Youth Suicide

Instructions:

Please choose a health topic that interests you and that you might operate as a health promotional program in the future or as part of this class. Using the Internet, find sources and review the current literature on this topic. Find 5 sources that are relevant to your topic¾the majority (4 sources) should be from peer-reviewed journals.

Some guiding questions to help your Internet search:

· How significant is this health condition?
 ·  What causes this condition?
 ·  What is this health condition linked to (genetic, behavior, or environment)?
 ·  Who is more affected by this health issue?
 ·  What is currently being done to address this condition nationally, statewide, and locally?
 ·  What health education programs are being done with the health condition topic?
 ·  In what innovative ways are researchers addressing your health issues?

The annotated bibliography should be prepared using APA (American Psychological Association) format and include a brief summary paragraph about each source below its entry, as shown in the examples below.

ONE Health Topics I find interesting: youth suicide and prevention.

Resources:

Preventing Adolescent and Young Adult Suicide: Do States With

Greater Mental Health Treatment Capacity Have Lower Suicide

Rates?

Youth suicide in the school context

Youth Suicide Risk and Preventive Interventions:

A Review of the Past 10 Years

School-Based Suicide Prevention Laws in Action: A Nationwide Investigation of Principals’ Knowledge of and Adherence to State School-Based Suicide Prevention Laws

https://www.apa.org/research/action/suicide

Instructions:

Please choose a health topic that interests you and that you might operate as a health promotional program in the future or as part of this class. Using the Internet, find sources and review the current literature on this topic. Find 5 sources that are relevant to your topic¾the majority (4 sources) should be from peer-reviewed journals.

Some guiding questions to help your Internet search:

        ·  How significant is this health condition?
        ·  What causes this condition?
        ·  What is this health condition linked to (genetic, behavior, or environment)?
        ·  Who is more affected by this health issue?
        ·  What is currently being done to address this condition nationally, statewide, and locally?
        ·  What health education programs are being done with the health condition topic?
        ·  In what innovative ways are researchers addressing your health issues?

The annotated bibliography should be prepared using APA (American Psychological Association) format and include a brief summary paragraph about each source below its entry, as shown in the examples below.

Example Annotated Bibliography Entries

Adams, T., Moore, M., & Dye, J. (2007). The relationship between physical activity and mental health in a national sample of college females. Women & Health, 45(1), 69-85. Retrieved from EBSCOhost.

This study analyzed the effects of physical activity on the mental health of college females. 22,073 females participated where depression, anxiety, suicidal ideation, and perceived health were the defendant variables and two bouts of weekly exercise were the independent variables. Exercise was shown to endorse a positive perceived health and alleviate feelings of depression. This article is important because depression and self-esteem in college-aged females is a prevalent issue and needs more attention. This population is sometimes forgotten about and the mental health of these students is very important.

Justine, M., & Hamid, T. (2010). A multicomponent exercise program for institutionalized older adults: effects on depression and quality of life. Journal of Gerontological Nursing, 36(10), 32-41. doi: 10.3928/00989134-20100330-09

This study is different because it used exercise as a treatment for depression in institutionalized older adults. The study took place in a shelter home in Malaysia where 23 volunteers over the age of 60 performed 60 minutes of exercise three times a week for 12 weeks. The control was 20 sedentary older adults. At the end of 12 weeks, the physically active older adults reported an improvement in quality of life. This study is also important to include because it examines the relationship between exercise and depression in a country other than the United States.

See attached rubric.

Objectives/Criteria Performance Indicators
Needs
Improvement

Meets
Expectations Exceptional

Quantity of Work (1 point)
Less than 5
sources used or 3
or more non-peer-
reviewed journals
used.

(1.5 points)
5 sources used
with 2 non-peer-
reviewed
sources.

(2 points)
At least 5 appropriate sources were
used with 4 or fewer non-peer
reviewed.

Currency
The timeliness of the
information.

(1 point)
Less than 50% of
the sources had
currency
described.

(1.5 points)
Inconsistently
answered the
following
questions about

the currency of
each source.

(2 points)
Able to consistently answer the
following questions about the
currency of each source:
• When was the information

published or posted?
• Has the information been revised

or updated?
• Is the information current or out-

of-date for the topic?
• Is the source URL functional?

Relevance
The importance of the
information for your
needs.

(0-4 point)
Less than 50% of
the sources had
the relevance
described.

(5 points)
Inconsistently
answered the
following
questions about

(7 points)
Able to consistently answer the
following questions about the
relevance of each source:

the relevance of
each source.

• Does the information relate to
your topic or answer your
question?

• Who is the intended audience?
• Is the information at an

appropriate level (i.e., not too
elementary or advanced for your
needs)?

• Have you looked at a variety of
sources before determining this is
one you will use?

• Would you consider using this
source for a research paper?

Authority
The source of the
information.

(1 point)
Less than 50% of
the sources had
the authority
described.

(1.5 points)
Inconsistently
answered the
following
questions about
the authority of
each source.

(2 points)
Able to consistently answer the
following questions about the
authority of each source:
• Who is the author/

publisher/source/sponsor?
• Are the author’s credentials or

organizational affiliations given?
• What are the author’s

qualifications to write on the
topic?

• Is there contact information, such
as a publisher or email address?

• Does the source URL reveal
anything about the author or
source (e.g., .com, .edu, .gov,
.org, .net)?

Accuracy
The reliability,
truthfulness, and
correctness of the
informational content.

(0-4 points)
Less than 50% of
the sources had
the accuracy
described.

(5 points)
Inconsistently
answered the
following
questions about
the accuracy of
each source.

(7 points)
Able to consistently answer the
following questions about the
accuracy of each source:
• Where does the information come

from?
• Is the information supported by

evidence?
• Has the information been

reviewed or refereed?
• Can you verify any of the

information in another source or
from personal knowledge?

• Does the language or tone seem
biased and free of emotion?

• Are there spelling, grammar, or
other typographical errors?

Purpose
The reason the
information exists.

(1 point)
Less than 50% of
the sources had
the purpose
described.

(1.5 points)
Inconsistently
answered the
following
questions about

(2 points)
Able to consistently answer the
following questions about the
purpose of each source:

the purpose of
each source.

• What is the purpose of the
information? Inform? Teach?
Sell? Entertain? Persuade?

• Do the authors/sponsors make
their intentions or purpose clear?

• Is the information fact? Opinion?
Propaganda?

• Does the point of view appear
objective and impartial?

• Are there political, ideological,
cultural, religious, institutional, or
personal biases?

Audience
Awareness

(1.5 points)
Multiple errors:
4+ errors in the
APA formatting,
personal
references were
used, and/or
issues with
grammar, spelling,
and format.

(2.5 points)
Minor errors:
1–2 errors in the
APA formatting,
formatting
issues, language
issues, and/or
grammar and
spelling
problems.

(3 points)
Clear understanding of the
audience was demonstrated in the
annotations. Appropriate language
was used, with no personal
references (I, we, my). APA style
was used and document formatted
for easy reading.

Out of 25 points:

The research contributing to our understanding of who
is at risk for suicide and how to prevent and treat suicide
will be critically evaluated. A comprehensive understanding
of this information is critical to clinicians who deal with
the mental health problems of children and adolescents.
Each year, one in five teenagers in the United States seri-

ously considers suicide (Grunbaum et al., 2002); 5% to
8% of adolescents attempt suicide, representing approx-
imately 1 million teenagers, of whom nearly 700,000
receive medical attention for their attempt (Grunbaum
et al., 2002); and approximately 1,600 teenagers die by
suicide (Anderson, 2002). Only by recognizing who is at
risk for suicide, and knowing how to prevent suicidal
behavior and provide treatment for suicidal individuals,
will mental health practitioners and those designing edu-
cational and public health prevention programs have suf-
ficient armamentaria to combat this major public health
and clinical problem in youths. The current review is
based on a comprehensive, but not exhaustive, review of
the research on youth suicide conducted in the past decade.
Preference was given to population-based epidemiolog-
ical and longitudinal investigations and controlled pre-
vention/intervention studies.

OVERALL RATES AND SECULAR PATTERNS

Suicide was the third leading cause of death among
10- to 14-year-olds and 15- to 19-year-olds in the United

Accepted December 3, 2002.
Dr. Gould is a Professor at Columbia University in the Division of Child and

Adolescent Psychiatry (College of Physicians & Surgeons) and Department of
Epidemiology (School of Public Health) and a Research Scientist at the New York
State Psychiatric Institute (NYSPI). Mr. Greenberg is with the Division of Child
and Adolescent Psychiatry, Columbia University, NYSPI. Dr. Velting is an Assistant
Professor at Columbia University in the Division of Child and Adolescent Psychiatry
(College of Physicians & Surgeons), and Dr. Shaffer is Irving Philips Professor
of Child Psychiatry and Pediatrics at the College of Physicians & Surgeons at
Columbia University.

The expert assistance of Margaret Lamm in the preparation of this manu-
script is gratefully acknowledged.

Reprint requests to Dr. Gould, Division of Child and Adolescent Psychiatry,
NYSPI, 1051 Riverside Drive, Unit 72, New York, NY 10032; e-mail:
gouldm@childpsych.columbia.edu.

0890-8567/03/4204–0386�2003 by the American Academy of Child
and Adolescent Psychiatry.

DOI: 10.1097/01.CHI.0000046821.95464.CF

Youth Suicide Risk and Preventive Interventions:
A Review of the Past 10 Years

MADELYN S. GOULD, PH.D., M.P.H., TED GREENBERG, M.P.H., DREW M. VELTING, PH.D.,
AND DAVID SHAFFER, M.D.

ABSTRACT

Objective: To review critically the past 10 years of research on youth suicide. Method: Research literature on youth suicide

was reviewed following a systematic search of PsycINFO and Medline. The search for school-based suicide prevention pro-

grams was expanded using two education databases: ERIC and Education Full Text. Finally, manual reviews of articles’ ref-

erence lists identified additional studies. The review focuses on epidemiology, risk factors, prevention strategies, and treatment

protocols. Results: There has been a dramatic decrease in the youth suicide rate during the past decade. Although a num-

ber of factors have been posited for the decline, one of the more plausible ones appears to be the increase in antidepres-

sants being prescribed for adolescents during this period. Youth psychiatric disorder, a family history of suicide and

psychopathology, stressful life events, and access to firearms are key risk factors for youth suicide. Exciting new findings have

emerged on the biology of suicide in adults, but, while encouraging, these are yet to be replicated in youths. Promising pre-

vention strategies, including school-based skills training for students, screening for at-risk youths, education of primary care

physicians, media education, and lethal-means restriction, need continuing evaluation studies. Dialectical behavior ther-

apy, cognitive-behavioral therapy, and treatment with antidepressants have been identified as promising treatments but

have not yet been tested in a randomized clinical trial of youth suicide. Conclusions: While tremendous strides have been

made in our understanding of who is at risk for suicide, it is incumbent upon future research efforts to focus on the devel-

opment and evaluation of empirically based suicide prevention and treatment protocols. J. Am. Acad. Child Adolesc.

Psychiatry, 2003, 42(4):386–405. Key Words: suicide, epidemiology, risk factors, prevention, treatment, adolescence.

386 J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I AT RY, 4 2 : 4 , A P R I L 2 0 0 3

R E S E A R C H U P D A T E R E V I E W

States in 2000 (Anderson, 2002). While the rates of com-
pleted suicide are low (1.5 per 100,000 among 10- to 14-
year-olds and 8.2 per 100,000 among 15- to 19-year-olds),
when nonlethal suicidal behavior and ideation are taken
into account, the magnitude of the problem becomes obvi-
ous. The surge of general population studies of suicide
attempts and ideation has yielded reliable estimates of
their rates (e.g., Andrews and Lewinsohn, 1992; Fergusson
and Lynskey, 1995; Fergusson et al., 2000; Garrison et al.,
1993; Gould et al., 1998; Grunbaum et al., 2002;
Lewinsohn et al., 1996; Roberts and Chen, 1995; Sourander
et al., 2001; Swanson et al., 1992; Wichstrom, 2000;
Windle et al., 1992). Of these studies, the largest and the
most representative is the Youth Risk Behavior Survey
(YRBS) (Grunbaum et al., 2002), conducted by the
Centers for Disease Control and Prevention (CDC). The
YRBS indicated that during the past year, 19% of high
school students “seriously considered attempting suicide,”
nearly 15% made a specific plan to attempt suicide, 8.8%
reported any suicide attempt, and 2.6% made a medically
serious suicide attempt that required medical attention.
These results are consistent with those cited in the epi-
demiological literature.

Age

Suicide is uncommon in childhood and early adoles-
cence. Within the 10- to 14-year-old group, most sui-
cides occur between ages 12 and 14. Suicide incidence
increases markedly in the late teens and continues to rise
until the early twenties, reaching a level that is maintained
throughout adulthood until the sixth decade, when the
rates increase markedly among men (Anderson, 2002).

In 2000, the suicide mortality rate for 10- to 14-year-
olds in the United States was 1.5 per 100,000. Although
10- to 14-year-olds represented 7.2% of the U.S. popu-
lation, the 300 children who committed suicide repre-
sented only 1.0% of all suicides. The suicide mortality
rate for 15- to 19-year-olds was 8.2 per 100,000, five times
the rate of the younger age group.

The rarity of completed suicide before puberty is a
universal phenomenon (World Health Organization,
2002). Shaffer et al. (1996) suggested that the most likely
reason underlying the age of onset of suicide is that depres-
sion and exposure to drugs and alcohol, two significant
risk factors for suicide in adults (e.g., Barraclough et al.,
1974; Robins et al., 1959) and adolescents (e.g., Brent
et al., 1993a; Shaffer et al., 1996), are rare in very young
children and become prevalent only in later adolescence.

Like completed suicides, suicide attempts are relatively
rare among prepubertal children and increase in frequency
through adolescence (Andrus et al., 1991; Velez and
Cohen, 1988). However, unlike completed suicides,
attempts peak between 16 and 18 years of age, after which
there is a marked decline in frequency (Kessler et al.,
1999), particularly for young women (Lewinsohn et al.,
2001).

Gender

Paradoxically, although suicidal ideation and attempts
are more common among females (Garrison et al., 1993;
Gould et al., 1998; Grunbaum et al., 2002; Lewinsohn
et al., 1996) in the United States, completed suicide is
more common among males. Five times more 15- to 19-
year-old boys than girls commit suicide (Anderson, 2002).
The same pattern of sex differences does not exist in all
countries (World Health Organization, 2002). While
completed suicide is more common in 15- to 24-year old
males than females in North America, Western Europe,
Australia, and New Zealand, sex rates are equal in some
countries in Asia (e.g., Singapore), and in China, the
majority of suicides are committed by females.

The YRBS (Grunbaum et al., 2002) indicated that
girls were significantly more likely to have seriously con-
sidered attempting suicide (23.6%), made a specific plan
(17.7%), and attempted suicide (11.2%) than were boys
(14.2%, 11.8%, 6.2%, respectively); however, no signif-
icant difference by gender in the prevalence of medically
serious attempts (3.1% females, 2.1% males) was found.

Both psychopathological factors and sex-related method
preferences are considered to contribute to the pattern of
sex differences (Shaffer and Hicks, 1994). Completed sui-
cide is often associated with aggressive behavior and sub-
stance abuse (see discussion below), and both are more
common in males. Methods favored by women, such as
overdoses, which account for 30% of all female suicides
yet only 6.7% of all male suicides (CDC, 2002), tend to
be less lethal in the United States. However, in societies
where treatment resources are not readily available or
when the chosen ingestant is untreatable, overdoses are
more likely to be lethal. Whereas in the United States,
only 11% of completed suicides in 1999 resulted from
an ingestion, in some South Asian and South Pacific coun-
tries, the majority of suicides are due to ingestions of her-
bicides, such as paraquat, for which no effective treatment
is available (Haynes, 1987; Shaffer and Hicks, 1994).

YO U T H S U I C I D E R I S K A N D I N T E RV E N T I O N S

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Ethnicity

Youth suicide is more common among whites than
African Americans in the United States (Anderson, 2002),
although the rates are highest among Native Americans
and generally the lowest among Asian/Pacific Islanders
(Anderson, 2002; Shiang et al., 1997; Wallace et al., 1996).
Latinos are not overrepresented among completed sui-
cides in the United States (Demetriades et al., 1998; Gould
et al., 1996; Smith et al., 1985). The historically higher
suicide rate among Native Americans is not fully under-
stood, but proposed risk factors include low social inte-
gration, access to firearms, and alcohol or drug use
(Borowsky et al., 1999; Middlebrook et al., 2001). The
historically lower suicide rate among African Americans
has been attributed to greater religiosity and differences
in “outwardly” rather “inwardly” directed aggression
(Gibbs, 1997; Shaffer et al., 1994). However, the differ-
ence in suicide rates between whites and African Americans
has decreased during the past 15 years because of a marked
increase in the suicide rate among African-American males
between 1986 and 1994.

