since October 1998. To find more recent guidelines, please visit the following:. at. at Youth Suicide Prevention Programs: A Resource Guide U.S Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Injury Prevention and Control Publication date: Table of Contents Tables Figures Acknowledgments We wish to express our thanks to the many people who, on their own or as representatives of organizations, provided assistance in the development of this Guide. We are particularly grateful for the guidance in the design and conduct of this study provided by Dr. Mark Rosenberg, Mr. Albert Brasile, and Mr.
Mark Long in the National Center for Injury Prevention and Control, and Ms. Floy Cross and Ms. Diane Roberts in CDC's Office of Program Planning and Evaluation. We would like to especially recognize and thank Ms. Rachel Lysne in the Epidemiology Branch for her extraordinary dedication in providing administrative and clerical support for this project.
Valuable help in initiating and conducting this study was provided by the following individuals:. Barbara Blanton and the staff at the Crisis Center of Collin County, Texas;.
Dr. Ross Connor at the University of California-Davis;. Dr. Martin Gold at the University of Michigan;.
Ms. Myra Herbert at Fairfax County Public Schools in Virginia;. Dr. Joyce Hickson, formerly at Dade County Public Schools in Florida;. Dr. Avram Machtiger, formerly at the Pennsylvania Teenage Suicide Prevention Project;. Ms.
Julie Perlman, Executive Officer at the American Association of Suicidology;. Ms. Diane Ryerson at South Bergen Mental Health Center in New Jersey; and. Ms. Judie Smith at Dallas Independent School District in Texas. Most especially, we want to thank the many volunteers and staff of youth suicide prevention programs who spoke with us, sent us materials, and shared much of their joys, frustrations, and experiences in working to help our country's youth. Patrick O'Carroll, M.D., M.P.H.
James Mercy, Ph.D. James Hersey, Ph.D. Casey Boudreau, M.S. Mary Odell-Butler, Ph.D. Executive Summary/Background and Approach Given the continued high rates of suicide among adolescents and young adults (15-24 years of age), it is more urgent than ever that we apply our limited resources for prevention in the most effective manner possible. To that end, we developed this resource guide to describe the rationale and evidence for the effectiveness of various youth suicide prevention strategies and to identify model programs that incorporate these different strategies. The guide is for use by persons who are interested in developing or augmenting suicide prevention programs in their own communities.
Because the diagnosis and treatment of mental disorders is so widely accepted as a cornerstone of suicide prevention, we excluded from this guide programs that provide mental health services in traditional health service delivery settings. We did include, however, programs that were designed to increase referral to existing mental health services. We developed this resource guide through networking. Initially, 40 experts in youth suicide prevention around the country were asked to identify exemplary youth suicide prevention programs. Representatives from these programs were then contacted and asked to describe their activities and to identify other programs that they considered exemplary.
The list was supplemented by contacting program representatives who participated in the 1990 national meeting of the American Association of Suicidology (AAS) and by soliciting program identification through Newslink, the newsletter of AAS. The resulting list of programs is not meant to represent all exemplary youth suicide prevention programs, but it does characterize the diversity of existing programs and can serve as a resource guide for those interested in learning about the types of prevention activities in the field.
For this guide, we delineated eight different suicide prevention strategies, most of which were incorporated in some combination into the programs we reviewed. These were:. School Gatekeeper Training. This type of program is directed at school staff (teachers, counselors, coaches, etc.
) to help them identify students at risk of suicide and refer such students for help. These programs also teach staff how to respond in cases of a tragic death or other crisis in the school. Community Gatekeeper Training.
This type of gatekeeper program provides training to community members such as clergy, police, merchants, and recreation staff. This training is designed to help these people identify youths at risk of suicide and refer them for help. General Suicide Education.
These school-based programs provide students with facts about suicide, alert them to suicide warning signs, and provide them with information about how to seek help for themselves or for others. These programs often incorporate a variety of self-esteem or social competency development activities. Screening Programs.
Screening involves administration of an instrument to identify high-risk youth in order to provide more thorough assessment and treatment for a smaller, targeted population. Peer Support Programs. These programs, which can be conducted in either school or non-school settings, are designed to foster peer relationships, competency development, and social skills as a method to prevent suicide among high-risk youth. Crisis Centers and Hotlines. These programs primarily provide emergency counseling for suicidal people. Hotlines are usually staffed by trained volunteers. Some programs offer a 'drop-in' crisis center and referral to traditional mental health services.
Means Restriction. This prevention strategy consists of activities designed to restrict access to firearms, drugs, and other common means of committing suicide. Intervention After a Suicide. Strategies have been developed to cope with the crisis sometimes caused by one or more youth suicides in a community. They are designed in part to help prevent or contain suicide clusters and to help youth effectively cope with feelings of loss that come with the sudden death or suicide of a peer.
Preventing further suicides is but one of several goals of intervention made with friends and relatives of a suicide victim- so-called 'postvention' efforts. Findings Overall, we noted that:. Despite many differences, the various prevention strategies incorporated into current youth suicide prevention programs have two common themes. As noted above, we delineated eight different strategies for youth suicide prevention that were generally incorporated in some combination into the programs we reviewed.
Despite their obvious differences, these eight strategies may be considered to constitute just two conceptual categories: (1) strategies to enhance the recognition of suicidal youth and their referral to existing mental health resources, and (2) strategies designed to directly address known or suspected risk factors for youth suicide. Strategies to enhance recognition and referral. This category includes active strategies to identify and refer suicidal youth (general screening programs, targeted screening in the context of an apparent suicide cluster) as well as passive strategies to increase referrals (training school and community gatekeepers, general education about youth suicide, establishing crisis centers and hotlines). Some of the passive strategies are designed to lower barriers to self-referral for those with suicidal feelings; others are designed to increase referrals by persons who recognize suicidal tendencies in someone they know. Strategies to address known or suspected risk factors. This category includes interventions designed to promote self-esteem and build competency in stress management (general suicide education, peer support programs); to develop support networks for youths who have attempted suicide or who are otherwise thought to be at high risk (peer support programs); and to provide crisis counseling or otherwise address the proximal stress events that increase the risk of suicide among susceptible youths (crisis centers and hotlines, interventions to minimize contagion in the context of suicide clusters).
