Programs for the Prevention of Suicide Among Adolescents and Young Adults

The following CDC staff members prepared this report:

Patrick W. O'Carroll, M.D., M.P.H.

Office of the Director Office of Program Support

Lloyd B. Potter, Ph.D., M.P.H.

James A. Mercy, Ph.D. National Center for Injury Prevention and Control

Summary

Incidence rates of suicide and attempted suicide among adolescents and young adults aged 15-24 years continue to remain at high levels. In 1992, to aid communities in developing new or augmenting existing suicide prevention programs directed toward this age group, CDC's National Center for Injury Prevention and Control published Youth Suicide Prevention Programs: A Resource Guide. The Resource Guide describes the rationale and evidence for the effectiveness of various suicide prevention strategies, and it identifies model programs that incorporate these strategies. This summary of the Resource Guide describes eight suicide prevention strategies and provides general recommendations for the development, implementation, and evaluation of suicide prevention programs targeted toward this age group.

INTRODUCTION

The continued high rates of suicide among adolescents (i.e., persons aged 15-19 years) and young adults (persons aged 20-24 years) (Table_1) have heightened the need for allocation of prevention resources. To better focus these resources, CDC's National Center for Injury Prevention and Control recently published Youth Suicide Prevention Programs: A Resource Guide (1). The guide describes the rationale and evidence for the effectiveness of various suicide prevention strategies and identifies model programs that incorporate these strategies. It is intended as an aid for communities interested in developing or augmenting suicide prevention programs targeted toward adolescents and young adults. This report summarizes the eight prevention strategies described in the Resource Guide.

METHODOLOGY

Suicide prevention programs were identified by contacting suicide prevention experts in the United States and Canada and asking them to name and describe suicide prevention programs for adolescents and young adults that, based on their experience and assessment, were likely to be effective in preventing suicide. After compiling an initial list, program represen- tatives were contacted and asked to describe the number of persons exposed to the intervention, the number of years the program had been operating, the nature and intensity of the intervention, and the availability of data to facilitate evaluation. Program representatives were also asked to identify other programs that they considered exemplary. Representatives from these programs were contacted and asked to describe their programs. The list of programs was further supplemented by contacting program representatives who participated in the 1990 national meeting of the American Association of Suicidology and by soliciting program contacts through Newslink, the association's newsletter.

Suicide prevention programs on the list were then categorized according to the nature of the prevention strategy using a framework of eight suicide prevention strategies:

• School gatekeeper training. This type of program is designed to help school staff (e.g., teachers, counselors, and coaches) identify and refer students at risk for suicide. These programs also teach staff how to respond to suicide or other crises in the school.

• Community gatekeeper training. These programs train community members (e.g., clergy, police, merchants, and recreation staff) and clinical health-care providers who see adolescent and young adult patients (e.g., physicians and nurses) to identify and refer persons in this age group who are at risk for suicide.

• General suicide education. Students learn about suicide, its warning signs, and how to seek help for themselves or others. These programs often incorporate a variety of activities that develop self-esteem and social competency.

• Screening programs. A questionnaire or other screening instrument is used to identify high-risk adolescents and young adults and provide further assessment and treatment. Repeated assessment can be used to measure changes in attitudes or behaviors over time, to test the effectiveness of a prevention strategy, and to detect potential suicidal behavior.

• Peer support programs. These programs, which can be conducted in or outside of school, are designed to foster peer relationships and competency in social skills among high-risk adolescents and young adults.

• Crisis centers and hotlines. Trained volunteers and paid staff provide telephone counseling and other services for suicidal persons. Such programs also may offer a "drop-in" crisis center and referral to mental health services.

• Restriction of access to lethal means. Activities are designed to restrict access to handguns, drugs, and other common means of suicide.

• Intervention after a suicide. These programs focus on friends and relatives of persons who have committed suicide. They are partially designed to help prevent or contain suicide clusters and to help adolescents and young adults cope effectively with the feelings of loss that follow the sudden death or suicide of a peer.

After categorizing suicide prevention efforts according to this framework, an expert group at CDC reviewed the list to identify recurrent themes across the different categories and to suggest directions for future research and intervention.

FINDINGS

The following conclusions were derived from information published in the Resource Guide:

• Strategies in suicide prevention programs for adolescents and young adults focus on two general themes. Although the eight strategies for suicide prevention programs for adolescents and young adults differ, they can be classified into two conceptual categories:

1. Strategies to identify and refer suicidal adolescents and young adults for mental health care. This category includes active strategies (e.g., general screening programs and targeted screening in the event of a suicide) and passive strategies (e.g., training school and community gatekeepers, providing general education about suicide, and establishing crisis centers and hotlines). Some passive strategies are designed to lower barriers to self-referral, and others seek to increase referrals by persons who recognize suicidal tendencies in someone they know.

2. Strategies to address known or suspected risk factors for suicide among adolescents and young adults. These interventions include promoting self-esteem and teaching stress management (e.g., general suicide education and peer support programs); developing support networks for high-risk adolescents and young adults (peer support programs); and providing crisis counseling (crisis centers, hotlines, and interventions to minimize contagion in the context of suicide clusters). Although restricting access to the means of committing suicide may be critically important in reducing risk, none of the programs reviewed placed major emphasis on this strategy.