The YRBS (Grunbaum et al., 2002) found that African-
American students were significantly less likely (13.3%)
than white or Latino students (19.7% and 19.4%, respec-
tively) to have considered suicide or to have made a spe-
cific plan (African-Americans: 10.3%; whites: 15.3%;
Latinos: 14.1%). Latino students (12.1%) were signifi-
cantly more likely than either African-American or white
students to have made a suicide attempt (8.8% and 7.9%,
respectively); however, there was no preponderance of
medically serious attempts among Latinos (3.4%) com-
pared with whites (2.3%) or African Americans (3.4%).
Although some studies have found higher rates of sui-
cidal ideation and attempts among Latino youths
(Roberts et al., 1997; Roberts and Chen, 1995), Grunbaum
et al. (1998) and Walter et al. (1995) did not find a higher
prevalence of either among Latinos. These equivocal find-
ings highlight the need for further research in this area.

Secular Trends

Secular changes in the incidence of a disease are impor-
tant because they may give an indication of causal and/or
preventive factors. Following a nearly threefold increase
in the adolescent male suicide rate between 1964 and
1988, the consistent increase in the white male suicide
rate ceased and in the mid 1990s started to decline. Rates
in African-American males, while still lower than among
whites, showed no sign of a plateau or decrease until 1995.

At that time the decline gathered pace and included both
white and African-American males and females. The rate
among white males, nearly 20/100,000 in 1988, had fallen
to approximately 14/100,000 by the year 2000 (Fig. 1).

The reasons for the decline are by no means clear. One
of the more plausible reasons for the earlier increase had
been the effects of greater exposure of the youth popu-
lation to drugs and alcohol. Alcohol use had been noted
to be a significant risk factor for suicide since the first
psychological autopsy study (Robins et al., 1959), and at
least in some studies (Shaffer et al., 1996) it has been a
significantly more important risk factor for males, the
group that had showed the dramatic increase. However,
repeat benchmark studies that use similar measures and
sampling methods such as the YRBS (CDC, 1995, 1996,
1998, 2000; Grunbaum et al., 2002) give no indication
of a decline in alcohol or cocaine use during this time.
Another reason posited for the earlier increase was an
increased availability of firearms (Brent et al., 1991).
Legislation restricting access to firearms was passed in
1994 (Ludwig and Cook, 2000), at the time that the
decrease became more marked and the rate of handling
firearms among high school students declined (CDC,
1995, 1996, 1998, 2000; Grunbaum et al., 2002). However,
the proportion of suicides by firearms, a plausible proxy
for method availability (Cutright and Fernquist, 2000),
did not change between 1988 and 1999. There has been
a decline ranging from 20% to 30% in the youth suicide
rates in England, Finland, Germany, and Sweden, where
firearms account for very few suicides (Krug et al., 1998),
and a systematic examination of the proportion of sui-
cides committed with firearms over a long period of time
has shown that the proportion is only weakly related to
overall changes in the rate (Cutright and Fernquist, 2000).

Another plausible cause of the reduction has been the
extraordinary increase in antidepressants being prescribed
for adolescents during this period. Olfson et al. (2002b)
showed that between 1987 and 1996 the annual rate of
antidepressant use increased from approximately 0.3%
to 1.0% of those aged 6 to 19 years in the United States.
Selective serotonin reuptake inhibitors (SSRIs) affect not
only depression (see “Psychopharmacological Interventions”
below), but also aggressive outbursts, and have been shown
in adults to reduce suicidal thinking. It is unlikely that
the increase in the prescription of antidepressants is an
indication of a more general increase in access or use of
mental health services. During the period from 1987 to
1997, the number of adolescents who received psycho-

G O U L D E T A L .

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therapy actually declined (Olfson et al., 2002a). The delay
in the onset of the decline in African-American suicides
is compatible with a treatment effect because of African
Americans’ greater difficulty in accessing treatment resources
(Goodwin et al., 2001). Another indication that antide-
pressant treatment may be a factor in the recent decline
is the finding in Sweden that the proportion of suicide
victims who received antidepressant treatment is lower
than the rest of the depressed population (Isacsson, 2000).
Firm conclusions, however, are not possible given the
ecological nature of the supporting data. Randomized
clinical trials will be necessary before the decline in rates
can be confidently attributed to treatment with antide-
pressants.

RISK FACTORS

Personal Characteristics

Psychopathology. More than 90% of youth suicides have
had at least one major psychiatric disorder, although
younger adolescent suicide victims have lower rates of
psychopathology, averaging around 60% (Beautrais, 2001;
Brent et al., 1999; Groholt et al., 1998; Shaffer et al.,
1996). Depressive disorders are consistently the most

prevalent disorders among adolescent suicide victims,
ranging from 49% to 64% (Brent et al., 1993a; Marttunen
et al., 1991; Shaffer et al., 1996). The increased risk of
suicide (odds ratios) for those with an affective disorder
ranges from 11 to 27 (Brent et al., 1988, 1993a; Groholt
et al., 1998; Shaffer et al., 1996; Shafii et al., 1988). Female
victims are more likely than males to have had an affec-
tive disorder (Brent et al., 1999; Shaffer et al., 1996).
Substance abuse is another significant risk factor, espe-
cially among older adolescent male suicide victims
(Marttunen et al., 1991; Shaffer et al., 1996). A high
prevalence of comorbidity between affective and sub-
stance abuse disorder has consistently been found
(Brent et al., 1993a; Shaffer et al., 1996). Disruptive dis-
orders are also common in male teenage suicide victims
(Brent et al., 1993a; Shaffer et al., 1996). Approximately
one third of male suicides have had a conduct disorder,
often comorbid with a mood, anxiety, or substance abuse
disorder. Discrepant results have been reported for bipo-
lar disorder: Brent et al. (1988, 1993a) reported relatively
high rates, whereas others reported no or few bipolar cases
(Apter et al., 1993a; Marttunen et al., 1991; Rich et al.,
1990; Runeson, 1989; Shaffer et al., 1994). Despite the
generally high risk of suicide among people with schizo-

Fig. 1 Teen suicide rates, 1964–2000: United States, ages 15–19 years. Sources: Anderson, 2002; CDC, 2002;
National Center for Health Statistics, 1999. *Crude rates; prior to 1979, African-American data not broken out.

phrenia, schizophrenia accounts for very few of all youth
suicides (Brent et al., 1993a; Shaffer et al., 1996).

The psychiatric problems and gender-specific diag-
nostic profiles of youth suicide attempters are quite sim-
ilar to the profiles of those who complete suicide (e.g.,
Andrews and Lewinsohn, 1992; Beautrais et al., 1996,
1998; Gould et al., 1998). However, despite the overlap
between suicidal attempts and ideation (Andrews and
Lewinsohn, 1992; Reinherz et al., 1995) and the signif-
icant prediction of future attempts from ideation (Lewin-
sohn et al., 1994; McKeown et al., 1998; Reinherz et al.,
1995), the diagnostic profiles of attempters and ideators
are somewhat distinct (Gould et al., 1998). Substance
abuse/dependence is more strongly associated with sui-
cide attempts than with ideation (Garrison et al., 1993;
Gould et al., 1998; Kandel, 1988). Recent studies have
found an association between posttraumatic stress disor-
der and suicidal behavior among adolescents (Giaconia
et al., 1995; Mazza, 2000; Wunderlich et al., 1998), but
in the largest and most representative of the studies
(Wunderlich et al., 1998), the association was not main-
tained after adjusting for comorbid psychiatric problems.
Panic attacks have also been reported to be associated
with an increased risk of suicidal behavior in adolescents,
even after adjusting for comorbid psychiatric disorders
and demographic factors (Gould et al., 1996; Pilowsky
et al., 1999). The negative finding by Andrews and
Lewinsohn (1992) may be due to a gender specificity of
the association: panic attacks may increase suicide risk
for girls only (Gould et al., 1996). Inconsistent findings
have been reported in the adult literature (Johnson et al.,
1990; Warshaw et al., 2000; Weissman et al., 1989)

Prior Suicide Attempts. A history of a prior suicide
attempt is one of the strongest predictors of completed
suicide, conferring a particularly high risk for boys (30-
fold increase) and a less elevated risk for girls (3-fold
increase) (Shaffer et al., 1996). Between one quarter to
one third of youth suicide victims have made a prior sui-
cide attempt (see Groholt et al., 1997). Similarly strong
associations between a history of suicidal behavior and
future attempts have been reported in general popula-
tion surveys and longitudinal studies (Lewinsohn et al.,1994;
McKeown et al., 1998; Reinherz et al., 1995; Wichstrom,
2000) and clinical samples (Hulten et al., 2001; Pfeffer
et al., 1991), with risk for an attempt increasing between
3 and 17 times for those with prior suicidal behavior.

Cognitive and Personality Factors. Hopelessness has been
linked with suicidality (Howard-Pitney et al., 1992;

Marcenko et al., 1999; Overholser et al., 1995; Ruben-
stein et al., 1989; Russell and Joyner, 2001; Shaffer et al.,
1996); however, it has not consistently proven to be an
independent predictor, once depression is taken into
account (Cole, 1988; Howard-Pitney et al., 1992; Lewinsohn
et al., 1994; Reifman and Windle, 1995; Rotheram-Borus
and Trautman, 1988). Poor interpersonal problem-solv-
ing ability has also been reported to differentiate suicidal
from nonsuicidal youths (Asarnow et al., 1987; Rotheram-
Borus et al., 1990), even after adjusting for depression
(Rotheram-Borus et al., 1990). Social problem-solving
has been found to partially mediate the influence of life
stress on suicide, although life stress was a stronger pre-
dictor than social problem-solving (Chang, 2002). Aggressive-
impulsive behavior has also been linked with an increased
risk of suicidal behavior (Apter et al., 1993b; McKeown
et al., 1998; Sourander et al., 2001). In a Finnish school
study (Sourander et al., 2001), aggressive 8-year-olds were
more than twice as likely to think about or attempt sui-
cide at age 16.

Sexual Orientation. Recent cross-sectional and longi-
tudinal epidemiological studies found a significant two-
to sixfold increased risk of nonlethal suicidal behavior for
homosexual and bisexual youths (Blake et al., 2001; Faulkner
and Cranston, 1998; Garofalo et al., 1998; Remafedi et al.,
1998; Russell and Joyner, 2001; see McDaniel et al., 2001,
for a recent review). In a study of a nationally represen-
tative sample of nearly 12,000 adolescents, those who
reported same-sex sexual orientation also exhibited sig-
nificantly higher rates of other suicide risk factors (Russell
and Joyner, 2001). After adjusting for these risks, the
effects of same-sex sexual orientation on suicidal behav-
ior remained, but were substantially mediated by depres-
sion, alcohol abuse, family history of attempts, and
victimization. Notably, most youths who reported same-
sex sexual orientation reported no suicidality at all: 84.6%
of males and 71.7% of females.

Biological Factors. Over the past 25 years, a substantial
body of knowledge has accrued, indicating abnormali-
ties of serotonin function in suicidal and in impulsive,
aggressive individuals, regardless of psychiatric diagno-
sis. Earlier studies focused on simple indices of seroto-
nin activity, such as the reduced concentration of serotonin
metabolites in the brain and cerebrospinal fluid (CSF) in
suicide victims or among suicide attempters compared
with age- and gender-matched controls (see Oquendo
and Mann, 2000). More recently, neuroanatomical stud-
ies have shown a reduction in the overall density of sero-

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tonin 1A receptors and serotonin transporter receptors
(which regulate serotonin uptake) in the prefrontal cor-
tex. Most recently, Arango and her colleagues (2001)
found significant reductions in the number and binding
capacity of serotonin 1A receptors in the dorsal raphe
nucleus, from which serotonin innervation of the pre-
frontal cortex arises (Arango et al., 2001).

To explain the often-replicated finding that serotonin
dysregulation is associated with suicidality regardless of
diagnosis, Mann et al. (1999) suggested that the dysreg-
ulation is a biological trait that predisposes to suicide—
a stress-diathesis model. Thus a mentally ill person with
the diathesis is more likely to respond to a stressful expe-
rience in an impulsive fashion that may include a deci-
sion to commit suicide.

Despite the great volume of work, unanswered ques-
tions remain. The behavioral correlates of low-serotonin
states are assumed to include irritability, impulsivity, and
emotional volatility, but most studies address diagnosis
rather than specific symptoms and the correlation has yet
to be explored in the general population. An absence of
representative studies has meant that neither the relative
risk of serotonin dysfunction nor the fraction of suicides
attributable to serotonin underfunctioning is yet known.
Finally, the examination of the association of serotonin
metabolism with suicide has largely been limited to stud-
ies of adults.

The documented suicide risk associated with family
history (see “Family History of Suicidal Behavior” below)
has led to an active investigation of candidate genes,
attempting to identify what suicidogenic factor might be
inherited. Given the substantial body of data that point
to reduced serotonin neurotransmission in suicide (see
above), the target of most recent association studies has
been polymorphisms in three genes that play important
roles in the regulation of serotonin. One gene is trypto-
phan hydroxylase (TPH), the rate-limiting enzyme for
the biosynthesis of serotonin. Early studies (Mann and
Stoff, 1997; Nielsen et al., 1994, 1998) reported a rela-
tionship between attempted suicide and a polymorphism
on intron 7 of the TPH gene. Since then, a large num-
ber of studies with inconsistent findings have been car-
ried out on suicidal patients with various diagnoses with
and without suicidality. The Utah Youth Suicide Study
has been the main study to have examined adolescents
(Bennet et al., 2000), and it has failed to find an associ-
ation. There are several possible reasons for the inconsis-
tent findings, including the probable heterogeneity and

complexity of the suicide phenotype; that the genetic
effect is small and requires examination of large samples;
or because a single genetic variant is less important than
patterns of variance (Marshall et al., 1999). Support for
this is offered by haplotype analyses (haplotypes are clus-
ters of genes that are usually found together) that have
shown a distinctive profile among both suicide completers
(Turecki et al., 2001) and attempters (Rotondo et al.,
1999) in samples in which single-gene polymorphisms
did not differ significantly from those of controls.

The other two candidate genes that have been studied
are the serotonin transporter (SERT ) gene and the sero-
tonin A receptor gene. Polymorphisms in these genes have
been reported in completed and attempted suicide
(Arango et al., 2001; Courtet et al., 2001; Du et al., 2001;
Neumeister et al., 2002).

While biological findings currently have little impact
on clinical practice, Nordstrom and colleagues’ (1994)
finding that suicide attempters with low levels of CSF 5-
hydroxyindoleacetic acid have a significantly higher like-
lihood of making further suicide attempts and/or committing
suicide, coupled with the promising research on candi-
date genes, may eventually take suicide prediction and
prevention to new, more precise levels and/or may lead to
specific interventions that will reduce the impact of the
predisposing trait.

Family Characteristics

Family History of Suicidal Behavior. A family history
of suicidal behavior greatly increases the risk of com-
pleted suicide (Agerbo et al., 2002; Brent et al., 1988,
1994a, 1996; Gould et al., 1996; Shaffer, 1974; Shafii
et al., 1985) and attempted suicide (Bridge et al., 1997;
Glowinski et al., 2001; Johnson et al., 1998). Because
suicide and psychiatric illness almost always co-occur,
account has to be taken of whether apparent familiality
reflects suicide specifically or instead an association with
parental psychiatric illness (Brent et al., 1996). Most
recently, the Danish Registry study (Agerbo et al., 2002)
found youth suicide to be nearly five times more likely
in the offspring of mothers who have completed suicide
and twice as common in the offspring of fathers, adjust-
ing for parental psychiatric history.

The Missouri Adolescent Twin Study (Heath et al.,
2002) addressed the question of inheritance versus envi-
ronment among teenage suicide attempters. One hun-
dred thirty twin pairs had been affected by a suicide
attempt within the total representative sample of 3,416

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female adolescent twins. After controlling for other psy-
chiatric risk factors, the twin/cotwin odds ratio was 5.6
(95% confidence interval [CI] 1.75–17.8) for monozy-
gotes and 4.0 (95% CI 1.1–14.7) for dizygotes, suggest-
ing a degree of inheritance for suicidality (Glowinski
et al., 2001). The heritability of youth suicide gains fur-
ther support from a meta-analysis by McGuffin et al.
(2001), who reexamined a large body of published twin
data (all ages). They concluded that first-degree relatives
of suicides have more than twice the risk of the general
population, with the relative risk increasing among iden-
tical cotwins of suicides to about 11. The estimated her-
itability for completed suicide was 43% (95% CIs 25–60).

Parental Psychopathology. High rates of parental psy-
chopathology, particularly depression and substance abuse,
have been found to be associated with completed suicide
(Brent et al., 1988, 1994a; Gould et al., 1996) and with
suicidal ideation and attempts in adolescence (e.g.,
Fergusson and Lynskey, 1995; Joffe et al., 1988; Kashani
et al., 1989). Brent and his colleagues (1994a) reported
that a family history of depression and substance abuse
significantly increased the risk of completed suicide, even
after controlling for the victim’s psychopathology. They
concluded that familial psychopathology adds to suicide
risk by mechanisms other than merely increasing the lia-
bility for similar psychopathology in an adolescent. In
contrast, Gould and her colleagues (1996) found that the
impact of parental psychopathology no longer contributed
to the youth’s suicide risk after the study controlled for
the youth’s psychopathology. To date, it is unclear pre-
cisely how familial psychopathology increases the risk for
completed suicide.