Although means restriction may be critically important in reducing the risk of youth suicide, none of the programs we reviewed placed a major emphasis on this prevention strategy. Most programs focus on teenagers with little emphasis given to suicide among young adults. With a few important exceptions, most programs designed to reduce youth suicide were developed with high school-aged youth in mind. This may be due to the fact that adolescents in high school are easier to reach than young adults 20-24 years of age. But it may also be due to a failure to appreciate that the suicide rate is generally twice as high among persons 20-24 years of age as among adolescents 15-19 years of age. More prevention efforts need to be targeted toward young adults at high risk of suicide.
Current programs are sometimes inadequately linked with existing community mental health resources. Some programs, notably the Pennsylvania Student Assistance Program, have deliberately worked to develop very close ties with community mental health resources. In a substantial number of other programs, however, linkages with existing mental health resources have been somewhat tenuous. We believe that strengthening these ties would substantially enhance suicide prevention efforts. Some strategies are applied very infrequently-despite great apparent potential for success-whereas others are very commonly applied. In particular, despite evidence that restricting access to lethal means of suicide (e.g., firearms and lethal dosages of drugs) may prevent some youths from completing suicide, none of the youth suicide prevention programs we reviewed incorporated this strategy as a major focus of their efforts.
Parents should be educated in suicide warning signs and encouraged to restrict their teens' access to lethal suicide means. Other promising strategies, such as peer support programs for previous suicide attempters or high-risk youth, might also be more widely incorporated into current suicide prevention programs, but great care should be taken to ensure that there are no adverse consequences from involving peers in such activities. Certain potentially effective programs targeted at high-risk youth are not thought of as 'youth suicide prevention' programs. Alcohol and drug abuse treatment programs and programs that provide help and services to runaways, pregnant teens. Or school dropouts are examples of programs that address risk factors for suicide and yet are rarely considered to be suicide prevention programs.
Few of the programs we reviewed had any formal ties with such programs. There is very little evaluation research in this area-indeed, there is very little data collected that would facilitate such research. The tremendous dearth of evaluation research stands as the single greatest obstacle to improving current efforts to prevent youth suicide. In the final analysis, despite many years of experience and hard work, all we can say-and scientifically defend-is that every one of the eight strategies described herein, as currently implemented, may or may not prevent youth suicide.
Clearly, this is an unsatisfactory state of affairs. We urgently need to evaluate existing suicide prevention programs wherever possible and to incorporate the potential for evaluation into al/new prevention programs. Moreover, whenever possible, the outcome measure for such evaluations should be changes in suicidal behavior. After all, it is the level of suicidal behavior-not attitudes toward suicide or knowledge of warning signs-that we are ultimately working to change.
When measuring a program's effect on the level of suicidal behavior is not feasible, the outcomes measured should be those that are closely associated with actual suicidal behavior. In this regard, it is worth noting that any health intervention may have unforeseen negative consequences; suicide prevention efforts are no exception. This is another, even more important reason why evaluation must be built into every youth suicide prevention program. Regardless of the prevention strategy employed, we must be vigilant to ensure that efforts to prevent suicide do not result in untoward consequences. Recommendations Although we do not have sufficient information to recommend one suicide prevention strategy over another at this stage, the following recommendations seem prudent:. Ensure that new and existing suicide prevention programs are linked as closely as possible with professional mental health resources on the community.
As noted, many of the strategies are designed to increase referrals of at-risk youth-this approach can be successful only to the extent that there are appropriate, trained counselors to whom referrals can be made. Avoid reliance on one prevention strategy. Most of the programs we reviewed already incorporate several if not all of the eight strategies we described. However, certain strategies tend to predominate, despite limited evidence of their effectiveness. Incorporate promising but underused strategies into current programs where possible.
The restriction of lethal means by which to commit suicide may be the most important candidate strategy here. Peer support groups for those who have felt suicidal or have attempted suicide also appear promising.
Expand suicide prevention efforts for young adults 20-24 years of age, among whom the suicide rate is twice as high as for adolescents. Incorporate evaluation efforts into all new and existing suicide prevention programs, preferably based on outcome measures such as the incidence of suicidal behavior, or measures closely associated with such incidence. Be aware that suicide prevention efforts, like all health interventions, may have unforeseen negative consequences. Evaluation measures should be designed to identify such consequences, should they occur. Like many prevention programs, the suicide prevention programs described in this resource guide are evolving. They are subject to changes in staff, funding, and program emphasis. Hence, readers should contact programs directly to obtain current information on their activities.
Introduction and Summary/Background For many years, we have known that persons suffering from mental disorders, particularly affective illnesses, are at markedly increased risk of committing suicide. In past decades, most people who died from suicide were older adult males who appeared to have been suffering from clinical depression or other treatable mental disorders at the time of their death.
As a consequence, suicide prevention was viewed primarily as a problem of identifying and treating persons with mental disorders associated with increased risk of suicide. Mental illness is not, of course, a sufficient cause of suicide in itself; if it were, everyone who suffered from mental illness would die from suicide. There are, in fact, a variety of other factors that contribute to any given suicide and, consequently, a variety of potential points for preventive intervention.
Nevertheless, identifying and treating persons with mental disorders remains an important mainstay of suicide prevention. In recent years, however, there has been increasing evidence that we need to go beyond this paradigm for suicide prevention, particularly for young people (CDC, 1986). In 1950, the rate of suicide among adolescents (15-19) was 2.7 per 100,000; among young adults (20-24), the rate was 6.2 per 100,000. By 1980, the rate among both adolescents and young adults had tripled, to 8.5 and 16.1 per 100,000, respectively. This alarming increase in the rate of youth suicide was accompanied by research indicating that only about one-third of adolescent suicide victims appeared to satisfy clinical criteria for depression or other treatable mental illness (Shaffer, et al., 1988).