In contrast, school-based education on suicide is a common strategy. This approach is relatively simple to implement, and it is a cost-effective way to reach a large proportion of adolescents. However, evidence to indicate the effectiveness of school-based suicide education is sparse. Educational interventions often consist of a brief, one-time lecture on the warning signs of suicide -- a method that is unlikely to have substantial or sustained impact and that may not reach high-risk students (e.g., those who have considered or attempted suicide). Further, students who have attempted suicide previously may react more negatively to such curricula than students who have not. The relative balance of the positive and the potentially negative effects of these general educational approaches is unclear.

• Many programs with potential for reducing suicide among adolescents and young adults are not considered or evaluated as suicide prevention programs. Programs designed to improve other psychosocial problem areas among adolescents and young adults (e.g., alcohol- and drug-abuse treatment programs or programs that provide help and services to runaways, pregnant teenagers, and/or high school dropouts) often address risk factors for suicide. However, such programs are rarely considered suicide prevention programs, and evaluations of such programs rarely consider their effect on suicidal behavior. A review of the suicide prevention programs discussed in the Resource Guide indicated that only a small number maintained working relationships with these other programs.

• The effectiveness of suicide prevention programs has not been demon- strated. The lack of evaluation research is the single greatest obstacle to improving current efforts to prevent suicide among adolescents and young adults. Without evidence to support the potential of a program for reducing suicidal behavior, recommending one approach over another for any given population is difficult.

RECOMMENDATIONS

Because current scientific information about the efficacy of suicide prevention strategies is insufficient, the Resource Guide does not recommend one strategy over another. However, the following general recommendations should be considered:

• Ensure that suicide prevention programs are linked as closely as possible with professional mental health resources in the community. Strategies designed to increase referrals of at-risk adolescents and young adults can be successful only to the extent that trained counselors are available and mechanisms for linking at-risk persons with resources are operational.

• Avoid reliance on one prevention strategy. Most of the programs reviewed already incorporate several of the eight strategies described. However, as noted, certain strategies tend to predominate despite insufficient evidence of their effectiveness. Given the limited knowledge regarding the effectiveness of any one program, a multi-faceted approach to suicide prevention is recommended.

• Incorporate promising, but underused, strategies into current programs where possible. Restricting access to lethal means of committing suicide may be the most promising underused strategy. Parents should be taught to recognize the warning signs for suicide and encouraged to restrict their teenagers' access to lethal means. Peer support groups for adolescents and young adults who have exhibited suicidal behaviors or who have contemplated and/or attempted suicide also appear promising but should be implemented carefully. Establishment of working relationships with other prevention programs, such as alcohol- and drug-abuse treatment programs, may enhance suicide prevention efforts. Furthermore, when school-based education is used, program planners should consider broad curricula that address suicide prevention in conjunction with other adolescent health issues before considering curricula that address only suicide.

• Expand suicide prevention efforts for young adults. The suicide rate for persons in this age group is substantially higher than that for adoles- cents, yet programs targeted toward them are sparse. More prevention efforts should be targeted toward young adults at high risk for suicide.

• Incorporate evaluation efforts into suicide prevention programs. Planning, process, and outcome evaluation are important components of any public health effort. Efforts to conduct outcome evaluation are imper- ative given the lack of knowledge regarding the effectiveness of suicide prevention programs. Outcome evaluation should include measures such as incidence of suicidal behavior or measures closely associated with such incidence (e.g., measures of suicidal ideation, clinical depression, and alcohol abuse). Program directors should be aware that suicide prevention efforts, like most health interventions, may have unforeseen negative consequences. Evaluation measures should be designed to detect such consequences.

For a copy of the full report, Youth Suicide Prevention Programs: A Resource Guide, write to Lloyd Potter, Ph.D., M.P.H., at the Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 4770 Buford Highway, Mailstop K-60, Atlanta, GA 30341-3724. Single copies are available free of charge.

Reference

1. CDC. Youth suicide prevention programs: a resource guide. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992.

TABLE 1. Suicide rates * for persons 15-24 years of age, by age group and sex -- United
States, 1950, 1960, 1970, 1980, and 1990
=========================================================================================
                                                 Year
                               ----------------------------------------
Age group (yrs)/Sex            1950     1960     1970     1980     1990
-----------------------------------------------------------------------
   15-19
     Male                       3.5      5.6      8.8     13.8     18.1
     Female                     1.8      1.6      2.9      3.0      3.7
     Total                      2.7      3.6      5.9      8.5     11.1

   20-24
     Male                       9.3     11.5     19.2     26.8     25.7
     Female                     3.3      2.9      5.6      5.5      4.1
     Total                      6.2      7.1     12.2     16.1     15.1

   15-24
     Male                       6.5      8.2     13.5     20.2     22.0
     Female                     2.6      2.2      4.2      4.3      3.9
     Total                      4.5      5.2      8.8     12.3     13.2
-----------------------------------------------------------------------
* Per 100,000 persons.

Source: National Center for Health Statistics, CDC.
=========================================================================================

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