Parental Divorce. Suicide victims are more likely to come
from nonintact families of origin (Beautrais, 2001; Brent
et al., 1993a, 1994a; Gould et al., 1996; Groholt et al.,
1998; Sauvola et al., 2001). However, the association
between separation/divorce and suicide decreases when
accounting for parental psychopathology (Brent et al.,
1994a; Gould et al., 1996). Similarly, although many
population-based studies have found significant univari-
ate associations (e.g., Andrews and Lewinsohn, 1992;
Fergusson and Lynskey, 1995), these associations are no
longer evident or are markedly attenuated once psychosocial
risk factors are taken into account (e.g., Beautrais et al.,
1996; Fergusson et al., 2000; Groholt et al., 2000).

Parent–Child Relationships. Impaired parent–child rela-
tionships are associated with increased risk of suicide and
suicide attempts among youths (Beautrais et al., 1996;

Brent et al., 1994a, 1999; Fergusson and Lynskey, 1995;
Fergusson et al., 2000; Gould et al., 1996; Lewinsohn
et al., 1993, 1994; McKeown et al., 1998; Tousignant
et al., 1993). However, because an underlying psychiat-
ric problem in the youth may precipitate impaired par-
ent–child relationships, it is necessary to disentangle these
factors. While Gould et al. (1996) found that suicide vic-
tims still had significantly less frequent and less satisfy-
ing communication with their mothers and fathers than
community controls, even after adjusting for their psy-
chiatric disorders, others have found that the associations
between nonlethal suicidal behavior and poor attachment
and family cohesion are not independent of the youth’s
psychological problems (Fergusson et al., 2000; McKeown
et al., 1998). Similarly, parent–child conflict has been
found to be no longer associated with completed suicide
(Brent et al., 1994a) or attempts (Lewinsohn et al., 1993)
once the youth’s psychopathology is taken into account.

Adverse Life Circumstances

Stressful Life Events. Life stressors, such as interpersonal
losses (e.g., breaking up with a girlfriend or boyfriend)
and legal or disciplinary problems, are associated with
completed suicide (Beautrais, 2001; Brent et al., 1993c;
Gould et al., 1996; Marttunen et al., 1993; Rich et al.,
1988; Runeson, 1990) and suicide attempts (Beautrais
et al., 1997; Fergusson et al., 2000; Lewinsohn et al.,
1996), even after adjusting for psychopathology (Brent
et al., 1993c; Gould et al., 1996) and antecedent social,
family, and personality factors (Beautrais et al., 1997).
The prevalence of specific stressors among suicide vic-
tims varies by age: parent–child conflict is a more com-
mon precipitant for younger adolescent victims, whereas
romantic difficulties are more common in older adoles-
cents (Brent et al., 1999; Groholt et al., 1998). Stressors
also vary by psychiatric disorder: interpersonal losses are
more common among suicide victims with substance
abuse disorders (Brent et al., 1993c; Gould et al., 1996;
Marttunen et al., 1994; Rich et al., 1988), and legal or
disciplinary crises are more common in victims with dis-
ruptive disorders (Brent et al., 1993c; Gould et al., 1996)
or substance abuse disorders (Brent et al., 1993c). Bullying,
whether as victim or perpetrator, has also recently been
demonstrated to increase the risk for suicidal ideation
(Kaltiala-Heino et al., 1999).

Physical Abuse. The association between physical abuse
and suicide reported in case-control psychological autopsy
studies (Brent et al., 1994a, 1999) has been replicated in

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prospective longitudinal community studies (Brown et al.,
1999; Johnson et al., 2002; Silverman et al., 1996), the
most methodologically rigorous design to examine this
issue. Childhood physical abuse has been found to be
associated with an increased risk of suicide attempts in
late adolescence or early adulthood, even after adjusting
for demographic characteristics, psychiatric symptoms
during childhood and early adolescence, and parental
psychiatric disorders (Johnson et al., 2002). Interpersonal
difficulties during middle adolescence, such as frequent
arguments with adults and peers and having no close
friends, were found to mediate the association between
child abuse and later suicide attempts (Johnson et al.,
2002). Johnson and his colleagues (2002) suggested that
children who are physically abused may have difficulty
developing the social skills necessary for healthy rela-
tionships, which leads to social isolation and/or antago-
nistic interactions with others, which in turn puts them
at increased risk for suicidal behavior.

Sexual Abuse. Longitudinal community studies are also
the most methodologically rigorous design to examine
the association between child sexual abuse (CSA) and
subsequent suicidality due to the serious problems of ret-
rospective recall in this area. Two such studies have found
self-reported CSA to be significantly associated with an
increased risk of suicidal behavior in adolescence
(Fergusson et al., 1996; Silverman et al., 1996). Because
CSA may be associated with reported risk factors for sui-
cide (e.g., parental substance abuse), it is necessary to
control for such factors. Fergusson et al. (1996) found
that the association between CSA and suicidality was
greatly reduced but was not eliminated, after controlling
for a wide range of potentially confounding factors. This
suggests that the increased risk of suicide from CSA may
be partly, but not entirely, accounted for by other factors.

Socioenvironmental and Contextual Factors

Socioeconomic Status. Studies of suicide victims gener-
ally have found no or small effects of socioeconomic dis-
advantage (Agerbo et al., 2002; Brent et al., 1988).
Specifically, Agerbo et al. (2002) noted that the effect of
socioeconomic disadvantage decreased after adjustment
for family history of mental illness or suicide. Gould et al.
(1996) also found no effect of socioeconomic status for
white or Latino victims, but African-American victims
had a significantly higher socioeconomic status than their
general population counterparts. Youth suicide attempters,
compared with community controls, have consistently

been found to have higher rates of sociodemographic dis-
advantage, even after controlling for other social and psy-
chiatric risk factors (Beautrais et al., 1996; Fergusson
et al., 2000; Wunderlich et al., 1998).

School and Work Problems. Difficulties in school, nei-
ther working nor being in school, and not going to col-
lege pose significant risks for completed suicide (Gould
et al., 1996). Beautrais et al. (1996) reported that serious
suicide attempters were also more likely to drop out of
high school or not attend college, and Wunderlich and
colleagues (1998) reported that German school dropouts
were 37 times more likely to attempt suicide, even after
adjusting for diagnostic and social risk factors.

Contagion/Imitation. Evidence continues to amass from
studies of suicide clusters and the impact of the media,
supporting the existence of suicide contagion. Several
studies have reported significant clustering of suicides,
defined by temporal-spatial factors, among teenagers and
young adults (Brent et al., 1989; Gould et al., 1990a,b,
1994), with only minimal effects beyond 24 years of age
(Gould et al., 1990a,b). Similar age-specific patterns have
been reported for clusters of attempted suicides (Gould
et al., 1994). Since 1990, the effect of the media on sui-
cide rates has been documented in many other countries
besides the United States, including Australia (e.g., Hassan,
1995), Austria (e.g., Etzersdorfer et al., 1992), Germany
(e.g., Jonas, 1992), Hungary (e.g., Fekete and Macsai,
1990), and Japan (Ishii, 1991; Stack, 1996), adding to
the extensive work prior to 1990 in the United States on
newspaper articles, television news reports, and fictional
dramatizations. Overall, the magnitude of the suicide
increase is proportional to the amount, duration, and
prominence of media coverage, and the impact of sui-
cide stories on subsequent completed suicides appears to
be greatest for teenagers (see Gould, 2001; Schmidtke
and Schaller, 2000; Stack, 2000).

Stack’s (2000) review of 293 findings from 42 studies
indicates that methodological differences among studies are
strong predictors of differences in their findings. For exam-
ple, although a highly publicized recent study (Mercy et al.,
2001) found that exposure to media accounts of suicidal
behavior and exposure to suicidal behavior in friends or
acquaintances were associated with a lower risk of youth
suicide attempts, the interpretability of the findings is lim-
ited because (1) the media exposure factor was a conglom-
erate of different types of media stories; (2) attempters may
have had less exposure to media generally (e.g., read fewer
books, fewer newspapers, etc.); (3) attempters had signifi-

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cantly more proximal stressors, possibly overshadowing their
recollection of media exposure; (4) the timing of exposure
was a 30-day interval, in contrast to most other studies,
which examined a shorter interval following the exposure;
and (5) nearly half of the sample was between 25 and 34
years of age, a group not particularly sensitive to imitation.
Another study finding—no effect of parental suicide—was
also inconsistent with the prevailing research literature. A
summary of interactive factors that may moderate the impact
of media stories, including characteristics of the stories,
individual reader/viewer attributes, and social context of
the stories, is presented by Gould (2001).

PROTECTIVE FACTORS

Family Cohesion

Family cohesion has been reported as a protective fac-
tor for suicidal behavior among adolescents in a longitu-
dinal study of middle school students (McKeown et al.,
1998) and cross-sectional community studies of high
school (Rubenstein et al., 1989, 1998) and college stu-
dents (Zhang and Jin, 1996). Students who described fam-
ily life in terms of a high degree of mutual involvement,
shared interests, and emotional support were 3.5 to 5.5
times less likely to be suicidal than were adolescents from
less cohesive families who had the same levels of depres-
sion or life stress (Rubenstein et al., 1989, 1998).

Religiosity

Since Durkheim’s (1966) formulation of a social inte-
gration model, the protective role of religiosity on sui-
cide has been a focus of scientific investigation (e.g.,
Hovey, 1999; Lester, 1992; Neeleman, 1998; Neeleman
and Lewis, 1999; Sorri et al., 1996; Stack, 1998; Stack
and Lester, 1991). As noted previously, greater religios-
ity has been posited as underlying the historically lower
suicide rate among African Americans. However, only
recently has the protective value of religiosity against sui-
cidal behavior (Hilton et al., 2002; Siegrist, 1996; Zhang
and Jin, 1996) and depression (Miller et al., 1997b) been
documented in adolescents and young adults. Regrettably,
these studies have not controlled for potential confounders,
such as substance abuse, which may be less prevalent
among religious youths.

PREVENTION STRATEGIES

Youth suicide prevention strategies have primarily been
implemented within three domains—school, commu-

nity, and health-care systems—and generally have one of
two general goals: case finding with accompanying refer-
ral and treatment or risk factor reduction (CDC, 1994;
Gould and Kramer, 2001).

School-Based Suicide Prevention Programs

Suicide Awareness Curriculum. These programs seek to
increase awareness of suicidal behavior in order to facil-
itate self-disclosure and prepare teenagers to identify at-
risk peers and take responsible action (Kalafat and Elias,
1994). The underlying rationale of these programs is that
teenagers are more likely to turn to peers than adults for
support in dealing with suicidal thoughts (Hazell and
King, 1996; Kalafat and Elias, 1994; Ross, 1985).

Several studies evaluated school-based suicide awareness
programs in the past decade (Ciffone, 1993; Kalafat and
Elias, 1994; Kalafat and Gagliano, 1996; Shaffer et al.,
1991; Silbert and Berry, 1991; Vieland et al., 1991). While
improvements in knowledge (Kalafat and Elias, 1994;
Silbert and Berry, 1991), attitudes (Ciffone, 1993; Kalafat
and Elias, 1994; Kalafat and Gagliano, 1996), and help-
seeking behavior (Ciffone, 1993) have been found, other
studies reported either no benefits (Shaffer et al., 1990,
1991; Vieland et al., 1991) or detrimental effects of sui-
cide prevention education programs (Overholser et al.,
1989; Shaffer et al., 1991). Detrimental effects included a
decrease in desirable attitudes (Shaffer et al., 1991); a reduc-
tion in the likelihood of recommending mental health eval-
uations to a suicidal friend (Kalafat and Elias, 1994); more
hopelessness and maladaptive coping responses among
boys after exposure to the curriculum (Overholser et al.,
1989); and negative reactions among students with a his-
tory of suicidal behavior, including their not recommending
the programs to other students and feeling that talking
about suicide in the classroom “makes some kids more
likely to try to kill themselves” (Shaffer et al., 1990). Other
limitations of this strategy are that baseline knowledge and
attitudes of students are generally sound (Kalafat and Elias,
1994; Shaffer et al., 1991), changes in attitudes and knowl-
edge are not necessarily highly correlated with behavioral
change (Kirby, 1985; McCormick et al., 1985), and the
format and content of some programs might inadvertently
stimulate imitation (Gould, 2001).

To date there is insufficient evidence to either support
or not support curriculum-based suicide awareness pro-
grams in schools (Guo and Harstall, 2002). Accordingly,
emphasis has shifted toward alternative school-based
strategies that will be presented below.

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Skills Training. In contrast to suicide awareness cur-
riculum in schools, skills training programs emphasize
the development of problem-solving, coping, and cog-
nitive skills, as suicidal youths have deficits in these areas
(e.g., Asarnow et al., 1987; Cole, 1989; Rotheram-Borus
et al., 1990). It is hoped that an “immunization” effect
can be produced against suicidal feelings and behaviors.
The reduction of suicide risk factors (e.g., depression,
hopelessness, and drug abuse) is also a targeted outcome.

Several evaluation studies have shown promising results,
with some evidence for reductions in completed and
attempted suicides (Zenere and Lazarus, 1997) and
improvements in attitudes, emotions, and distress cop-
ing skills (Klingman and Hochdorf, 1993; Orbach and
Bar-Joseph, 1993). The most systematic evaluations have
been conducted by a team of researchers (Eggert et al.,
1995; Randell et al., 2001; Thompson et al., 2000, 2001)
who have focused on skills training and social support
programs for students at high risk for school failure or
dropout. Enhancements of protective factors and reduc-
tions in risk factors following the “active” interventions
were consistently found, while the control “intervention
as usual” did not yield an increase of protective factors.
However, “intervention as usual” sometimes produced
significant reductions in suicide risk behaviors (Eggert
et al., 1995; Randell et al., 2001). Thus it is not clear
which aspects of the skills training program were respon-
sible for risk reduction, a limitation of other studies also
(Zenere and Lazarus, 1997). While these studies yield
encouraging data, additional research is sorely needed to
refine the evaluation of this type of intervention.

Screening. A prevention strategy that has received
increased attention is case-finding through direct screen-
ing of individuals. Self-report and individual interviews
are used to identify youngsters at risk for suicidal behav-
ior (Joiner et al., 2002; Reynolds, 1991; Shaffer and Craft,
1999; Thompson and Eggert, 1999). School-wide screen-
ings, involving multistage assessments, have focused on
depression, substance abuse problems, recent and fre-
quent suicidal ideation, and past suicide attempts. The
few studies that have examined the efficacy of school-
based screening (Reynolds, 1991; Shaffer and Craft, 1999;
Thompson and Eggert, 1999) found that the sensitivity
of the screens ranged from 83% to 100%, while the speci-
ficities ranged from 51% to 76%. Thus, while there were
few false-negatives, there were many false-positives.
Although the number of false-positives could be mini-
mized by using a more stringent cutoff criterion, the seri-

ousness of missing a suicidal individual precludes this
scheme. Thus a tolerance for false-positives is essential
for such endeavors (Thompson and Eggert, 1999), neces-
sitating second-stage assessments to determine who is not
actually at risk for suicide. Second-stage assessments usu-
ally employ systematic clinical evaluations, using inter-
views such as the Suicidal Behaviors Interview (Reynolds,
1990) or the Diagnostic Interview Schedule for Children
(DISC), now available in a spoken, self-completion (Voice-
DISC) version (Shaffer and Craft, 1999).

Although a screening strategy appears to be quite
promising, a number of dilemmas still need to be addressed.
First, because suicide risk “waxes and wanes” over time,
multiple screenings may be necessary in order to mini-
mize “false-negatives” (Berman and Jobes, 1995). Second,
school-wide student screening programs have been rated
by high school principals as significantly less acceptable
than curriculum-based and staff in-service programs,
although most respondents in this study have had either
no or minimal exposure to screening programs (Miller
et al., 1999). Finally, the ultimate success of this strategy
is dependent on the effectiveness of the referral. Considerable
effort must be made to assist the families and adolescents
in obtaining help if it is needed.

Gatekeeper Training. Programs to train school person-
nel as gatekeepers are based on the premise that suicidal
youths are underidentified and that we can increase iden-
tification by providing adults with knowledge about sui-
cide. Only 9% of a national random sample of U.S. high
school teachers believed they could recognize a student
at risk for suicide, and while the overwhelming majority
of counselors knew the risk factors for suicide, only one
in three believed they could identify a student at risk
(King et al., 1999).

The purpose of gatekeeper training is to develop the
knowledge, attitudes, and skills to identify students at
risk, determine the levels of risk, and make referrals when
necessary (Garland and Zigler, 1993; Kalafat and Elias,
1995). Research examining the effectiveness of gatekeeper
training is limited, but the findings are encouraging, with
significant improvements in school personnel’s knowl-
edge, attitudes, intervention skills, preparation for cop-
ing with a crisis, referral practices (Garland and Zigler,
1993; King and Smith, 2000; Mackesy-Amiti et al., 1996;
Shaffer et al., 1988; Tierney, 1994), and general satisfac-
tion with the training (Nelson, 1987). As previously noted,
in-service training programs are significantly more accept-
able by principals than school-wide screening programs

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(Miller et al., 1999). This is consistent with the finding
that 46% of school districts in Washington have gate-
keeper training programs, while no districts use group
screening of students (Hayden and Lauer, 2000).