In response to these findings, concerned people began to implement a variety of innovative programs they believed might help to reduce the rate of youth suicide- Many such programs were designed to enhance the ability of people to recognize signs of suicidal tendencies, either in themselves or in others, and to increase referrals of adolescents and young adults with psychiatric disorders to existing mental health services. Other programs tried to interrupt the chain of suicide causation at another point, by focusing on the social milieu in which suicide occurs, or on so-called 'trigger factors', for suicide, such as a stressful event or the loss of a loved one. Despite these efforts, the rate of youth suicide remains high: in 1988, the rate among adolescents was 11.3 per 100,000; among young adults, the rate was 15.0. Faced with these continuing high suicide rates, it is more urgent than ever that we determine which of the current prevention strategies are effective and, in particular, which are most effective relative to their cost. Over the years, a great variety of suicide prevention programs have been implemented, incorporating many different strategies. Despite this experience, there is still (1) no ready way to identify model programs for others who are interested in developing suicide prevention programs in their own communities, and (2) no consensus as to the relative effectiveness of particular suicide prevention strategies. In the absence of this information, people interested in suicide prevention have had no choice but to employ whatever strategies seemed most appealing, often requiring them to 're-invent the wheel' in their community and, at least potentially, leading them to expend scarce prevention resources on ineffective or relatively less effective strategies.
Development of CDC Resource Guide for Youth Suicide Prevention We developed this resource guide to address these two needs. It is intended as an aid to those who are interested in developing or augmenting youth suicide prevention programs in their own communities. To gather information for the guide, we contacted a wide variety of suicide prevention experts and asked them to identify and describe 'exemplary' youth suicide prevention programs (i.e., programs that in their judgment were likely to be effective in the prevention of suicide). When we cast our net for youth suicide prevention programs, we deliberately excluded programs designed to deliver mental health services in traditional health service delivery settings.
As mentioned previously, the diagnosis and treatment of mental disorders has been and continues to be a cornerstone of suicide prevention. Even among teenagers, at least 1 in 5 suicide victims appears to have been suffering from clinical depression when he or she committed suicide; almost 4 in 10 appear to have had a diagnosable drug abuse disorder (Shaffer, et al., 1988). In addition, the evidence is clear that current treatment for clinical depression and certain other mental disorders is effective in reducing the duration of mental illness. Although there is surprisingly little objective evidence that treating persons with mental disorders actually reduces the overall rate of death from suicide, no one doubts that we must continue our efforts to diagnose and treat persons with mental disorders as part of any larger effort to prevent suicide. Because this approach to suicide prevention is so widely accepted, we excluded traditional mental health service delivery programs from our review. We did include, however, programs that were designed to increase referral to existing mental health services. Study Approach This study was designed to help clarify the issues involved in preventing suicide by describing the types of youth suicide prevention programs that are in operation or that have been proposed.
We began by reviewing research studies on youth suicide prevention. We then attempted to identify and describe exemplary youth suicide prevention programs around the United States. Our general approach was, first, to identify a wide variety of suicide prevention programs that suicide prevention experts considered most likely to be effective and that might be evaluated and replicated. These judgments were made on the basis of a number of broad criteria, including the number of persons exposed to the intervention. The number of years of program operation, the nature and intensity of the intervention, and the availability of data to facilitate evaluation. After identifying these reportedly exemplary programs, we contacted the various program directors to gather further information that we believed would be valuable to others in the suicide prevention community and valuable to us in identifying programs that might be amenable to scientific evaluation. Finally, in compiling this information, we attempted to identify knowledge gaps and the kinds of evaluation questions that, if addressed, would increase our understanding of the effects of youth suicide prevention activities.
We identified the programs described in this report by contacting more than 40 experts in youth suicide prevention around the country and asking them to identify exemplary youth suicide prevention programs. Directors of these programs were then asked to describe their activities and send us any written material about their operations. We expanded our list of contacts by asking the director of each program to identify other programs that they considered exemplary. We supplemented our list by contacting participants in the 1990 national meeting of the American Association of SuicidologY (AAS) and by soliciting responses from program staff in Newslink, the newsletter of AAS. Staff in suicide prevention programs rarely identified more than one or two other exemplary programs- Moreover, the programs nominated were typically in other areas of the country rather than in the same state. This leads us to speculate that the resource network that would allow programs to provide advice to one another and share information is not as well developed as it might be. Programs in the resulting list are described in this report.
This list is not meant to represent all exemplary youth suicide prevention programs, nor does the Centers for Disease Control endorse this list of programs as being the most effective or worthy of emulation. Rather, the programs we describe are intended to characterize the diversity of programs that exists and to serve as a resource guide for those interested in learning about the various types of suicide prevention activities in this field. Youth Suicide prevention programs There is a broad spectrum of youth suicide prevention programs ranging from general education about suicide to crisis center hotlines. The different prevention strategies are designed to prevent suicide in various ways ( ). For example, gatekeeper training and screening programs are designed to identify people at risk of suicide and refer them to mental health services. Conversely, hotlines are intended to help people who are experiencing a crisis. This report focuses on eight different kinds of program activities representing different strategies for suicide prevention-However, suicide prevention programs are typically quite comprehensive, incorporating several different strategies.
For example, general suicide education programs in schools are almost always associated with gatekeeper training for school personnel. Similarly, in many communities, general suicide education programs are conducted by crisis center personnel. Many suicide prevention programs include several of these components in their activities, and many in the field believe that comprehensive programs offering multiple components facilitate the type of synergy and coordination that is more effective than any individual component. Still, in planning, implementing, or evaluating suicide prevention efforts, we need to think about individual program components and prevention strategies. Although prevention programs are typically comprehensive, many program directors recommend implementing one component at a time, in order to get the activity fully operational before new program components are added. In addition, the types of evaluation questions that need to be asked will be quite different for various types of prevention strategies. Therefore, this report has been organized according to major program components and strategies.