Peer Helpers. The rationale underlying these programs
is similar to that of suicide awareness programs: Suicidal
youths are more likely to confide in a peer than an adult
(e.g., Kalafat and Elias, 1994). The role that peers play
varies considerably by program, with some limited to lis-
tening and reporting any possible warning signs and oth-
ers involving counseling responsibilities. Many programs
address serious mental health problems, such as drug
abuse, eating disorders, and depression, with 24% of pro-
grams in Washington State involving some suicide pre-
vention role (Lewis and Lewis, 1996). Empirical evaluations
of these programs are quite limited (Lewis and Lewis,
1996) and often confined to student satisfaction mea-
sures (Morey et al., 1993). Potential negative side effects
are rarely examined. To date, there is not a sufficient body
of evidence documenting the efficacy or safety of peer
helping programs, despite their widespread use (Lewis
and Lewis, 1996).

Postvention/Crisis Intervention. The rationale for school-
based postvention/crisis intervention is that a timely response
to a suicide is likely to reduce subsequent morbidity and
mortality in fellow students, including suicidality, the onset
or exacerbation of psychiatric disorders (e.g., posttraumatic
stress disorder, major depressive disorder), and other symp-
toms related to pathological bereavement (Brent et al.,
1993b,e, 1994b). The major goals of postvention programs
are to assist survivors in the grief process, identify and refer
those individuals who may be at risk following the suicide,
provide accurate information about suicide while attempt-
ing to minimize suicide contagion, and implement a struc-
ture for ongoing prevention efforts (Hazell, 1993; Underwood
and Dunne-Maxim, 1997).

The existing research on school-based postvention pro-
grams is sparse. Hazell and Lewin (1993) examined the
efficacy of 90-minute group counseling sessions offered to
groups of 20 to 30 students on the seventh day following
a suicide. No differences in outcome were found between
counseled subjects and matched controls. It was unclear
whether this finding was due to inclusion criteria for postven-
tion counseling (close friends of deceased student), the
intervention itself, or the duration of the distress, or whether
short-term effects dissipated by the assessment at 8 months
after the death. An encouraging, though small and method-
ologically limited, study by Poijula et al. (2001) found that

no new suicides took place during a 4-year follow-up period
in schools where an adequate intervention took place,
whereas the number of suicides significantly increased after
suicides with no adequate subsequent crisis intervention.
It is imperative for crisis interventions to be well planned
and evaluated; otherwise, not only may they not help sur-
vivors, but they may potentially exacerbate problems through
the induction of imitation.

Community-Based Prevention Programs

Crisis Centers and Hotlines. The rationale for crisis hot-
lines (Mishara and Daigle, 2001; Shaffer et al., 1988;
Shneidman and Farberow, 1957) is that suicidal behav-
ior is often associated with a crisis (Brent et al., 1993c;
Gould et al., 1996; Marttunen et al., 1993; Rich et al.,
1988, Runeson, 1990) and telephone crisis services can
provide the opportunity for immediate support at these
critical times by offering services that are convenient,
accessible, and available outside of usual office hours.

Evidence of their efficacy on adult suicide is equivo-
cal (Lester, 1997), and few studies have examined the uti-
lization or efficacy of hotlines among teenagers (Boehm
and Campbell, 1995; King, 1977; Slem and Cotler, 1973).
Overall, between 1% and 6% of adolescents in the com-
munity use hotlines (Offer et al., 1991; Slem and Cotler,
1973; Vieland et al., 1991) and only 4% of calls concern
suicide (Boehm and Campbell, 1995). However, between
14% and 18% of suicidal youths have used hotlines
(Beautrais et al., 1998; Shaffer et al., 1990). There is a
dearth of information about the efficacy of telephone cri-
sis services for teenagers and whether they adequately
address suicide risk.

Restrictions of Firearms. The underlying rationale for
means restrictions is that suicidal individuals are often
impulsive, they may be ambivalent about killing them-
selves, and the risk period for suicide is transient (Hawton
et al., 2001; Miller and Hemenway, 1999). Restricting
access to lethal methods during this period may prevent
suicides, although it is not clear that method restriction
has substantially contributed to the recent secular change
in youth suicide.

Because the most common method of committing sui-
cide in the United States is by firearms (CDC, 2002),
this review will focus on restricting their access. The pres-
ence of firearms in the home is a significant risk factor
for suicide in youths (Brent et al., 1988, 1991, 1993d,
1999) and adults (Kellermann et al., 1992). Several stud-
ies have found that restrictions on guns reduced the over-

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all suicide rate, as well as firearm-related suicides (e.g.,
Boor and Bair, 1990; Carrington and Moyer, 1994; Lester
and Murrell, 1980, 1986; Loftin et al., 1991; Medoff and
Magaddino, 1983), while others have found no overall
effect (Rich et al., 1990) or equivocal results (Cantor and
Slater, 1995; Cummings et al., 1997; Sloan et al., 1990).
The equivocal findings largely reflected age-specific effects
(Cantor and Slater, 1995; Sloan et al., 1990), in that
restrictive gun laws had a greater impact on adolescents
and young adults. Unfortunately, recent legislative ini-
tiatives such as the 1994 Brady Bill, which imposes a delay
in purchasing a handgun, did not find promising results:
A comparison of states that did and did not pass Brady
Bill statutes showed no impact on the proportion of sui-
cides attributable to firearms except in elderly males
(Ludwig and Cook, 2000).

Less controversial means-restriction measures in the
United States involve education to parents of high-risk
youths. Kruesi and colleagues (1999) demonstrated that
injury prevention education in emergency rooms led par-
ents to take new action to limit access to lethal means,
such as locking up their firearms. Unfortunately, Brent
et al. (2000) found that parents of depressed adolescents
were frequently noncompliant with recommendations to
remove firearms from the home.

A common concern is that method substitution will
occur following a means-restriction program. Some evi-
dence of method substitution exists (Lester and Leenaars,
1993; Lester and Murrell, 1982; Rich et al., 1990); how-
ever, method substitution does not appear to be an inevitable
reaction to firearms restriction (Cantor and Slater, 1995;
Carrington and Moyer, 1994; Lester and Murrell, 1986;
Loftin et al., 1991). Moreover, even if some individuals
do substitute other methods, the chances of survival may
be greater if the new methods are less lethal (Cantor and
Baume, 1998).

Media Education. Given the substantial evidence for
suicide contagion, a recommended suicide prevention strat-
egy involves educating media professionals about conta-
gion, in order to yield stories that minimize harm. Moreover,
the media’s positive role in educating the public about risks
for suicide and shaping attitudes about suicide should be
encouraged.

A set of recommendations on reporting of suicide were
recently developed by an international workgroup headed
by the American Foundation for Suicide Prevention and
the Annenberg School of Communication and Public
Policy (American Foundation for Suicide Prevention,

2001). Guidelines for media reporting now exist in sev-
eral countries. Recommendations generally include descrip-
tions of factors that should be avoided because they are
more likely to induce contagion (e.g., front page cover-
age) and suggestions on how to increase the usefulness of
the report (e.g., describing treatment resources).

Following the implementation of media guidelines in
Austria, suicide rates declined 7% in the first year, nearly
20% in the 4-year follow-up period, and subway suicides
(a particular focus of the media guidelines) decreased by
75% (Etzersdorfer et al., 1992; Etzersdorfer and Sonneck,
1998; Sonneck et al., 1994). In Switzerland, Michel et al.
(2000) found that following the implementation of guide-
lines, the number of articles increased but they were sig-
nificantly shorter and less likely to be on the front page;
headlines, pictures, and text were less sensational; there
were relatively fewer articles with pictures; and their over-
all “Imitation Risk Scores” were lower. Given the suc-
cessful strategy of engaging the media in Austria and
Switzerland, efforts to systematically disseminate and
evaluate media recommendations in the United States
are recommended.

Health Care-Based Prevention Programs

Educational/Training Programs for Primary Care Physicians
and Pediatricians. The need for training primary care physi-
cians and pediatricians in the United States is highlighted
by the finding that while 72% of 600 family physicians
and pediatricians in North Carolina had prescribed a SSRI
for a child or adolescent patient, only 8% said they had
received adequate training in the treatment of childhood
depression and only 16% reported that they felt com-
fortable treating children for depression (Voelker, 1999).
Furthermore, although many suicidal young people (15–34
years) seek general medical care in the month preceding
their suicidal behavior (Pfaff et al., 1999), fewer than half
of physicians surveyed reported that they routinely screen
their patients for suicide risk (Frankenfield et al., 2000).

Pfaff et al. (2001) demonstrated that after a 1-day train-
ing workshop for 23 primary care physicians in Australia,
inquiry about suicidal ideation increased by 32.5% and
identification of suicidal patients increased by 130%,
although no significant change in patient management
resulted and referrals of suicidal youths to mental health
specialists remained low. The effectiveness of educational
programs for health care professionals has also been demon-
strated by the Gotland study (Rutz et al., 1992). After the
implementation of an intensive postgraduate training pro-

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gram aimed at improving general practitioners’ diagnosis
and treatment of depression on the island of Gotland,
Sweden, the adult suicide rate significantly declined. The
decline was almost totally due to decreases in female sui-
cides with major depression (the number of male suicides
was unchanged). Three years after the project ended, the
suicide rate returned almost to baseline rates (Rihmer et al.,
1995), suggesting that ongoing repetition of the educa-
tional program is warranted. A similar educational pro-
gram for pediatricians could be an effective youth suicide
prevention strategy; however, other adjunctive approaches
to reach at-risk males should be considered.

TREATMENT

Recent reviews (e.g., Hawton et al., 1998, 2002; Rudd,
2000) note that few studies have systematically evaluated
interventions aimed at reducing suicidal ideation and
behavior in children and adolescents, i.e., randomized
controlled trials that obtain reliable and valid measures of
outcome variables during pretreatment, posttreatment,
and follow-up periods. Most treatment efficacy studies of
adolescent psychiatric populations exclude suicidal indi-
viduals, possibly because the potential risks of treating
high-risk youths outweigh benefits. The National Institute
of Mental Health recently published guidelines that high-
light a number of ethical, legal, and safety considerations
associated with such studies (Pearson et al., 2001).

Treatment Service Utilization

Many adolescents contact a mental health professional
before their suicidal behavior. Among suicide completers,
rates of contact vary from 7% to 15% within the previ-
ous month, 20% to 25% within the previous year, and
25% to 35% over the lifetime (Brent et al., 1993a; Groholt
et al., 1997; Marttunen et al., 1992; Shaffer et al., 1996).
Contact rates were higher, between 59% and 78%, in a
New Zealand sample of attempters admitted for 24-hour
hospital stay (Beautrais et al., 1998).

Emergency/Crisis-Service Interventions and Triage

Procedures for the acute care of suicidal adolescents
have been described elsewhere (American Academy of
Child and Adolescent Psychiatry, 2001). These recom-
mendations are largely based on common sense approaches
and expert clinical consensus. Such guidelines emphasize
that certain preconditions must be satisfied before chil-
dren and adolescents are discharged from the emergency
service, e.g., the need to “sanitize” the home—make

firearms and/or lethal medications inaccessible to the
child (Kruesi et al., 1999).

Similarly, a written or verbal “no-suicide” contract is
commonly negotiated at the start of treatment in the hope
that it will improve treatment compliance and reduce the
likelihood of further suicidal behavior (Brent, 1997;
Rotheram, 1987). However, no empirical studies have eval-
uated the effectiveness of no-suicide contracts (Reid, 1998).

Rotheram-Borus et al. (1999) found that the imple-
mentation of a brief set of specialized emergency room
procedures increased eventual treatment adherence among
Latina adolescent suicide attempters. The procedures aug-
mented typical emergency room care by (1) using a stan-
dardized protocol for training emergency room staff, (2)
presenting a 20-minute videotape to patients and their
families that models realistic expectations for aftercare
treatment, and (3) providing a bilingual crisis therapist
to promote compliance with outpatient therapy. Suicidal
adolescents receiving the specialized emergency room
procedure attended 3.8 more outpatient follow-up ses-
sions than those receiving standard aftercare. The research
was not able to identify which of these components were
responsible for the increase in compliance.

Inpatient Care and Partial Hospitalization

While inpatient and partial hospitalization offer inten-
sive multidisciplinary treatments and skilled observation
and support, there is no empirical evidence that either of
these interventions is effective in reducing rates of sui-
cidal ideation, nonlethal attempts, or completed suicide
among adolescents.

Outpatient Follow-up Treatment

Generally low rates of compliance with outpatient
treatment among adolescent suicide attempters (e.g.,
Piacentini et al., 1995) make such investigations difficult
to implement. Dropout rates as high as 59% have been
reported (Spirito et al., 1992). King et al. (1997) found
that compliance rates were highest for medication fol-
low-up (66.7%), relative to rates for individual therapy
(50.8%) and family therapy/parent psychoeducation
(33.3%). Results of that study also indicate that non-
compliance is associated with parental psychopathology
and family dysfunction.

Psychotherapy

Hawton et al. (1998, 2002) reviewed all randomized
controlled trials targeting suicide attempters. Of 23 stud-

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ies, only two explicitly obtained an adolescent sample
(Cotgrove et al., 1995; Harrington et al., 1998). Unsuccessful
treatments included problem-solving (e.g., Rudd et al.,
1996), enhanced access to clinical service (e.g., Cotgrove
et al., 1995; van der Sande et al., 1997), and home-based
family therapy (Harrington et al., 1998). The only psy-
chotherapy that has been shown to reduce repeat attempts
in a randomized clinical trial is dialectical behavior ther-
apy (DBT), a 12-month cognitive-behavioral intervention
designed for adults with borderline personality disorder
(Linehan et al., 1991). This study found that adults assigned
to DBT engaged in fewer and less severe parasuicidal behav-
iors post-treatment than patients assigned to treatment-
as-usual, but this may partly be attributable to higher
baseline attempt rates characteristic of patients with bor-
derline personality disorder. Downward extensions of DBT
such as DBT-A (Miller et al., 1997a) may be of value; how-
ever, they have not yet been systematically evaluated in this
age group or in males, who are most at risk for suicide
(Anderson, 2002). No studies of cognitive-behavioral ther-
apy with adolescent suicide attempters have been pub-
lished, although it has been used successfully in adolescent
patients with depression (Brent et al., 1997; Harrington
and Clark, 1998).

Psychopharmacological Interventions

To our knowledge, there have been no psychophar-
macological studies that have specifically targeted suicidal
adolescents. However, it is likely that in spite of the absence
of documented support, the use of SSRIs is common
among teenagers who have been referred for suicidal
ideation or after they have made an attempt. Rates of pre-
scription of antidepressants among teenagers are extremely
high (Olfson et al., 2002b) and almost certainly include
adolescents who have attempted suicide. Indeed, this prac-
tice may be a factor leading to the dramatic and encour-
aging decline in youth suicide rates over the past decade
(Isacsson, 2000). There are few a priori reasons not to treat
suicidal adolescents with SSRIs, providing their progress
and response to the medication is closely monitored.

SSRI antidepressants have been shown to reduce sui-
cidal ideation in both depressed (Letizia et al., 1996) and
nondepressed adults with cluster B personality disorders
(Verkes et al., 1998) and in individuals who have made
a limited number of previous suicide attempts. SSRIs
have been shown to be more effective than placebo in
treating depressed teenagers (Emslie and Mayes, 2001;
Emslie et al., 1997; Keller et al., 2001), they are consid-

erably less dangerous in overdose than are tricyclic anti-
depressants (Ryan and Varma, 1998), and there is evi-
dence that they reduce the frequency of impulsive and
aggressive behaviors (Coccaro and Kavoussi, 1997), which
are a common occurrence in suicidal teenagers.

In rare instances, ruminative suicidal ideation com-
bined with akathisia can occur during the course of antipsy-
chotic (Hamilton and Opler, 1992) or SSRI treatment
(King et al., 1991; Teicher et al., 1990). This complica-
tion has been reported to respond to propranolol (Adler
et al., 1985; Chandler, 1990). When SSRI treatment is
started, parents should be routinely advised to inform the
psychiatrist if akathisia develops; the suicidal teenager
should likewise be advised to inform parents or physi-
cians if there is an upsurge in suicidal ideation.

In adults with bipolar or other major affective disor-
ders, long-term lithium treatment significantly reduces
the recurrence of suicide attempts (Tondo et al., 1997)
and sudden withdrawal from lithium increases the risk of
suicide independent of any effect on other symptoms of
mania (Tondo and Baldessarini, 2000). Similarly, cloza-
pine is effective in reducing suicidality in adults with schizo-
phrenia even when there is no apparent effect or impact
on other symptoms of schizophrenia (see Meltzer, 2001).
The antisuicidal effects of lithium and clozapine have not
been assessed in children or adolescents. If lithium is being
used to treat an adolescent, it would be wise to observe
the same degree of caution as has been used in adults with
respect to sudden withdrawal of the medication.

CONCLUSIONS

The past decade has witnessed a surge in research on
youth suicide risk. The current review has underscored
youth psychiatric disorder, a family history of suicide and
psychopathology, stressful life events, and access to firearms
as key risk factors for youth suicide. Exciting new find-
ings have emerged on the biology of suicide in adults,
but, while encouraging, these are yet to be replicated in
youths. Factors that had been previously thought to be
risks for youth suicide, such as divorce and impaired par-
ent–child relationships, have been found to be largely
explained by underlying psychiatric problems in the youth
and/or parents, whereas other risk factors, such as same-
sex sexual orientation and sexual abuse, while mediated
by other psychosocial risks, have recently been found to
make an independent contribution to youth suicide.

Despite the burgeoning research literature on risk fac-
tors, there remains a paucity of information on protec-

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tive factors. Family cohesiveness and religiosity may be
somewhat protective, but much more work needs to be
done before we can have confidence that they mitigate
the impact of accumulating risk factors. Future research
needs to increasingly identify factors that protect against
suicidal behavior so that they may be enhanced.

Several promising empirically based prevention strate-
gies have been identified, including school-based skills
training for students, screening for at-risk youths, edu-
cation of primary care physicians, media education, and
lethal-means restriction; however, these strategies need
continuing evaluation studies before their efficacy can be
established.

Because the decline in youth suicide seems likely to be
a product of more widely administered and more effec-
tive treatment, the burden on professionals to identify
depressed and suicidal teenagers and bring them to treat-
ment is greater than ever before. Well-designed studies
on candidate medications and psychotherapies must be
conducted as a matter of urgency.

Given the complexity of the mechanism of youth sui-
cide, it seems likely that no one prevention/intervention
strategy, by itself, is enough to combat this critical prob-
lem. Rather, a comprehensive, integrated effort, involv-
ing multiple domains—the individual, family, school,
community, media, and health care system—is needed.

REFERENCES

Adler L, Angrist B, Peselow E, Corwin J, Rotrosen J (1985), Efficacy of pro-
pranolol in neuroleptic-induced akathesia. J Clin Psychopharmacol 5:164–166

Agerbo E, Nordentoft M, Mortensen PB (2002), Familial, psychiatric, and
socioeconomic risk factors for suicide in young people: nested case-
control study. BMJ 325:74

American Academy of Child and Adolescent Psychiatry (2001), Practice para-
meters for the assessment and treatment of children and adolescents with
suicidal behavior. J Am Acad Child Adolesc Psychiatry 40(suppl):24S–51S

American Foundation for Suicide Prevention (2001), Reporting a Suicide:
Recommendations for the Media. Available online: www.afsp.org (accessed
July 1, 2002)

Anderson RN (2002), Deaths: leading causes for 2000. National Vital Statistics
Reports 50(16). Hyattsville, MD: National Center for Health Statistics

Andrews JA, Lewinsohn PM (1992), Suicidal attempts among older adoles-
cents: prevalence and co-occurrence with psychiatric disorders. J Am Acad
Child Adolesc Psychiatry 31:655–662

Andrus JK, Fleming DW, Heumann MA, Wassell JT, Hopkins DD, Gordon
J (1991), Surveillance of attempted suicide among adolescents in Oregon,
1988. Am J Public Health 81:1067–1069

Apter A, Bleich A, King R et al. (1993a), Death without warning? A clinical
postmortem study of suicide in 43 Israeli adolescent males. Arch Gen
Psychiatry 50:138–142

Apter A, Plutchik R, van Praag HM (1993b), Anxiety, impulsivity and depressed
mood in relation to suicidal and violent behavior. Acta Psychiatr Scand
87:1–5

Arango V, Underwood MD, Boldrini M et al. (2001), Serotonin 1A recep-
tors, serotonin transporter binding and serotonin transporter mRNA

expression in the brainstem of depressed suicide victims. Neuropsycho-
pharmacology 25:892–903

Asarnow J, Carlson G, Guthrie D (1987), Coping strategies, self-perceptions,
hopelessness, and perceived family environments in depressed and suicidal
children. J Consult Clin Psychol 55:361–366

Barraclough BM, Bunch J, Nelson B, Sainsbury P (1974), A hundred cases of
suicide: clinical aspects. Br J Psychiatry 125:355–373

Beautrais AL (2001), Child and young adolescent suicide in New Zealand.
Aust N Z J Psychiatry 35:647–653

Beautrais AL, Joyce PR, Mulder RT (1996), Risk factors for serious suicide
attempts among youths aged 13 through 24 years. J Am Acad Child Adolesc
Psychiatry 35:1174–1182

Beautrais AL, Joyce PR, Mulder RT (1997), Precipitating factors and life events
in serious suicide attempts among youths aged 13 through 24 years. J Am
Acad Child Adolesc Psychiatry 36:1543–1551

Beautrais AL, Joyce PR, Mulder RT (1998), Psychiatric contacts among youths
aged 13 through 24 years who have made serious suicide attempts. J Am
Acad Child Adolesc Psychiatry 37:504–511

Bennett PJ, McMahon WM, Watabe J et al. (2000), Tryptophan hydroxylase
polymorphisms in suicide victims. Psychiatr Genet 10:13–17

Berman AL, Jobes DA (1995), Suicide prevention in adolescents (age 12–18).
Suicide Life Threat Behav 25:143–154

Blake SM, Ledsky R, Lehman T, Goodenow C, Sawyer R, Hack T (2001),
Preventing sexual risk behaviors among gay, lesbian, and bisexual adoles-
cents: the benefits of gay-sensitive HIV instruction in schools. Am J Public
Health 91:940–946

Boehm KE, Campbell NB (1995), Suicide: a review of calls to an adolescent
peer listening phone service. Child Psychiatry Hum Dev 26:61–66

Boor M, Bair JH (1990), Suicide rates, handgun control laws, and socio-
demographic variables. Psychol Rep 66:923–930

Borowsky IW, Resnick MD, Ireland M, Blum RW (1999), Suicide attempts
among American Indian and Alaska Native youth: risk and protective fac-
tors. Arch Pediatr Adolesc Med 153:573–580

Brent DA (1997), The aftercare of adolescents with deliberate self-harm. J
Child Psychol Psychiatry 38:277–286

Brent DA, Baugher M, Birmaher B, Kolko DJ, Bridge J (2000), Compliance
with recommendations to remove firearms in families participating in a
clinical trial for adolescent depression. J Am Acad Child Adolesc Psychiatry
39:1220–1226

Brent DA, Baugher M, Bridge J, Chen T, Chiappetta L (1999), Age- and sex-
related risk factors for adolescent suicide. J Am Acad Child Adolesc Psychiatry
38:1497–1505

Brent DA, Bridge J, Johnson BA, Connolly J (1996), Suicidal behavior runs
in families: a controlled family study of adolescent suicide victims. Arch
Gen Psychiatry 53:1145–1152

Brent DA, Holder D, Kolko D et al. (1997), A clinical psychotherapy trial for
adolescent depression comparing cognitive, family, and supportive ther-
apy. Arch Gen Psychiatry 54:877–885

Brent DA, Kerr MM, Goldstein C, Bozigar J, Wartella ME, Allan MJ (1989),
An outbreak of suicide and suicidal behavior in high school. J Am Acad
Child Adolesc Psychiatry 28:918–924

Brent DA, Perper JA, Allman CJ, Moritz GM, Wartella ME, Zelenak JZ (1991),
The presence and accessibility of firearms in the homes of adolescent sui-
cides: a case-control study. JAMA 266:2989–2995

Brent DA, Perper JA, Goldstein CE et al. (1988), Risk factors for adolescent
suicide: a comparison of adolescent suicide victims with suicidal inpa-
tients. Arch Gen Psychiatry 45:581–588

Brent DA, Perper JA, Moritz G et al. (1993a), Psychiatric risk factors for ado-
lescent suicide: a case-control study. J Am Acad Child Adolesc Psychiatry
32:521–529

Brent DA, Perper JA, Moritz GM et al. (1993b), Bereavement or depression?
The impact of the loss of a friend to suicide. J Am Acad Child Adolesc
Psychiatry 32:1189–1197

Brent DA, Perper JA, Moritz G et al. (1993c), Stressful life events, psychopa-
thology and adolescent suicide: a case control study. Suicide Life Threat
Behav 23:179–187

Brent DA, Perper JA, Moritz GM, Baugher M, Schweers J, Ross C (1993d),
Firearms and adolescent suicide: a community case control study. Am J
Dis Child 147:1066–1071

G O U L D E T A L .

400 J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I AT RY, 4 2 : 4 , A P R I L 2 0 0 3

Brent DA, Perper JA, Moritz GM et al. (1993e), Adolescent witness to a peer
suicide. J Am Acad Child Adolesc Psychiatry 32:1184–1188

Brent DA, Perper JA, Moritz G et al. (1994a), Familial risk factors for ado-
lescent suicide: a case-control study. Acta Psychiatr Scand 89:52–58

Brent DA, Perper JA, Moritz GM, Liotus L, Schweers J, Canobbio R (1994b),
Major depression or uncomplicated bereavement? A follow-up of youth
exposed to suicide. J Am Acad Child Adolesc Psychiatry 33:231–239

Bridge JA, Brent D, Johnson BA, Connolly J (1997), Familial aggregation of
psychiatric disorders in a community sample of adolescents. J Am Acad
Child Adolesc Psychiatry 36:628–636

Brown J, Cohen P, Johnson JG, Smailes EM (1999), Childhood abuse and
neglect: specificity of effects on adolescent and young adult depression
and suicidality. J Am Acad Child Adolesc Psychiatry 38:1490–1496

Cantor CH, Baume PJ (1998), Access to methods of suicide: what impact?
Aust N Z J Psychiatry 31:8–14

Cantor CH, Slater PJ (1995), The impact of firearm control legislation on
suicide in Queensland: preliminary findings. Med J Aust 162:583–585

Carrington PJ, Moyer S (1994), Gun control and suicide in Ontario. J Psychiatry
151:606–608

Centers for Disease Control and Prevention (1994), Programs for the pre-
vention of suicide among adolescents and young adults; and Suicide con-
tagion and the reporting of suicide: recommendations from a national
workshop. MMWR Morb Mortal Wkly Rep 43:1–19

Centers for Disease Control and Prevention (1995), Youth Risk Behavior
Surveillance—United States, 1993. MMWR Morb Mortal Wkly Rep
44(SS01):1–56

Centers for Disease Control and Prevention (1996), Youth Risk Behavior
Surveillance—United States, 1995. MMWR Morb Mortal Wkly Rep
45(SS04):1–84

Centers for Disease Control and Prevention (1998), Youth Risk Behavior
Surveillance—United States, 1997. MMWR Morb Mortal Wkly Rep
47(SS03):1–89

Centers for Disease Control and Prevention (2000), Youth Risk Behavior
Surveillance—United States, 1999. MMWR Morb Mortal Wkly Rep
49(SS05):1–96

Centers for Disease Control and Prevention (2002), Mortality Query, CDC
Wonder, Data and Statistics (http://wonder.cdc.gov/mortsql.html; accessed
4/10/02)

Chandler JD (1990), Propranolol treatment of akathesia in Tourette’s syn-
drome. J Am Acad Child Adolesc Psychiatry 29:475–477

Chang EC (2002), Predicting suicide ideation in an adolescent population:
examining the role of social problem solving as a moderator and a medi-
ator. Pers Individ Dif 32:1279–1291

Ciffone J (1993), Suicide prevention: a classroom presentation to adolescents.
Soc Work 38:197–203

Coccaro EF, Kavoussi RJ (1997), Fluoxetine and impulsive aggressive behav-
ior in personality-disordered subjects. Arch Gen Psychiatry 54:1081–1088

Cole DA (1988), Hopelessness, social desirability, depression, and parasuicide
in two college student samples. J Consult Clin Psychol 56:131–136

Cole DA (1989), Psychopathology of adolescent suicide: hopelessness, cop-
ing beliefs, and depression. J Abnorm Psychol 98:248–255

Cotgrove A, Zirinsky L, Black D, Weston D (1995), Secondary prevention of
attempted suicide in adolescence. J Adolesc 18:569–577

Courtet P, Baud P, Abbar M et al. (2001), Association between violent sui-
cidal behavior and the low activity allele of the serotonin transporter gene.
Mol Psychiatry 6:338–341

Cummings P, Koepsell TD, Grossman DC, Savarino J, Thompson RS (1997),
The association between the purchase of a handgun and homicide or sui-
cide. Am J Public Health 87:974–978

Cutright P, Fernquist RM (2000), Firearms and suicide: the American expe-
rience, 1926–1996. Death Stud 24:705–719

Demetriades D, Murray J, Myles D et al. (1998), Epidemiology of major
trauma and trauma deaths in Los Angeles County. J Am Coll Surg 187:373–383

Du L, Faludi G, Palkovits M, Bakish D, Hrdina PD (2001), Serotonergic
genes and suicidality. Crisis 22:54–60

Durkheim E (1966), Suicide. New York: Free Press
Eggert LL, Thompson EA, Herting JR, Nicholas LJ (1995), Reducing suicide

potential among high-risk youth: tests of a school-based prevention pro-
gram. Suicide Life Threat Behav 25:276–296

Emslie GJ, Mayes TL (2001), Mood disorders in children and adolescents:
psychopharmacological treatment. Biol Psychiatry 49:1082–1090

Emslie GJ, Rush AJ, Weinberg WA et al. (1997), A double-blind, random-
ized, placebo-controlled trial of fluoxetine in children and adolescents with
depression. Arch Gen Psychiatry 54:1031–1037

Etzersdorfer E, Sonneck G (1998), Preventing suicide by influencing mass-
media reporting: the Viennese experience 1980–1996. Arch Suicide Res
4:67–74

Etzersdorfer E, Sonneck G, Nagel-Kuess S (1992), Newspaper reports and sui-
cide. N Engl J Med 327:502–503

Faulkner AH, Cranston K (1998), Correlates of same-sex behavior in a ran-
dom sample of Massachusetts high school students. Am J Public Health
88:262–266

Fekete S, Macsai E (1990), Hungarian suicide models, past and present. In:
Suicidal Behavior and Risk Factors, Ferrari G, ed. Bologna: Monduzzi
Editore, pp 149–156

Fergusson DM, Horwood LJ, Lynskey MT (1996), Childhood sexual abuse
and psychiatric disorder in young adulthood, II: psychiatric outcomes of
childhood sexual abuse. J Am Acad Child Adolesc Psychiatry 35:1365–1374

Fergusson DM, Lynskey M (1995), Childhood circumstances, adolescent
adjustment, and suicide attempts in a New Zealand birth cohort. J Am
Acad Child Adolesc Psychiatry 34:612–622

Fergusson DM, Woodward LJ, Horwood LJ (2000), Risk factors and life
processes associated with the onset of suicidal behaviour during adoles-
cence and early adulthood. Psychol Med 30:23–39

Frankenfield DL, Keyl PM, Gielen A, Wissow LS, Werthamer L, Baker SP
(2000), Adolescent patients: healthy or hurting? Missed opportunities to
screen for suicide risk in the primary care setting. Arch Pediatr Adolesc Med
154:162–168

Garland AF, Zigler E (1993), Adolescent suicide prevention: current research
and social policy implications. Am Psychol 48:169–182

Garofalo R, Wolf R, Cameron MS, Kessel S, Palfrey J, DuRant RH (1998),
The association between health risk behaviors and sexual orientation among
a school-based sample of adolescents. Pediatrics 101:895–902

Garrison CZ, McKeown RE, Valois RF, Vincent ML (1993), Aggression, sub-
stance use, and suicidal behaviors in high school students. Am J Public
Health 83:179–184

Giaconia RM, Reinherz HZ, Silverman AB, Pakiz B, Frost AK, Cohen E
(1995), Traumas and posttraumatic stress disorder in a community pop-
ulation of older adolescents. J Am Acad Child Adolesc Psychiatry 34:1369–1380

Gibbs JT (1997), African-American suicide: a cultural paradox. Suicide Life
Threat Behav 27:68–79

Glowinski AL, Bucholz KK, Nelson EC et al. (2001), Suicide attempts in an
adolescent female twin sample. J Am Acad Child Adolesc Psychiatry
40:1300–1307

Goodwin R, Gould MS, Blanco C, Olfson M (2001), Prescription of psy-
chotropic medications to youths in office-based practice. Psychiatr Serv
52:1081–1087

Gould MS (2001), Suicide and the media. In: Suicide Prevention: Clinical and
Scientific Aspects, Annals of the New York Academy of Sciences, Hendin H,
Mann JJ, eds. New York: New York Academy of Sciences

Gould MS, Fisher P, Parides M, Flory M, Shaffer D (1996), Psychosocial risk
factors of child and adolescent completed suicide. Arch Gen Psychiatry
53:1155–1162

Gould MS, King R, Greenwald S et al. (1998), Psychopathology associated
with suicidal ideation and attempts among children and adolescents. J Am
Acad Child Adolesc Psychiatry 37:915–923

Gould MS, Kramer RA (2001), Youth suicide prevention. Suicide Life Threat
Behav 31(suppl):6–31

Gould MS, Petrie K, Kleinman M, Wallenstein S (1994), Clustering of attempted
suicide: New Zealand national data. Int J Epidemiol 23:1185–1189

Gould MS, Wallenstein S, Kleinman M (1990a), Time-space clustering of
teenage suicide. Am J Epidemiol 131:71–78

Gould MS, Wallenstein S, Kleinman M, O’Carroll P, Mercy J (1990b), Suicide
clusters: an examination of age-specific effects. Am J Public Health 80:211–212

Groholt B, Ekeberg O, Wichstrom L, Haldorsen T (1997), Youth suicide in
Norway, 1990–1992: a comparison between children and adolescents com-
pleting suicide and age- and gender-matched controls. Suicide Life Threat
Behav 27:250–263