School Gatekeeper Training. This type of program is directed at school staff (teachers, counselors, coaches, etc.) to help them identify students at risk of suicide and refer such students as appropriate. These programs also teach staff how to respond in cases of a tragic death or other crisis in the school. Community Gatekeeper Training. This type of gatekeeper program provides training to community members, such as clergy, police, merchants, and recreation staff, as well as physicians, nurses, and other clinicians who see youthful patients. This training is designed to help these people identify youth at risk of suicide and refer them as appropriate.
General Suicide Education. These programs provide students with facts about suicide, alert them to suicide warning signs, and provide information about how to seek help for themselves or for others. These programs often incorporate a variety of self-esteem or social competency development activities.
Screening Programs. Screening involves the administration of an instrument to identify high-risk youth in order to provide more targeted assessment and treatment. Repeated administration of the screening instrument can also be used to measure changes in attitudes or behaviors over time, to test the effectiveness of an employed prevention strategy, and to obtain early warning signs of potential suicidal behavior.
Peer Support Programs. These programs, which can be conducted in either school or non-school settings, are designed to foster peer relationships, competency development, and social skills among youth at high risk of suicide or suicidal behavior. Crisis Centers and Hotlines. Among other services, these programs primarily provide telephone counseling for suicidal people.
Hotlines are usually staffed by trained volunteers. Such programs may also offer a 'drop-in' crisis center and referral to mental health services.
Means Restriction. This prevention strategy consists of activities designed to restrict access to handguns, drugs, and other common means of suicide.
Intervention After a Suicide. Strategies have been developed to cope with the crisis sometimes caused by one or more youth suicides in a community. They are designed in part to help prevent or contain suicide clusters and to help youth effectively cope with feelings of loss that come with the sudden death or suicide of a peer. Preventing further suicides is but one of several goals of interventions made with friends and relatives of a suicide victim-so-called 'postvention' efforts. Report Organization In the chapters that follow, we describe and present the rationale for various types of suicide prevention strategies, review the research on these strategies, provide a brief summary of our judgments concerning the potential and pitfalls of these approaches, and then present brief descriptions of programs that might serve as a resource or guide for others. When program descriptions were sent out for review, program staffers were asked what advice they would share with others who might want to implement that type of program. When supplied, these comments are reported as well.
Summary of Overall Findings Several important conclusions may be drawn from an overall consideration of the information we gathered and collated in this resource guide:. Despite many differences, the various prevention strategies incorporated into current youth suicide prevention programs have two common themes. As noted previously, we delineated eight different strategies for youth suicide prevention that were generally incorporated in some combination into the programs we reviewed. Despite their obvious differences, these eight strategies may be considered to constitute just two conceptual categories:(1) strategies to enhance the recognition of suicidal youth and their referral to existing mental health resources, and (2) strategies designed to directly address known or suspected risk factors for youth suicide.
Suicide
Strategies to enhance recognition and referral. This category includes active strategies to identify and refer suicidal youth (general screening programs, targeted screening in the context of an apparent suicide cluster)as well as passive strategies to increase referrals (training school and community gatekeepers, general education about youth suicide, establishing crisis centers and hotlines). Some of the passive strategies are designed to lower barriers to self-referral for those with suicidal feelings; others are designed to increase referrals by persons who recognize suicidal tendencies in someone they know. Strategies to address known or suspected risk factors. This category includes interventions designed to promote self-esteem and build competency in stress management (general suicide education, peer support programs); to develop support networks for youths who have attempted suicide or who are otherwise thought to be at high risk (peer support programs); and to provide crisis counseling or otherwise address the proximal stress events that increase the risk of suicide among susceptible youths (crisis centers and hotlines, interventions to minimize contagion in the context of suicide clusters). Although means restriction may be critically important in reducing the risk of youth suicide, none of the programs we reviewed placed a major emphasis on this prevention strategy. Most programs focus on teenagers, with little emphasis given to suicide prevention among young adults- With a few important exceptions, most programs designed to reduce youth suicide were developed with high school-aged youth in mind.
This may be due to the fact that adolescents in high school are easier to reach than young adults 20-24 years of age. But it may also be due to a failure to appreciate that the suicide rate is generally twice as great among persons 20-24 years of age as among adolescents 15-19 years of age. More prevention efforts need to be targeted toward young adults at high risk of suicide. Current programs are sometimes inadequately linked with existing community mental health resources.
Some programs, notably the pennsylvania Student Assistance Program, have deliberately worked to develop very close ties with community mental health resources. In a substantial number of other programs, linkages with existing mental health resources have been somewhat tenuous. We believe that strengthening these ties would substantially enhance suicide prevention efforts. Some strategies are applied very infrequently-despite great apparent potential for success-whereas others are very commonly applied.
In particular, despite evidence that restricting access to lethal means of suicide (e.g., firearms and lethal dosages of drugs) may prevent some youths from completing suicide, none of the youth suicide prevention programs we reviewed incorporated this strategy as a major focus of their efforts. Parents should be educated in suicide warning signs and encouraged to restrict their teens' access to lethal suicide means.
Other promising strategies, such as peer support programs for previous suicide attempters or high-risk youth, might also be more widely incorporated into current suicide prevention programs, but great care should be taken to ensure that there are no adverse consequences from involving peers in such activities. In contrast, school-based general suicide education is a commonly employed youth suicide prevention strategy (Appendix B). This is probably because it is a fairly easy and inexpensive way to reach a large audience. In addition, school-based educational efforts may be an intuitively appealing approach to addressing any problem among adolescents. In this case, however, there is little evidence to support school-based education as a predominant approach to adolescent suicide prevention. In many instances (not necessarily in the programs described herein, but in many other programs of which the authors are aware), the educational intervention consists of a very brief, one-time lecture on the warning signs of suicide, a method which seems unlikely to have any substantial or lasting impact on a student's risk of suicide. Moreover, general school-based suicide curricula may not be effective for those adolescents whom one most wishes to reach: those who have attempted suicide or have considered suicide as a solution to their problems in the past.
Students who have previously attempted suicide may react more negatively to such curricula than students without a history of attempted suicide. While the effects-positive or negative-of such general educational approaches are still unclear, many suicide researchers believe that broader curricula that address suicide prevention in the context of other adolescent health issues are preferable to curricula that only address suicide. Certain potentially effective programs targeted at high-risk youth are not thought of as 'youth suicide prevention' programs. Alcohol and drug abuse treatment programs and programs that provide help and services to runaways, pregnant teens, or school dropouts are examples of programs that address risk factors for suicide and yet are rarely considered to be suicide prevention programs.
Few of the programs we reviewed had any formal ties with such programs. There is very little evaluation research in this area- indeed, there is very little data collected that would facilitate such research. The tremendous dearth of evaluation research in this area stands as the single greatest obstacle to improving current efforts to prevent youth suicide. In the final analysis, despite many years of experience and hard work, all we can say-and scientifically defend-is that every one of the eight strategies described herein, as currently implemented, may or may not prevent youth suicide.
Clearly, this is an unsatisfactory state of affairs. We urgently need to evaluate existing suicide prevention programs wherever possible and to incorporate the potential for evaluation into all new prevention programs. Moreover, whenever possible, the outcome measure for such evaluations should be changes in suicidal behavior. After all, it is the level of suicidal behavior-not attitudes toward suicide or knowledge of warning signs-that we are ultimately working to change.
When measuring a program's effect on the level of suicidal behavior is not feasible, the outcomes measured should be those that are closely associated with actual suicidal behavior. In this regard, it is worth noting that any health intervention may have unforeseen negative consequences; suicide prevention efforts are no exception. This is another, even more important reason why evaluation must be built into every youth suicide prevention program. Regardless of the prevention strategy employed, we must be vigilant to ensure that efforts to prevent suicide do not result in untoward consequences. Recommendations Although we do not have sufficient information to recommend one suicide prevention strategy over another at this stage, the following recommendations seem prudent:. Ensure that new and existing suicide prevention programs are linked as closely as possible with professional mental health resources in the community. As noted, many of the strategies are designed to increase referrals of at-risk youth-this approach can be successful only to the extent that there are appropriate, trained counselors to whom referrals can be made.
Avoid reliance on one prevention strategy. Most of the programs we reviewed already incorporate several if not all of the eight strategies we described. However, as noted, certain strategies tend to predominate, despite limited evidence of their effectiveness. Incorporate promising but underused strategies into current programs where possible.
The restriction of lethal means by which to commit suicide may be the most important candidate strategy here. Peer support groups for those who have felt suicidal or have attempted suicide also appear promising, but great care should be taken to ensure that there are no adverse consequences from involving peers in such activities. Expand suicide prevention efforts for young adults 20-24 years of age, among whom the suicide rate is twice as high as for adolescents.
Incorporate evaluation efforts into all new and existing suicide prevention programs, preferably based on outcome measures, such as the incidence of suicidal behavior, or measures closely associated with such behavior. Be aware that suicide prevention efforts, like all health interventions, may have unforeseen negative consequences. Evaluation measures should be designed to identify such consequences, should they occur. When developing a youth suicide prevention program in a particular community, the needs and resources of the community must be identified to determine which strategy or combination of strategies is most appropriate.
We hope that the information in this document will help communities make this determination. Finally, like many prevention programs, the suicide prevention programs described in this resource guide are evolving. They are subject to changes in staff, funding, and program emphasis. Hence, readers should contact programs directly to obtain current information on their activities. References Used in the Introduction Centers for Disease Control. Youth Suicide in the United States, 1970-1980. Atlanta: Centers for Disease Control, 1986.
Shaffer, D., Garland, A., Gould, M., Fisher, P., and Trautman, P. Preventing teenage suicide: a critical review. Journal of the American Academy of Child and Adolescent Psychiatry 1988;27:675-687. School Gatekeeper Training/Overview and Rationale Gatekeeper training programs are designed to help members of the community identify youth with a high potential for suicide and refer them to appropriate sources of help. A 'gatekeeper' can be anyone who has significant contact with youth during the course of the day, such as coaches, clergy, police, or volunteers.
A particularly important group of gatekeepers is school personnel. Because of their importance and the effort that has been devoted to developing programs for school personnel, these programs are described in this chapter. The next chapter, 'Community Gatekeeper Training,' focuses on programs for gatekeepers who can reach youth in other settings.
School gatekeeper training programs are school-based programs designed to help school staff identify students at risk of suicide and to refer them for help. School gatekeepers may include any adult in the school (e.g., counselors, teachers, coaches, administrators or cafeteria staff) in a position to observe and interact with students.
Gatekeeper training usually consists of learning about warning signs of suicide, what referral sources exist and how to contact them, and what the school policy is for handling crisis situations. Other topics include legal issues involved with suicide and how to communicate with at-risk students. As illustrated in, knowledge of these topics enhances the ability of school staff to handle potentially suicidal students and to refer them to appropriate sources of help. School gatekeeper training is primarily intended to educate staff on how to identify students with emotional or other problems who may also be potentially suicidal. It is not meant to replace professional mental health care or to empower school staff to act as counselors but is simply meant to enable staff to 'sound the alarm.' Combined with appropriate professional treatment, this intervention may help prevent suicides.
School gatekeeper programs may also help school staff recognize and take action to reduce sources of stress in the social environment of the school system, such as adjustment to a new school (Caplan, 1964, Kelly, 1979), and to develop relationships with students at times of transition or vulnerability that can help them in their subsequent functioning (Hersey, 1977). Research Findings School gatekeeper training programs have been well received by teachers and school staff. Staff have reported these programs as helpful in California (Nelson, 1987), Colorado (Barrett, 1985), and Rhode Island (Spirito, et al., 1988). For example, as shown in , researchers evaluating the school gatekeeper education component of the New Jersey Adolescent Suicide Prevention Project found that school personnel who participated in a 2-hour training program showed increased awareness of suicide warning signs, knowledge of treatment resources, and willingness to make referrals to mental health professionals (Shaffer, Garland, and Whittle, 1988). Improvements in knowledge were also observed in the evaluation of a gatekeeper education program in Colorado (Barrett, 1985).