YO U T H S U I C I D E R I S K A N D I N T E RV E N T I O N S

J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I AT RY, 4 2 : 4 , A P R I L 2 0 0 3 401

Groholt B, Ekeberg O, Wichstrom L, Haldorsen T (1998), Suicide among
children and younger and older adolescents in Norway: a comparative
study. J Am Acad Child Adolesc Psychiatry 37:473–481

Groholt B, Ekeberg O, Wichstrom L, Haldorsen T (2000), Young suicide
attempters: a comparison between a clinical and an epidemiological sam-
ple. J Am Acad Child Adolesc Psychiatry 39:868–875

Grunbaum JA, Basen-Engquist K, Pandey D (1998), Association between vio-
lent behaviors and substance use among Mexican-American and non-
Hispanic white high school students. J Adolesc Health 23:153–159

Grunbaum JA, Kann L, Kinchen SA et al. (2002), Youth Risk Behavior
Surveillance—United States, 2001. MMWR CDC Surveill Summ 51(SS4):1–64

Guo G, Harstall C (2002), Efficacy of Suicide Prevention Programs for Children
and Youth. HTA 26: Services A Health Technology Assessment. Alberta,
Canada: Alberta Heritage Foundation for Medical Research (available from
Director, Health Technology Assessment, Alberta Heritage Foundation
for Medical Research, 1500, 10104-103 Avenue, Edmonton, Alberta,
Canada T5J 4A7; 780-423-5727)

Hamilton MS, Opler LA (1992), Akathisia, suicidality, and fluoxetine. J Clin
Psychiatry 53:401–406

Harrington R, Clark A (1998), Prevention and early intervention for depres-
sion in adolescence and early adult life. Eur Arch Psychiatry Clin Neurosci
248:32–45

Harrington R, Kerfoot M, Dyer E et al. (1998), Randomized trial of a home-
based family intervention for children who have deliberately poisoned
themselves. J Am Acad Child Adolesc Psychiatry 37:512–518

Hassan R (1995), Effects of newspaper stories on the incidence of suicide in
Australia: a research note. Aust N Z J Psychiatry 29:480–483

Hawton K, Arensman E, Townsend E et al. (1998), Deliberate self harm: sys-
tematic review of efficacy of psychosocial and pharmacological treatments
in preventing repetition. BMJ 317:441–447

Hawton K, Townsend E, Arensman E et al. (2002), Psychosocial versus phar-
macological treatments for deliberate self-harm. Cochrane Database Syst
Rev 2:CD001764

Hawton K, Townsend E, Deeks J et al. (2001), Effects of legislation restrict-
ing pack sizes of paracetamol and salicylate on self poisoning in the United
Kingdom: before and after study. BMJ 322:1203–1207

Hayden DC, Lauer P (2000), Prevalence of suicide programs in schools and
roadblocks to implementation. Suicide Life Threat Behav 30:239–251

Haynes RH (1987), Suicide and social response in Fiji: a historical survey. Br
J Psychiatry 151:21–26

Hazell P (1993), Adolescent suicide clusters: evidence, mechanisms and pre-
vention. Aust N Z J Psychiatry 27:653–665

Hazell P, King R (1996), Arguments for and against teaching suicide preven-
tion in schools. Aust N Z J Psychiatry 30:633–642

Hazell P, Lewin T (1993), An evaluation of postvention following adolescent
suicide. Suicide Life Threat Behav 23:101–109

Heath AC, Howells W, Bucholz KK, Glowinski AL, Nelson EC, Madden PA
(2002), Ascertainment of a mid-western US female adolescent twin cohort
for alcohol studies: assessment of sample representativeness using birth
record data. Twin Res 5:107–112

Hilton SC, Fellingham GW, Lyon JL (2002), Suicide rates and religious com-
mitment in young adult males in Utah. Am J Epidemiol 155:413–419

Hovey JD (1999), Religion and suicidal ideation in a sample of Latin American
immigrants. Psychol Rep 85:171–177

Howard-Pitney B, LaFromboise TD, Basil M, September B, Johnson M (1992),
Psychological and social indicators of suicide ideation and suicide attempts
in Zuni adolescents. J Consult Clin Psychol 60:473–476

Hulten A, Jiang GX, Wasserman D et al. (2001), Repetition of attempted sui-
cide among teenagers in Europe: frequency, timing and risk factors. Eur
Child Adolesc Psychiatry 10:161–169

Isacsson G (2000), Suicide prevention: a medical breakthrough? Acta Psychiatr
Scand 102:113–117

Ishii K (1991), Measuring mutual causation: effect of suicide news on suicides
in Japan. Soc Sci Res 20:188–195

Joffe RT, Offord DR, Boyle MH (1988), Ontario Child Health Study: sui-
cidal behavior in youth aged 12–16 years. Am J Psychiatry 145:1420–1423

Johnson BA, Brent DA, Bridge J, Connolly J (1998), The familial aggregation
of adolescent suicide attempts. Acta Psychiatr Scand 97:18–24

Johnson J, Weissman MM, Klerman GL (1990), Panic disorder, comorbid-
ity, and suicide attempts. Arch Gen Psychiatry 47:805–808

Johnson JG, Cohen P, Gould MS, Kasen S, Brown J, Brook JS (2002), Childhood
adversities, interpersonal difficulties, and risk for suicide attempts during
late adolescence and early adulthood. Arch Gen Psychiatry 59:741–749

Joiner TE, Pfaff JJ, Acres JG (2002), A brief screening tool for suicidal symp-
toms in adolescents and young adults in general health settings: reliabil-
ity and validity data from the Australian National General Practice Youth
Suicide Prevention Project. Behav Res Ther 40:471–481

Jonas K (1992), Modelling and suicide: a test of the Werther effect. Br J Soc
Psychol 31:295–306

Kalafat J, Elias M (1994), An evaluation of a school-based suicide awareness
intervention. Suicide Life Threat Behav 24:224–233

Kalafat J, Elias M (1995), Suicide prevention in an educational context: broad
and narrow foci. Suicide Life Threat Behav 25:123–133

Kalafat J, Gagliano C (1996), The use of simulations to assess the impact of
an adolescent suicide response curriculum. Suicide Life Threat Behav
26:359–364

Kaltiala-Heino R, Rimpela M, Marttunen M, Rimpela A, Rantanen P (1999),
Bullying, depression, and suicidal ideation in Finnish adolescents: school
survey. BMJ 319:348–351

Kandel DB (1988), Substance use, depressive mood, and suicidal ideation in
adolescence and young adulthood. In: Advancement in Adolescent Mental
Health, Stiffman AR, Feldman RA, eds. Greenwich, CT: JAI Press, pp
127–142

Kashani JH, Goddard P, Reid JC (1989), Correlates of suicidal ideation in a
community sample of children and adolescents. J Am Acad Child Adolesc
Psychiatry 28:912–917

Keller MB, Ryan ND, Strober M et al. (2001), Efficacy of paroxetine in the
treatment of adolescent major depression: a randomized, controlled trial.
J Am Acad Child Adolesc Psychiatry 40:762–772

Kellermann AL, Rivera FP, Somes G et al. (1992), Suicide in the home in rela-
tion to gun ownership. N Engl J Med 327:467–472

Kessler RC, Borges G, Walters EE (1999), Prevalence of and risk factors for
lifetime suicide attempts in the National Comorbidity Study. Arch Gen
Psychiatry 36:617–626

King CA, Hovey JD, Brand E, Wilson R, Ghaziuddin N (1997), Suicidal ado-
lescents after hospitalization: parent and family impacts on treatment
follow-through. J Am Acad Child Adolesc Psychiatry 36:85–93

King GD (1977), An evaluation of the effectiveness of a telephone counsel-
ing center. Am J Community Psychol 5:75–83

King KA, Price JH, Telljohann SK, Wahl J (1999), High school health teach-
ers’ perceived self-efficacy in identifying students at risk for suicide. J Sch
Health 69:202–207

King KA, Smith J (2000), Project SOAR: a training program to increase school
counselors’ knowledge and confidence regarding suicide prevention and
intervention. J Sch Health 70:402–407

King RA, Riddle MA, Chappell PB et al. (1991), Emergence of self-destructive
phenomena in children and adolescents during fluoxetine treatment. J Am
Acad Child Adolesc Psychiatry 30:179–186

Kirby D (1985), Sexuality education: a more realistic view of its effects. J Sch
Health 55:421–424

Klingman A, Hochdorf Z (1993), Coping with distress and self harm: the
impact of a primary prevention program among adolescents. J Adolesc
16:121–140

Kruesi MJ, Grossman J, Pennington JM, Woodward PJ, Duda D, Hirsch JG
(1999), Suicide and violence prevention: parent education in the emer-
gency department. J Am Acad Child Adolesc Psychiatry 38:250–255

Krug EG, Powell KE, Dahlbert LL (1998), Firearm-related deaths in the United
States and 35 other high- and upper-middle-income countries. Int J
Epidemiol 27:214–221

Lester D (1992), Religiosity, suicide and homicide: a cross-national examina-
tion. Psychol Rep 71:1282

Lester D (1997), The effectiveness of suicide prevention centers: a review.
Suicide Life Threat Behav 27:304–310

Lester D, Leenaars A (1993), Suicide rates in Canada before and after tight-
ening firearm control laws. Psychol Rep 72:787–790

Lester D, Murrell M (1980), The influence of gun control laws on suicidal
behavior. Am J Psychiatry 137:121–122

G O U L D E T A L .

402 J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I AT RY, 4 2 : 4 , A P R I L 2 0 0 3

Lester D, Murrell M (1982), The preventive effect of strict gun control laws
on suicide and homicide. Suicide Life Threat Behav 12:131–141

Lester D, Murrell M (1986), The influence of gun control laws on personal
violence. J Community Psychol 14:315–318

Letizia C, Kapik B, Flanders WD (1996), Suicidal risk during controlled clin-
ical investigations of fluvoxamine. J Clin Psychiatry 57:415–421

Lewinsohn PM, Rohde P, Seeley JR (1993), Psychosocial characteristics of
adolescents with a history of suicide attempt. J Am Acad Child Adolesc
Psychiatry 32:60–68

Lewinsohn PM, Rohde P, Seeley JR (1994), Psychosocial risk factors for future
adolescent suicide attempts. J Consult Clin Psychol 62:297–305

Lewinsohn PM, Rohde P, Seeley JR (1996), Adolescent suicidal ideation and
attempts: prevalence, risk factors, and clinical implications. Clin Psychol
Sci Pract 3:25–36

Lewinsohn PM, Rohde P, Seeley JR, Baldwin CL (2001), Gender differences
in suicide attempts from adolescence to young adulthood. J Am Acad Child
Adolesc Psychiatry 40:427–434

Lewis MW, Lewis AC (1996), Peer helping programs: helper role, supervisor
training, and suicidal behavior. J Couns Dev 74:307–313

Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard HL (1991),
Cognitive-behavioral treatment of chronically parasuicidal borderline
patients. Arch Gen Psychiatry 48:1060–1064

Loftin C, McDowall D, Wiersema B, Cottey TJ (1991), Effects of restrictive
licensing of handguns on homicide and suicide in the District of Columbia.
N Engl J Med 325:1615–1620

Ludwig J, Cook PJ (2000), Homicide and suicide rates associated with imple-
mentation of the Brady Handgun Violence Prevention Act. JAMA 284:
585–591

Mackesy-Amiti ME, Fendrich M, Libby S, Goldenberg D, Grossman J (1996),
Assessment of knowledge gains in proactive training for postvention.
Suicide Life Threat Behav 26:161–174

Mann JJ, Stoff DM (1997), A synthesis of current findings regarding neuro-
biological correlates and treatment of suicidal behavior. Ann N Y Acad Sci
836:352–363

Mann JJ, Waternaux C, Haas GL, Malone KM (1999), Toward a clinical model
of suicidal behavior in psychiatric patients. Am J Psychiatry 156:181–189

Marcenko MO, Fishman G, Friedman J (1999), Reexamining adolescent sui-
cidal ideation: a developmental perspective applied to a diverse popula-
tion. J Youth Adolesc 28:121–138

Marshall SE, Bird TG, Hart K, Welsh KI (1999), Unified approach to the
analysis of genetic variation in serotonergic pathways. Am J Med Genet
88:621–627

Marttunen MJ, Aro HM, Henriksson MM, Lonnqvist JK (1991), Mental dis-
orders in adolescent suicide. Arch Gen Psychiatry 48:834–839

Marttunen MJ, Aro HM, Henrikksson MM, Lonnqvist JK (1994), Psychosocial
stressors more common in adolescent suicides with alcohol abuse com-
pared with depressive adolescent suicides. J Am Acad Child Adolesc Psychiatry
33:490–497

Marttunen MJ, Aro HM, Lonnqvist JK (1992), Adolescent suicide: endpoint
of long-term difficulties. J Am Acad Child Adolesc Psychiatry 31:649–654

Marttunen MJ, Aro HM, Lonnqvist JK (1993), Precipitant stressors in ado-
lescent suicide. J Am Acad Child Adolesc Psychiatry 32:1178–1183

Mazza JJ (2000), The relationship between posttraumatic stress symptom-
atology and suicidal behavior in school-based adolescents. Suicide Life
Threat Behav 30:91–103

McCormick N, Folcik J, Izzo A (1985), Sex-education needs and interests of
high school students in a rural New York county. Adolescence 20:581–592

McDaniel JS, Purcell D, D’Augelli AR (2001), The relationship between sex-
ual orientation and risk for suicide: research findings and future directions
for research and prevention. Suicide Life Threat Behav 31(suppl):84–105

McGuffin P, Marusic A, Farmer A (2001), What can psychiatric genetics offer
suicidology? Crisis 22:61–65

McKeown RE, Garrison CZ, Cuffe SP, Waller JL, Jackson KL, Addy CL (1998),
Incidence and predictors of suicidal behaviors in a longitudinal sample of
young adolescents. J Am Acad Child Adolesc Psychiatry 37:612–619

Medoff MH, Magaddino JP (1983), Suicides and firearm control laws. Eval
Rev 7:357–372

Meltzer HY (2001), Treatment of suicidality in schizophrenia. Ann N Y Acad
Sci 932:44–58

Mercy JA, Kresnow MJ, O’Carroll PW et al. (2001), Is suicide contagious? A
study of the relation between exposure to the suicidal behavior of others
and nearly lethal suicide attempts. Am J Epidemiol 154:120–127

Michel K, Frey C, Wyss K, Valach L (2000), An exercise in improving suicide
reporting in print media. Crisis 21:1–10

Middlebrook DL, LeMaster PL, Beals J, Novins DK, Manson SM (2001),
Suicide prevention in American Indian and Alaska Native communities:
a critical review of programs. Suicide Life Threat Behav 31(suppl):132–149

Miller AL, Rathus JH, Linehan MM, Wetzler S, Leigh E (1997a), Dialectical
behavior therapy adapted for suicidal adolescents. J Pract Psychol Behav
Health 3:78–86

Miller DN, Eckert TL, DuPaul GJ, White GP (1999), Adolescent suicide pre-
vention: acceptability of school-based programs among secondary school
principals. Suicide Life Threat Behav 29:72–85

Miller L, Warner V, Wickramaratne P, Weissman M (1997b), Religiosity and
depression: ten-year follow-up of depressed mothers and offspring. J Am
Acad Child Adolesc Psychiatry 36:1416–1425

Miller M, Hemenway D (1999), The relationship between firearms and sui-
cide: a review of the literature. Aggress Violent Behav 4:59–75

Mishara BL, Daigle MS (2001), Helplines and crisis intervention services:
challenges for the future. In: Suicide Prevention: Resources for the Millennium,
Lester D, ed. Philadelphia: Brunner/Mazel, pp 153–171

Morey RE, Miller CD, Rosen LA, Fulton R (1993), High school peer coun-
seling: the relationship between student satisfaction and peer counselors’
style of helping. Sch Couns 40:293–300

National Center for Health Statistics (Centers for Disease Control and Prevention)
(1999), Data provided by Division of Vital Statistics, Mortality Statistics
Branch. Bethesda, MD: National Center for Health Statistics

Neeleman J (1998), Regional suicide rates in the Netherlands: does religion
still play a role? Int J Epidemiol 27:466–472

Neeleman J, Lewis G (1999), Suicide, religion, and socioeconomic conditions:
an ecological study in 26 countries, 1990. J Epidemiol Community Health
53:204–210

Nelson F (1987), Evaluation of a youth suicide prevention school program.
Adolescence 88:813–825

Neumeister A, Konstantinidis A, Stastny J et al. (2002), Association between
serotonin transporter gene promoter polymorphism (5HTTLPR) and
behavioral responses to tryptophan depletion in healthy women with and
without family history of depression. Arch Gen Psychiatry 59:613–620

Nielsen DA, Goldman D, Virkkunen M, Tokola R, Rawlings R, Linnoila M
(1994), Suicidality and 5-hydroxyindoleacetic acid concentration associ-
ated with a tryptophan hydroxylase polymorphism. Arch Gen Psychiatry
51:34–38

Nielsen DA, Virkkunen M, Lappalainen J et al. (1998), A tryptophan hydrox-
ylase gene marker for suicidality and alcoholism. Arch Gen Psychiatry
55:593–602