In addition, Barrett found that referrals for counseling increased after a school gatekeeper training program. A delphi panel of experts estimated that school gatekeeper programs could reduce youth suicide by about 12 percent (Eddy, Wolpert, and Rosenberg, 1989). We are not aware, however, of any formal evaluation of the effect of school gatekeeper training on changes in the behavior of trainees. Illustrative Programs This report lists eight programs as examples of school gatekeeper training programs. These programs were selected because of their substantial time in operation, the extensiveness of the training they provided, and their tie-in with mental health or other more comprehensive youth suicide prevention programs. These programs are included: Program Rationale for Inclusion - - East: BRIDGES - Comprehensive program Piscataway, New Jersey - Plans for evaluation Pennsylvania Network for Student - Extent of training Assistance Services (PNSAS) - Linkage with mental health Pittsburgh, Pennsylvania agencies.
Background To respond to the rapid surge in the incidence of suicide in Japan, which appears to be an ongoing trend, the Japanese Multimodal Intervention Trials for Suicide Prevention (J-MISP) have launched a multimodal community-based suicide prevention program, NOCOMIT-J. The primary aim of this study is to examine whether NOCOMIT-J is effective in reducing suicidal behavior in the community. Methods/DesignThis study is a community intervention trial involving seven intervention regions with accompanying control regions, all with populations of statistically sufficient size. The program focuses on building social support networks in the public health system for suicide prevention and mental health promotion, intending to reinforce human relationships in the community. The intervention program components includes a primary prevention measures of awareness campaign for the public and key personnel, secondary prevention measures for screening of, and assisting, high-risk individuals, after-care for individuals bereaved by suicide, and other measures. The intervention started in July 2006, and will continue for 3.5 years. Participants are Japanese and foreign residents living in the intervention and control regions (a total of population of 2,120,000 individuals).
Recent rapid increase of suicide in Japan (1) Changes in suicide incidence According to vital statistics collected by the Japan Ministry of Health, Labour, and Welfare in 1997, there were 23,494 suicides (15,901 men and 7,593 women), with the number rising to 31,755 (22,349 men and 9,406 women) in 1998, which represented a 35% increase. This was the highest rate of increase recorded since the Ministry began tracking mortality statistics. The number of suicides remained high in subsequent years, reaching 29,949 in 2002 and 32,109 in 2003.
In 2002, the World Health Organization (WHO) reported that the suicide rate in Japan (25.3 per 100,000) was higher than in any other developed nation (for comparison: France: 17.5, Germany: 13.5, Canada: 11.7, United States of America: 10.4, United Kingdom: 7.5, Italy: 7.1). In terms of the number of suicides, three peaks have emerged since World War II. However, the most recent rise that started in 1998 has shown no signs of abating, and represents the worst in Japan's history. Therefore, it is clear that suicide prevention measures are urgently needed in Japan.
(2) Regional tendencies It has been pointed out that the suicide rate has traditionally been high in the three prefectures of the northern Tohoku area (Akita, Iwate, and Aomori), Niigata, Shimane, and the Kyushu area (Miyazaki, Kagoshima, and Okinawa). The increase in the number of suicides that began in 1998, however, was not necessarily attributable to suicides in these rural areas. Fujita (2003) conducted a comparative study of suicide rates by prefecture by comparing a time period with a low number of suicides (1989–1995) to time periods before and after, during which the number of suicides was on the rise (1983–1987 and 1998–2000, respectively).
The findings indicated that the recent increase in the number of suicides has been significantly more prominent in urban areas such as Tokyo, Osaka, and their surrounding areas, than in rural areas. During the two periods 1989–1995 and 1998–2000, the mean number of suicides among people 15 years of age or older rose from 894 to 1,658 in Osaka, from 713 to 1,309 in Kanagawa, and from 1,129 to 1,938 in Tokyo. With regard to recent trends in suicide rate by age, the middle-aged population was found to have higher suicide rates. In 2004, 42.1% of those who committed suicide were 45 to 64 years old. This tendency was particularly evident among men, in whom the suicide rate peaked at 55 to 59 years of age, whereas a similar trend was not found in women, in whom the suicide rate generally increased with age. (3) Causes and motives for suicide According to the statistics of the National Police Agency, health and financial/lifestyle problems were the top two reasons for suicide. Although this tendency remained the same during the increase in suicides that began in 1998, the number of suicides due to financial/lifestyle problems has increased more rapidly compared to suicides committed due to health problems.
Among those who committed suicide with or without suicide notes in 1997, 13,659 individuals (56.0%) did so due to health problems and 3,556 individuals (14.6%) due to financial/lifestyle problems. These numbers rose to 16,769 (51.0%, a 22.8% increase over the previous year) and 6,058 (18.4%, a 70.4% increase over the previous year), respectively, in 1998. In terms of those with health problems, the number of suicides subsequently decreased in 2004 to 14,786 (45.7%), whereas the number of suicides due to financial/lifestyle problems increased to 7,947 (24.6%). This indicates that the percentage of suicides due to financial/lifestyle problems has been increasing. Recent suicide prevention programs in Japan Many suicide prevention measures have been implemented internationally –.
In Japan, evidence has also emerged recently to support the effectiveness of community-based programs for suicide prevention. Seven community-based intervention trials implemented for five years or more have been conducted between 1985 and 2005 in Japan. All the trials used a quasi-experimental design and included suicide rate as the primary outcome. These suicide prevention programs included the development of social support networks in the community and/or depression screening for residents with follow-up by physicians. All the intervention programs were also administered by local governments. Six of the seven trials targeted individuals aged 65 years and older.
The first trial was conducted in Matsunoyama, Niigata prefecture. During the 10-year implementation period, the suicide rate of over 150 per 100,000 decreased by 75% for both men and women aged 65 years and older. In the trials conducted in Joboji (Iwate pref.), Nagawa (Aomori pref.), Matsudai and Yasuzuka (Niigata pref.), and Yuri (Akita pref.), the suicide prevention program significantly reduced the suicide risk for individuals aged 65 years and older –. Recently, a relatively large, multimodal intervention trial targeting all age groups was conducted in four municipalities of Akita. During the four-year implementation period, the suicide rate of 68 per 100,000 for all residents was reduced by 27%.
The results of these seven trials suggest that community-based intervention would be effective for preventing suicide and that the increase of suicide deaths in Japan may be related to more pervasive social isolation than in the past, and to an absence of personal psycho-social development compared with financial success. However, the sample sizes in these trials were relatively small and the monitoring of the implementation process was insufficient. Furthermore, since the trials were conducted in rural areas with high suicide rates, it is still unclear whether similar community-based programs would be effective in urban areas where the suicide rates have increased rapidly. Therefore large, community-based intervention trials with adequate controls should be conducted to develop an effective, evidence-based suicide prevention program to reduce the future suicide rate in Japan. Objectives of this study.
A community intervention trial will be conducted to evaluate the effectiveness of a novel suicide intervention program. In this study, the incidence of suicidal behavior in an intervention group and a control group will be compared. Organization The Japan Ministry of Health, Labour, and Welfare selected the Japan Foundation for Neuroscience and Mental Health (JFNMH) as the primary institution responsible for the strategic research program for suicide prevention. The JFNMH conducts the program 'Japanese Multimodal Intervention Trials for Suicide Prevention, J-MISP' in close collaboration with the National Center of Neurology and Psychiatry.
NOCOMIT-J is one of two research projects being conducted by J-MISP. The other is a randomized, controlled, multicenter trial of post-suicide attempt case management for prevention of further attempts in Japan (ACTION-J). The principal investigator of NOCOMIT-J and the sub-leader will supervise the study group in order to conduct and complete the study effectively. The study group management office will engage in overall administrative procedures regarding the operation of the study group. It will also set up and operate the study group steering committee and the intervention program committees, hold the research conference, and respond to questions from institutions in the participating regions.
The J-MISP director, the principal investigator of the NOCOMIT-J, and the regional leaders share the information and collaborate to resolve problems and safety issues with the help of the steering committee and the Central and Local Research Ethics Committee. The study group steering committee will be composed of regional leaders and other key members of the study group. Research meetings will be held upon the principal investigator's request.
At the meetings, the intervention program committee will present the agenda, after which important issues, such as revision of the protocol or stopping of the study, will be discussed. Participants and Participating Areas Participants The participants will include Japanese and foreign residents living in the intervention and control regions. Eligibility Criteria. These assumptions of the outcome and suicide rates (2002–2004) are used to calculate the sample sizes in this study.
Group1: regions with a relatively high suicide rate compared to control regions, examined to gauge the effectiveness of the community-based multimodal intervention program for suicide prevention. Group 2: highly-populated regions, examined in order to explore the effectiveness of the community-based multimodal intervention program for suicide prevention. Although the estimated sample sizes are not adjusted for 5-year age group, sex, and regional characteristics, if all assumptions are met, the statistical power will be over 80% for each group, regarding person-year incidences in the intervention and control regions. Using the O'Brien-Fleming method in the interim analysis, the significance level in the final analysis is estimated to be 4.9% for a two-sided test.
In addition, the statistical power will be over 80% in each group. Intervention The intervention program will be implemented by local authorities. Suicide prevention program in control regions The interventions in the control regions include the usual suicide prevention programs. Suicide prevention programs in intervention regions The local health authorities will implement the suicide prevention measures in accordance with the intervention manual developed by the program committee of the study group. To better enhance the quality of the essential intervention activities, the local health authority is also requested to share with the other study group members the information on the program tools. The program components.
Study period Study period: August 2005 to March 2010. Intervention period: July 2006 to December 2009. Approval of the study protocol This study protocol was reviewed and approved by the Central Research Ethics Committee of the J-MISP. Additionally, the regional leaders will ask the local governors for cooperation, and obtain written authorization to conduct the study. Regional leaders will obtain approval from the ethics committees of affiliated universities or hospitals.
Data collection Baseline Information Data will be collected for the items below: (1) Statistics on suicide The number of suicides in the 3 years prior to the study (2003–2005) in the study regions was recorded by sex and 5-year age group the Japan Ministry of Health, Labour, and Welfare. (2) Information from the emergency report Information on 'self-harmed' individuals transported by ambulance in the 3 years prior to the study was collected from the emergency reports of ambulance service. (3) Demographic information A total population count in the regions in the 3 years prior to the study was recorded by sex and 5-year age group by each local governments. (4) Regional characteristics The following information was collected from published statistical data sources: geographic information, proportion of unmarried individuals, widowed spouses, divorcees, nuclear families, the unemployed, individuals in the labor force, and the annual population turnover in the regions. (5) Suicide prevention programs in existence prior to the study Baseline information concerning suicide prevention programs implemented in each region 3 years prior to the study will be recorded by each regions.
Intervention program process monitoring Every 6 months, each regional leader will collect information regarding the implemented projects described in the intervention program manual. Data collection during the study (1) Information on suicides After consent is obtained for the use of designated statistics for other purposes, information regarding the number of suicides in the participating regions will be collected.
Death certificates from the Vital Statistics records from 2006, 2007, 2008, and 2009 for the intervention and control regions will be used to collect the following data items: International Classification of Diseases 10th Revision (ICD-10) code for intentional self-harm (ICD-10 codes X60–X84), residence of individuals who committed suicide (municipality codes), cause of death, external cause of death (ICD-10 code), measure of suicide (ICD-10), sex, age, reported place (municipality codes), and identification number. (2) Information regarding suicidal behavior Information regarding 'self-harmed' individuals transported by ambulance will be collected from emergency reports. The following information will be collected regarding 'self-harmed' individuals every 6 months: type of transportation, date of notification, residence address, destination address, incidence location, severity (death, severe, moderate, mild, other), sex, age, and means of self-harm infliction.