Nordstrom P, Samuelsson M, Asberg M et al. (1994), CSF 5-HIAA predicts
suicide risk after attempted suicide. Suicide Life Threat Behav 24:1–9

Offer D, Howard KI, Schonert KA, Ostrov E (1991), To whom do adoles-
cents turn for help? Differences between disturbed and nondisturbed ado-
lescents. J Am Acad Child Adolesc Psychiatry 30:623–630

Olfson M, Marcus SC, Druss B, Pincus HA (2002a), National trends in the
use of outpatient psychotherapy. Am J Psychiatry 159:1914–1920

Olfson M, Marcus SC, Weissman MM, Jensen PS (2002b), National trends
in the use of psychotropic medications by children. J Am Acad Child Adolesc
Psychiatry 41:514–521

Oquendo MA, Mann JJ (2000), The biology of impulsivity and suicidality.
Psychiatr Clin North Am 23:11–25

Orbach I, Bar-Joseph H (1993), The impact of a suicide prevention program
for adolescents on suicidal tendencies, hopelessness, ego identity, and cop-
ing. Suicide Life Threat Behav 23:120–129

Overholser JC, Adams DM, Lehnert KL, Brinkman DC (1995), Self-esteem
deficits and suicidal tendencies among adolescents. J Am Acad Child Adolesc
Psychiatry 34:919–928

Overholser JC, Hemstreet A, Spirito A, Vyse S (1989), Suicide awareness pro-
grams in the schools: effect of gender and personal experience. J Am Acad
Child Adolesc Psychiatry 28:925–930

Pearson JL, Stanley B, King C, Fisher C (2001), Issues to Consider in Intervention
Research With Persons at High Risk for Suicidality. Bethesda, MD: National

YO U T H S U I C I D E R I S K A N D I N T E RV E N T I O N S

J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I AT RY, 4 2 : 4 , A P R I L 2 0 0 3 403

Institute of Mental Health. Available online: htttp://www.nimh.nih.gov/
research/highrisksuicide.cfm (accessed July 1, 2002)

Pfaff J, Acres J, Wilson M (1999), The role of general practitioners in para-
suicide: a Western Australia perspective. Arch Suicide Res 5:207–214

Pfaff JJ, Acres JG, McKelvey RS (2001), Training general practitioners to
recognise and respond to psychological distress and suicidal ideation in
young people. Med J Aust 174:222–226

Pfeffer CR, Klerman GL, Hurt SW, Lesser M, Peskin JR, Siefker CA (1991),
Suicidal children grow up: demographic and clinical risk factors for ado-
lescent suicide attempts. J Am Acad Adolesc Child Psychiatry 30:609–616

Piacentini J, Rotheram-Borus MJ, Gillis JR et al. (1995), Demographic pre-
dictors of treatment attendance among adolescent suicide attempters. J
Consult Clin Psychol 63:469–473

Pilowsky DJ, Wu L, Anthony JC (1999), Panic attacks and suicide attempts
in mid-adolescence. Am J Psychiatry 156:1545–1549

Poijula S, Wahlberg KE, Dyregrov A (2001), Adolescent suicide and suicide
contagion in three secondary schools. Int J Emerg Ment Health 3:163–168

Randell BP, Eggert LL, Pike KC (2001), Immediate post intervention effects
of two brief youth suicide prevention interventions. Suicide Life Threat
Behav 31:41–61

Reid WH (1998), Promises, promises: don’t rely on patients’ no-suicide/no-
violence “contracts.” J Pract Psychiatry Behav Health 4:316–318

Reifman A, Windle M (1995), Adolescent suicidal behaviors as a function of
depression, hopelessness, alcohol use, and social support: a longitudinal
investigation. Am J Community Psychol 23:329–354

Reinherz HA, Giaconia RM, Silverman AB et al. (1995), Early psychosocial
risks for adolescent suicidal ideation and attempts. J Am Acad Child Adolesc
Psychiatry 34:599–611

Remafedi G, French S, Story M, Resnick MD, Blum R (1998), The relation-
ship between suicide risk and sexual orientation: results of a population-
based study. Am J Public Health 88:57–60

Reynolds WM (1990), Development of a semi-structured clinical interview
for suicidal behaviors in adolescents. Psychol Assess 2:382–390

Reynolds WM (1991), A school-based procedure for the identification of ado-
lescents at risk for suicidal behaviors. Fam Community Health 14:64–75

Rich CL, Fowler RC, Fogarty LA, Young D (1988), San Diego Suicide Study,
III: relationships between diagnoses and stressors. Arch Gen Psychiatry
45:589–592

Rich CL, Young JG, Fowler RC, Wagner J, Black NA (1990), Guns and sui-
cide: possible effects of some specific legislation. Am J Psychiatry 147:342–346

Rihmer Z, Rutz W, Pihlgren H (1995), Depression and suicide on Gotland:
an intensive study of all suicides before and after a depression-training
program for general practitioners. J Affect Disord 35:147–152

Roberts RE, Chen Y (1995), Depressive symptoms and suicidal ideation among
Mexican-origin and Anglo adolescents. J Am Acad Child Adolesc Psychiatry
34:81–90

Roberts RE, Chen Y, Roberts CR (1997), Ethnocultural differences in preva-
lence of adolescent suicidal behaviors. Suicide Life Threat Behav 27:208–217

Robins E, Murphy PI, Wilkinson RH Jr, Gassner S, Kayes J (1959), Some
clinical considerations in the prevention of suicide based on a study of
134 successful suicides. Am J Public Health 49:888–988

Ross CP (1985), Teaching children the facts of life and death: suicide pre-
vention in the schools. In: Youth Suicide, Peck ML, Farberow NL, Litman
RE, eds. New York: Springer, pp 147–169

Rotheram MJ (1987), Evaluation of imminent danger for suicide among youth.
Am J Orthopsychiatry 57:102–110

Rotheram-Borus MJ, Piacentini J, Van Rossem R et al. (1999), Treatment
adherence among Latina female adolescent suicide attempters. Suicide Life
Threat Behav 29:319–331

Rotheram-Borus MJ, Trautman PD (1988), Hopelessness, depression and sui-
cidal intent among adolescent suicide attempters. J Am Acad Child Adolesc
Psychiatry 27:700–704

Rotheram-Borus MJ, Trautman PD, Dopkins SC, Shrout PE (1990), Cognitive
style and pleasant activities among female adolescent suicide attempters.
J Consult Clin Psychol 58:554–561

Rotondo A, Schuebel K, Bergen A et al. (1999), Identification of four vari-
ants in the tryptophan hydroxylase promoter and association to behavior.
Mol Psychiatry 4:360–368

Rubenstein JL, Halton A, Kasten L, Rubin C, Stechler G (1998), Suicidal
behavior in adolescents: stress and protection in different family contexts.
Am J Orthopsychiatry 68:274–284

Rubenstein JL, Heeren T, Housman D, Rubin C, Stechler G (1989), Suicidal
behavior in “normal” adolescents: risk and protective factors. Am J
Orthopsychiatry 59:59–71

Rudd MD (2000), Integrating science into the practice of clinical suicidol-
ogy: a review of the psychotherapy literature and a research agenda for the
future. In: Review of Suicidology, 2000, Maris RW, Canetto SS, eds. New
York: Guilford, pp 47–83

Rudd MD, Rajab MH, Orman DT, Joiner T, Stulman DA, Dixon W (1996),
Effectiveness of an outpatient intervention targeting suicidal young adults:
preliminary results. J Consult Clin Psychol 64:179–190

Runeson B (1989), Mental disorder in youth suicide: DSM-III-R Axes I and
II. Acta Psychiatr Scand 79:490–497

Runeson B (1990), Psychoactive substance use disorder in youth suicide.
Alcohol Alcohol 25:561–568

Russell ST, Joyner K (2001), Adolescent sexual orientation and suicide risk:
evidence from a national study. Am J Public Health 91:1276–1281

Rutz W, von Knorring L, Walinder J (1992), Long-term effects of an educa-
tional program for general practitioners given by the Swedish Committee
for the Prevention and Treatment of Depression. Acta Psychiatr Scand
85:83–88

Ryan ND, Varma D (1998), Child and adolescent mood disorders: experience
with serotonin-based therapies. Biol Psychiatry 44:336–340

Sauvola A, Rasanen PK, Joukamaa MI, Jokelainen J, Jarvelin MR, Isohanni
MK (2001), Mortality of young adults in relation to single-parent family
background: a prospective study of the northern Finland 1966 birth cohort.
Eur J Public Health 11:284–286

Schmidtke A, Schaller S (2000), The role of mass media in suicide preven-
tion. In: The International Handbook of Suicide and Attempted Suicide,
Hawton K, van Heeringen K, eds. New York: Wiley, pp 675–698

Shaffer D (1974), Suicide in childhood and early adolescence. J Child Psychol
Psychiatry 15:275–291

Shaffer D, Craft L (1999), Methods of adolescent suicide prevention. J Clin
Psychiatry 60:70–74

Shaffer D, Garland A, Gould M, Fisher P, Trautman P (1988), Preventing
teenage suicide: a critical review. J Am Acad Child Adolesc Psychiatry
27:675–687

Shaffer D, Garland A, Vieland V, Underwood MM, Busner C (1991), The
impact of curriculum-based suicide prevention program for teenagers. J
Am Acad Child Adolesc Psychiatry 30:588–596

Shaffer D, Gould M, Hicks R (1994), Worsening suicide rate in black teenagers.
Am J Psychiatry 151:1810–1812

Shaffer D, Gould MS, Fisher P et al. (1996), Psychiatric diagnosis in child and
adolescent suicide. Arch Gen Psychiatry 53:339–348

Shaffer D, Hicks R (1994), Suicide. In: The Epidemiology of Childhood Disorders,
Pless IB, ed. New York: Oxford University Press, pp 339–365

Shaffer D, Vieland V, Garland A, Rojas M, Underwood MM, Busner C (1990),
Adolescent suicide attempters: response to suicide-prevention programs.
JAMA 264:3151–3155

Shafii M, Carrigan S, Whittinghill JR, Derrick A (1985), Psychological autopsy
of completed suicide in children and adolescents. Am J Psychiatry
142:1061–1064

Shafii M, Steltz-Lenarsky J, Derrick AM, Beckner C, Whittinghill JR (1988),
Comorbidity of mental disorders in the post-mortem diagnosis of com-
pleted suicide in children and adolescents. J Affect Disord 15:227–233

Shiang J, Blinn R, Bongar B, Stephens B, Allison D, Schatzberg A (1997),
Suicide in San Francisco, CA: a comparison of Caucasian and Asian groups,
1987–1994. Suicide Life Threat Behav 27:80–91

Shneidman ES, Farberow NL (1957), Clues to Suicide. New York: Blakison
Siegrist M (1996), Church attendance, denomination, and suicide ideology.

J Soc Psychol 136:559–566
Silbert KL, Berry GL (1991), Psychological effects of a suicide prevention unit

on adolescents’ levels of stress, anxiety and hopelessness: implications for
counselling psychologists. Couns Psychol 4:45–58

Silverman AB, Reinherz HZ, Giaconia RM (1996), The long-term sequelae
of child and adolescent abuse: a longitudinal community study. Child
Abuse Negl 20:709–723

G O U L D E T A L .

404 J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I AT RY, 4 2 : 4 , A P R I L 2 0 0 3

YO U T H S U I C I D E R I S K A N D I N T E RV E N T I O N S

J . A M . A C A D . C H I L D A D O L E S C . P S Y C H I AT RY, 4 2 : 4 , A P R I L 2 0 0 3 405

Slem CM, Cotler S (1973), Crisis phone services: evaluation of a hotline pro-
gram. Am J Community Psychol 1:219–227

Sloan JH, Rivara FP, Reay DT, Ferris JA, Kellermann AL (1990), Firearm reg-
ulations and rates of suicide: a comparison of two metropolitan areas. N
Engl J Med 322:369–373

Smith JC, Mercy JA, Warren CW (1985), Comparison of suicides among
Anglos and Hispanics in five Southwest states. Suicide Life Threat Behav
15:14–26

Sonneck G, Etzersdorfer E, Nagel-Kuess S (1994), Imitative suicide on the
Viennese subway. Soc Sci Med 38:453–457

Sorri H, Henriksson M, Lonnqvist J (1996), Religiosity and suicide: findings
from a nationwide psychological autopsy study. Crisis 17:123–127

Sourander A, Helstela L, Haavisto A, Bergroth L (2001), Suicidal thoughts
and attempts among adolescents: a longitudinal 8-year follow-up study. J
Affect Disord 63:59–66

Spirito A, Plummer B, Gispert M et al. (1992), Adolescent suicide attempts:
outcomes at follow-up. Am J Orthopsychiatry 62:464–468

Stack S (1996), The effect of the media on suicide: evidence from Japan,
1955–1985. Suicide Life Threat Behav 26:132–142

Stack S (1998), Heavy Metal, religiosity, and suicide acceptability. Suicide Life
Threat Behav 28:388–394

Stack S (2000), Media impacts on suicide: a quantitative review of 293 find-
ings. Soc Sci Q 81:956–971

Stack S, Lester D (1991), The effect of religion on suicide ideation. Soc Psychiatry
Psychiatr Epidemiol 26:168–170

Swanson JW, Linskey AO, Quintero-Salinas R, Pumariega AJ, Holzer CE III
(1992), A binational school survey of depressive symptoms, drug use, and
suicidal ideation. J Am Acad Child Adolesc Psychiatry 31:669–678

Teicher MH, Glod C, Cole JO (1990), Emergence of intense suicidal preoc-
cupation during fluoxetine treatment. Am J Psychiatry 147:207–210

Thompson EA, Eggert LL (1999), Using the suicide risk screen to identify
suicidal adolescents among potential high school dropouts. J Am Acad
Child Adolesc Psychiatry 38:1506–1514

Thompson EA, Eggert LL, Herting JR (2000), Mediating effects of an indi-
cated prevention program for reducing youth depression and suicide risk
behaviors. Suicide Life Threat Behav 30:252–271

Thompson EA, Eggert LL, Randell BP, Pike KC (2001), Evaluation of indi-
cated suicide risk prevention approaches for potential high school dropouts.
Am J Public Health 91:742–752

Tierney RJ (1994), Suicide intervention training evaluation: a preliminary
report. Crisis 15:69–76

Tondo L, Baldessarini RJ (2000), Reduced suicide risk during lithium main-
tenance treatment. J Clin Psychiatry 61(suppl 9):97–104

Tondo L, Jamison KR, Baldessarini RJ (1997), Effect of lithium maintenance
on suicidal behavior in major mood disorders. Ann N Y Acad Sci 836:339–351

Tousignant M, Bastien MF, Hamel S (1993), Suicidal attempts and ideations
among adolescents and young adults: the contribution of the father’s and
mother’s care and of parental separation. Soc Psychiatry Psychiatr Epidemiol
28:256–261

Turecki G, Zhu Z, Tzenova J et al. (2001), TPH and suicidal behavior: a study
in suicide completers. Mol Psychiatry 6:98–102

Underwood MM, Dunne-Maxim K (1997), Managing sudden traumatic loss
in the schools. University of Medicine and Dentistry of New Jersey.
New Jersey Adolescent Suicide Prevention Project. 1–134 (available at
www.maximkd@cmhc.umdnj.edu)

van der Sande R, van Rooijen L, Buskens E et al. (1997), Intensive in-patient
and community intervention versus routine care after attempted suicide:
a randomised controlled intervention study. Br J Psychiatry 171:35–41

Velez CN, Cohen P (1988), Suicidal behavior and ideation in a community
sample of children: maternal and youth reports. J Am Acad Child Adolesc
Psychiatry 27:349–356

Verkes RJ, van der Mast RC, Hengeveld MW, Tuyl JP, Zwinderman AH, Van
Kempen GM (1998), Reduction by paroxetine of suicidal behavior in
patients with repeated suicide attempts but not major depression. Am J
Psychiatry 155:543–547

Vieland V, Whittle B, Garland A, Hicks R, Shaffer D (1991), The impact of
curriculum-based suicide prevention programs for teenagers: an 18-month
follow-up. J Am Acad Child Adolesc Psychiatry 30:811–815

Voelker R (1999), SSRI use common in children. JAMA 281:1882
Wallace JD, Calhoun AD, Powell KE, O’Neil J, James SP (1996), Homicide

and Suicide Among Native Americans, 1979–1992. Atlanta: Centers for
Disease Control and Prevention, National Center for Injury Prevention
and Control. Violence Surveillance Series, No. 2

Walter HJ, Vaughan RD, Armstrong B et al. (1995), Sexual, assaultive, and
suicidal behaviors among urban minority junior high school students. J
Am Acad Child Adolesc Psychiatry 34:73–80

Warshaw MG, Dolan RT, Keller MB (2000), Suicidal behavior in patients
with current or past panic disorder: five years of prospective data from the
Harvard/Brown anxiety research program. Am J Psychiatry 157:1876–1878

Weissman MM, Klerman GL, Markowitz JS, Ouellette R (1989), Suicidal ideation
and suicide attempts in panic disorder and attacks. N Engl J Med 321:1209–1214

Wichstrom L (2000), Predictors of adolescent suicide attempts: a nationally
representative longitudinal study of Norwegian adolescents. J Am Acad
Child Adolesc Psychiatry 39:603–610

Windle M, Miller-Tutzauer C, Domenico D (1992), Alcohol use, suicidal
behavior, and risky activities among adolescents. J Res Adolesc 2:317–330

World Health Organization (2002), Suicide rates and absolute numbers of
suicide by country (2002). Available online: http://www.who.int/mental_health
(accessed August 1, 2002)

Wunderlich U, Bronisch T, Wittchen HU (1998), Comorbidity patterns in
adolescents and young adults with suicide attempts. Eur Arch Psychiatry
Clin Neurosci 248:87–95

Zenere FJ, Lazarus PJ (1997), The decline of youth suicidal behavior in an
urban, multicultural public school system following the introduction of
a suicide prevention and intervention program. Suicide Life Threat Behav
27:387–403

Zhang J, Jin S (1996), Determinants of suicide ideation: a comparison of
Chinese and American college students. Adolescence 31:451–467

• Youth Suicide Risk and Preventive Interventions: A Review of the Past 10 Years

OVERALL RATES AND SECULAR PATTERNS
Age
Gender
Ethnicity
Secular Trends
RISK FACTORS
Personal Characteristics
Family Characteristics
Adverse Life Circumstances
Socioenvironmental and Contextual Factors
PROTECTIVE FACTORS
Family Cohesion
Untitled
PREVENTION STRATEGIES
School-Based Suicide Prevention Programs
Community-Based Prevention Programs
Health Care-Based Prevention Programs
TREATMENT
Treatment Service Utilization
Emergency/Crisis-Service Interventions and Triage
Inpatient Care and Partial Hospitalization
Outpatient Follow-up Treatment
Psychotherapy
Psychopharmacological Interventions
CONCLUSIONS
REFERENCES

Aggression and Violent Behavior xxx (xxxx) xxx

Please cite this article as: Scott Poland, Sara Ferguson, Aggression and Violent Behavior, https://doi.org/10.1016/j.avb.2021.10157

9

Available online 15 February 2021
1359-1789/© 2021 Elsevier Ltd. All rights reserved.