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(3) Demographic information Total population numbers in the regions will be collected every year between 2006 and 2009. (4) Information regarding ongoing suicide prevention programs Information regarding the existence and implementation of suicide prevention programs in each participating region will be collected every 6 months. Responsibility for data collection Regional leaders are responsible for collecting data from each municipality and sending the data set to the data management center in a timely manner.
Data management Collected data will be exclusively managed by the data management center. The data set will comply with the data management procedures and the Personal Information Protection Law. The data set will be periodically duplicated and saved as a backup file. Outcomes Primary outcome The incidence of suicidal behavior (completed suicides and suicide attempts excluding mild cases reported on emergency reports).
Secondary outcomes. Statistical analysis Primary analysis In the primary analysis, the incidence of suicidal behavior will be calculated based on the number of suicidal behavior per person-year for the annual population. Data obtained will include the incidence of suicidal behavior and its 95% confidence intervals adjusted by sex, 5-year age group, and regional characteristics. This data will be compared between the intervention and control regions in 'Group 1'. The significance level will be set at 0.05 for the two-sided test, and will be adjusted in the final analysis based on the methods of O'Brien and Fleming for interim analysis. Additionally, regression analysis will also be performed to examine the interactions among sex, 5-year age group, and regional characteristics. A statistician in the study group will determine the analysis plan, whereas a different independent statistician will perform the interim analysis.
The independent statistician will not contribute to the revision of the statistical analysis plan after interim analysis. Interim analysis and rules for stopping or revising the study protocol The interim analysis in 'Group 1' will be performed 2 years after the study's implementation to evaluate the achievement of the primary objectives. Multiplicity will be adjusted using the methods of O'Brien and Fleming, in order to maintain Type-1 error at 0.05 for the two-sided test. The results will be reported to the Central Research Ethics Committee, which is expected to make recommendations to the J-MISP director to either stop the study or revise the study protocol if the primary objective of the study has already been achieved or is unlikely to be achieved. Secondary analysis In addition to the primary analysis, it will also be evaluated whether the primary outcome (the incidence of suicidal behavior) is also significantly reduced in intervention regions of 'Group 2' areas, as a consequence of implementation of the program, when compared to control regions. The incidence of suicidal behavior will be investigated in Groups 1 and 2 combined. The analysis will be performed using the primary analysis plan described above.
Secondary outcomes will also be examined in order to determine whether the rate of completed suicides and suicide attempts – including individuals with severe, moderate, and mild self-harm transported to a hospital – is significantly reduced in the intervention regions, when compared to the control regions in 'Group 1' and 'Group 2'. The same will be examined for both groups combined. Subgroup analysis of the primary and secondary outcomes will be performed by sex, 5-year age group, and regional characteristics in 'Group 1', 'Group 2', and both groups combined. In addition, the incidence of suicidal behavior adjusted by sex and 5-year age group in the intervention and control regions will be calculated using the model population in 1985 as a reference population.
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Because of the exploratory nature of the secondary analysis, no adjustment for multiplicity will be made. Ethical considerations The rights and welfare of the participating residents will be protected according to the World Medical Association Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects. The study will comply with the ethical guidelines of the Ministry of Education, Culture, Sports, Science and Technology, as well as the Ministry of Health, Labour, and Welfare. Ethical validity, including safety, scientific legitimacy, and the reliability of results are to be ensured. This study will also comply with the ethical guidelines for epidemiologic studies and the Personal Information Protection law.
The NOCOMIT-J principal investigator and the J-MISP director will be responsible for the protection of personal information during the study. The data collected in this study will not include personal identification that would enable individuals to be identified. The data management center will collect only anonymous data. Stopping of the study.
Revision of the study protocol and due process The J-MISP director is to inform the NOCOMIT-J principal investigator of the decisions of the Central Research Ethics Committee as soon as possible, when the Central Research Ethics Committee recommends that the study be redesigned due to the emergence of safety issues based on the interim analysis, periodic monitoring, and/or emergence of serious issues that might affect the conduct of future studies. The J-MISP director is to call a meeting of the study group and discuss the revision of the study protocol.
If a recommendation to revise the study protocol is made, the principal investigator of the NOCOMIT-J will propose the revised study protocol as soon as possible and submit the proposal to the J-MISP director. The J-MISP director will deliberate and approve the proposal at the Central Research Ethics Committee meeting and adopt the revision of the study protocol after deliberation in the steering committee. The study group management office will inform all of the participating researchers, and regional leaders will submit the proposed revision to the Local Research Ethics Committee and local government in each of the participating regions.
The revision of the study protocol is to be implemented when approved. Study monitoring Periodic monitoring The regional leaders will periodically (once every 6 months) submit reports evaluating the progress of the study to the intervention program committee. The intervention program committee will submit a process evaluation monitoring report to the study group management office and J-MISP administration office once every 6 months. The J-MISP administration office will consider the progress of the research and submit the process evaluation monitoring report to the progress control committee and the Central Research Ethics Committee of the J-MISP. The data management center will submit an event monitoring report to the J-MISP administration office. The office will submit event monitoring reports to the progress control committee, Central Research Ethics Committee, and the study group management office. The event monitoring report, which will contain the results of the analysis separated by intervention and control groups, will be submitted to the progress control committee and Central Research Ethics Committee.
The results of the data analyzed from both groups combined will be submitted to the study group management office. The progress control committee will examine the monitoring reports and submit the evaluation to the J-MISP director. The Central Research Ethics Committee will examine the monitoring reports as a third party, and make recommendations to revise the study protocol or discontinue the study to the J-MISP director when and if ethical problems, such as safety and efficacy issues, arise.
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Monitoring reports.