Youth suicide in the school context

Scott Poland, Sara Ferguson *

Nova Southeastern University, 3301 College Ave, Fort Lauderdale, FL 33314, United States of America

A R T I C L E I N F O

Keywords:
School mental health professionals
Postvention
Intervention
School
Prevention
Youth suicide

A B S T R A C T

Across the domains of youth risk behavior, suicidality is a significant concern for parents and professionals alike,
requiring ongoing efforts to better understand and prevent rising trends. Recent examinations of suicidal be-
haviors in the United States over the last decade revealed an increase in emergency and inpatient hospital set-
tings. Of importance, seasonal variations were demonstrated, finding the lowest frequency of suicidality
encounters in summer months, and observed peaks in the fall and spring, during the school year. Given these
findings and the fact that youth spend nearly half of their time at school, consideration of youth suicide in the
school environment is critical. This paper will review the trends of youth suicide within the school context,
exploring factors such as at-risk youth, bullying, relevant legal issues, and the current state of crisis response in
school settings. Recommendations for prevention, intervention, and postvention will be provided. The authors
propose that school professionals play a vital role in addressing youth suicide and will aim to provide guidance
on effective crisis response within the school context.

1. Introduction

Suicide is a leading cause of death in the United States (CDC, 2018)
and a prominent concern in the mental health and medical fields given
the high rates of suicidal ideation and attempts. While death by suicide
is an incredibly difficult and often unfathomable tragedy, its occurrence
in the youth population can bring even more confusion and intense grief
for loved ones. In 2016, suicide became the second leading cause of
death for ages 10–34 (CDC, 2017b). Furthermore, a 2018 review of
injury mortality among youth during 1999–2016 identified suicide as
the second leading injury intent among 10–19 years (in which a 56%
increase was observed between 2007 and 2016 [Curtin et al., 2016]).

The Youth Risk Behavior Surveillance Survey ([YRBSS], CDC,
2017a), the Centers for Disease Control and Prevention’s (CDC) biennial
survey of adolescent health risk and health protective behaviors,
revealed upward trends in their survey of suicidality and related be-
haviors of high school students (see Fig. 1.1). Specifically, students re-
ported an increase over the last decade in seriously considering
attempting suicide and making a suicide plan. Of concern, among the
few states that queried middle school students, trends were observed at
an even higher rate.

Given the high rates of suicidal behavior among young people, ample
research has been dedicated to this topic, resulting in pertinent knowl-
edge necessary to better understand the matter. A variety of risk factors

have been consistently identified across the literature, many of which
inform prevention and intervention practices for clinicians. There is,
however, an area in which additional attention should be awarded: the
school context.

Young people spend a significant portion of their time in school
settings in which they are actively engaged with their peers and subject
to the potential stressors of academic achievement and future success. In
light of this, consideration of youth suicide in the school context is of
utmost importance. Evidence reports that school influences the behavior
and health of young people (Evans & Hurrell, 2016). This is additionally
supported by recent research that has demonstrated significant seasonal
variations in youth suicide patterns (Plemmons’ et al., 2018), suggesting
that involvement in school should be further examined as a critical
factor in youth suicidality.

This paper aims to contribute to this suggestion, in which we will
review relevant literature related to youth suicide in the school context,
including associated risk factors, existing prevention, intervention, and
postvention programming, and related legal implications. Recommen-
dations for best practices will be offered, specific to both school and
mental health professionals. The authors propose that school pro-
fessionals play an essential role in addressing youth suicide and will aim
to offer guidance on effective crisis response within the school context.

* Corresponding author.
E-mail addresses: spoland@nova.edu (S. Poland), sferguson@mynova.nsu.edu (S. Ferguson).

Contents lists available at ScienceDirect

Aggression and Violent Behavior

journal homepage: www.elsevier.com/locate/aggviobeh

https://doi.org/10.1016/j.avb.2021.101579
Received 1 December 2019; Received in revised form 19 July 2020; Accepted 5 February 2021

mailto:spoland@nova.edu

mailto:sferguson@mynova.nsu.edu

www.sciencedirect.com/science/journal/13591789

https://www.elsevier.com/locate/aggviobeh

https://doi.org/10.1016/j.avb.2021.101579

https://doi.org/10.1016/j.avb.2021.101579

https://doi.org/10.1016/j.avb.2021.101579

Aggression and Violent Behavior xxx (xxxx) xxx

2

2. Youth suicide & seasonal variations

As discussed, it has been well established that there are rising trends
in youth suicidal behavior. Recent research in related domains supports
these findings, such as observed increases in hospitalizations (Burstein
et al., 2019), attempts by females (CDC, 2017b), use of suffocation as
preferred method (Curtin et al., 2018), and serious considerations of
suicide, along with the creation of a plan (CDC, 2017a). Plemmons’ et al.
(2018) recent large-scale study examining youth suicidal encounters in
pediatric emergency and inpatient hospital settings further supported
the observed increases, demonstrating consistent upward trends of sui-
cidal ideation and attempts across age groups and genders. Of interest, a
pattern of seasonal variation was observed, in which a higher percentage
of cases was found during the fall and spring and conversely, a lower
number of cases during the summer months.

Such findings are of significance, as they shed light on a critical
factor of youth suicide that has not been historically explored. Research
related to this matter is limited and recent (see Hansen & Lang, 2011;
Lueck et al., 2015), suggesting a gap in the conceptualization of youth
suicide. Plemmons’ et al. (2018) findings of seasonal patterns lead one to
consider the variables associated with the months in which increased
and decreased rates were observed. Most glaringly, is the consideration
of youth participation in school during the fall and winter months and
the subsequent break during the summer months.

Lueck et al. (2015) set out to investigate this aspect of youth suicide,
in which they analyzed the relationship between weeks in school vs.
weeks out of school (i.e., vacation) with concern for danger to self or
others. Of note, the researcher’s review of 3223 subjects (mean age,
13.8 years) who presented to a local pediatric emergency unit included
youth with both suicidal and homicidal ideation, creating challenges in
isolating the results solely to the examination of suicidal behavior.
However, their findings of higher rates of such ideation during weeks in
which the subjects were in school vs. the reduced rates observed during
vacation weeks certainly contributes to the growing understanding that
the school context has a significant impact on risk behaviors such as
suicidality.

Similarly, Hansen and Lang (2011) hypothesized that youth in school
served as a crucial factor in the seasonal patterns of youth suicide. Their

investigation established a distinct alignment of youth suicide with the
school calendar, including a significant decrease during the summer
breaks; one that commenced upon entering adulthood. Further, unlike
many youth suicide studies, the researchers examined the data for each
gender separately, finding that the suicide rate, on average, was 95%
higher for boys in school months when compared to girls (33%). Addi-
tionally, the authors proposed theories regarding school specific factors
that likely influenced these trends, including negative peer interactions,
along with academic stressors and the related mental health impact.

These findings create a scientific foundation for youth suicide in the
school context that warrant a deeper investigation. Additionally, the
authors would be remiss not to highlight the fact that youth spend nearly
half of the total days of the year in school settings, thereby making it the
most logical place to intervene. Access to the youth, along with potential
resources within the school and community create an ideal environment
for prevention and intervention. These factors create a cogent argument
for continued exploration of youth suicide in the context of the school
environment.

3. Risk factors in the school context

In light of the reviewed findings of seasonal patterns of youth suicide
rates and their association to school participation, along with the sheer
amount of time spent in the school setting, consideration of the school
related factors that may contribute to youth suicidal behaviors is
essential. Risk factors associated with youth suicide have been broadly
identified, including specific individual and psychosocial variables.
Such factors include youth that have little social supports, many of
whom often present with pathologies such as mood and substance use
disorders, bullies and victims, individuals who identify as LGBTQ, and
youth exposed to adverse early childhood experiences such as trauma,
family system disturbances, and most notably, suicide (Gould et al.,
2003; Lieberman et al., 2008). Moreover, across the risk factors
reviewed, of greatest significance is a prior suicide attempt. Research
reveals that a prior attempt is the strongest predictor of a future death by
suicide (Harris & Barraclough, 1997).

Fig. 1.1. YRBSS suicide related behavioral trends.

S. Poland and S. Ferguson

Aggression and Violent Behavior xxx (xxxx) xxx

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3.1. Social connectedness

Specific to the context of school, a variety of risk factors are pertinent
to review in detail. As mentioned, level of social support has been
determined as a risk factor for youth suicide, in which a child or ado-
lescent’s connectedness to his or her peers can play a significant role in
his or her vulnerability to suicidal behavior (Lieberman et al., 2008). It is
broadly accepted that the development of positive and close relation-
ships with others can serve as a protective and preventive buffer against
suicidal ideation and behaviors. Connectedness typically results in high
rates of social contact and lower rates of feelings of loneliness and
isolation (CDC, 2011).

While social connectedness has been established as a prominent
factor in the conceptualization of suicidal behaviors (Joiner, 2005), it is
important to consider this variable specifically in the context of youth
suicide, given the easy access to potential social relationships (both
negative and positive). Furthermore, it has been well documented that
young people who are at higher risk for suicidal behaviors often face
adversity such as familial disturbances and related neglect, homeless-
ness, or involvement in social services (i.e., foster care), all of which
negatively impact an individual’s level of connectedness. Lack of social
connectedness in youth is a broad risk factor to consider and the related
vulnerabilities that arise as a result are certainly contributing factors to
suicidal behavior. Increased isolation, for example, can negatively
impact self-esteem and potentially lead to depression, another identified
risk factor of youth suicide (Lieberman et al., 2008).

The milieu of school provides an ideal setting to enhance social
connectedness for children and adolescents. Moreover, it gives the op-
portunity for school staff to act as warm and accepting social role models
that can aid in providing a formal support system of connectedness.
Recommendations for enhancing social support and connectedness as
means to buffer suicide risk have been discussed across the literature,
including the development of prevention programs that are founded
upon this concept (e.g., Gatekeeping Training (Burnette et al., 2015;
CDC, 2011)). While such programs (which will be reviewed in further
detail) have been demonstrated as being an effective intervention for
reducing suicide attempts in youth (see Aseltine et al., 2007; Aseltine &
DeMartino, 2004), there are a variety of factors in school settings that
not only create challenges in enhancing social connectedness across
diverse student bodies, but also contribute to higher rates of suicidal
behavior in young people.

3.2. Bullying

Relatedly, engagement in bullying (whether as the bully or the
victim), has been identified as a risk factor for youth suicide (Holt et al.,
2015; Lieberman et al., 2008). The Suicide Prevention Resource Center’s
(SPRC) (2011) Issue Brief on Suicide and Bullying revealed a strong
association between bullying and suicide, reporting that children who
are bullied are at highest risk for suicide due to the commonality of risk
factors. Dan Olweus, creator of the Olweus Bullying Prevention Program
(1993), defines bullying as occurring “when a person is exposed
repeatedly, and over time, to negative actions on the part of one or more
persons, and he or she has difficulty defending himself or herself” (p. 9,
Olweus, 1993). Lierberman and Cowan (2006) reported that interper-
sonal problems are frequently cited by adolescents as the antecedent of
suicidal behavior, in which loss of dignity and humanity is conceptu-
alized as a triggering event. Moreover, Gould and Kramer (2001) pro-
vided insight regarding bully behavior, suggesting that the more
frequently an adolescent engages in bullying, the more likely that she or
he is experiencing feelings of hopelessness and depression, has serious
suicidal ideation, or has attempted suicide in the past.

The 2017 School Crime Supplement (National Center for Education
Statistics and Bureau of Justice, 2018) found that in the United States,
approximately 20% of students ages 12–18 experienced bullying. It is
important to note that bullying can occur both in and out of the school

environment, especially given the rapidly evolving state of technology
and social media. Cyberbullying is a growing concern (YBRSS data es-
timates that 14.9% of high school students were electronically bullied in
the 12 months prior to the survey [CDC, 2017a]). It is defined as any
type of bullying (i.e., mean/hurtful comments, spreading rumors,
physical threats, pretending to be someone else, and mean/hurtful pic-
tures) through a cell phone text, e-mail, or any social media outlet or
online source (Hinduja & Patchin, 2012).

Cyberbullying presents significant concerns related to its aspects of
anonymity and ease of access. Moreover, it is pervasive and can occur in
both the home and school setting, creating an environment of contin-
uous bullying. The high frequency of cyberbullying is significant in the
conceptualization of youth suicide in the school context, as students
often have access to social media platforms where bullying frequently
occurs during school hours. This likely contributes to the finding that
reports of bullying continue to be highest within the school setting (U.S.
Department of Health and Human Services, 2019). This is further sup-
ported by the YRBSS data (CDC, 2017a), which revealed that nationally,
19% of students in grades 9–12 report being bullied on school property
in the 12 months preceding the survey. While bullying has received
increased public attention over time and actions have been taken to
target the issue, it clearly persists in the school settings. More so, the
findings certainly demonstrate the tragic and very permanent implica-
tions that bullying can lead to in the context of youth suicide.

3.3. LGBTQ population

Given the significant findings related to bullying and suicidal
behavior in children and adolescents, it is important to consider special
populations that may be at higher risk of being bullied, as this may serve
as an indirect route to suicidal behaviors. Children and adolescents who
are questioning their sexual orientation or gender identity have been
found to have high rates of negative outcomes in a number of areas
including harassment, victimization, and bullying, along with violence,
drug abuse, sexually transmitted diseases, and mental health problems,
such as depression (Birkett et al., 2015; CDC, 2017a). Strikingly, this
population has been found to be more likely to consider and attempt
suicide (Almeida et al., 2009; Hatzenbuehler, 2011; Kosciw, Greytak,
Bartkiewicz, Boesen, & Palmer, 2012; Lieberman et al., 2014). In fact,
YRBSS (CDC, 2017a) data revealed significantly higher percentages of
attempted suicides of lesbian, gay, or bisexual students (23.0%) and
students not sure of their sexual identity (14.3%) when compared to
their heterosexual students (5.4%).

Family acceptance appears to be a major factor in the experience of
suicidal ideation, as those who experience a high level of acceptance are
found to have lower rates (18.5%) when compared to those with low
acceptance from their families (38.3% (Ryan, Russell, Huebner, Diaz, &
Sanchez, 2010)). Furthermore, acceptance in other areas of a LGBTQ
identifying youth’s life, such as the school and broader community, has
been suggested as a significant protective factor to the many risks they
face (Birkett et al., 2015), thereby promoting self-acceptance and resil-
ience (Dahl & Galliher, 2012).

Consideration of the LGBTQ population in the school context is
critical, as it can serve as an environment of safety, acceptance, and
connectedness. There are a number of recommendations for school and
mental health professionals to best support LGBTQ youth; however,
despite the availability of specific recommendations (e.g., creation of
safe-spaces and student-led advocacy groups), LGBTQ youth continue to
widely report feeling unsafe at school (10%, CDC, 2017a), presenting
serious ongoing concerns for this population. These findings, paired
with the previously mentioned associated negative outcomes, including
high rates of suicidal behavior, certainly justify the need for special
attention and consideration in the school context.

S. Poland and S. Ferguson

Aggression and Violent Behavior xxx (xxxx) xxx

4

3.4. Ethnicity and culture

Consideration of high-risk populations must include the examination
of suicide rates and related risk factors of young people across diverse
ethnic and cultural backgrounds. While the prevalence rates of SI and SA
vary among differing identifications of race and ethnicity, there are
specific populations who have been identified as high risk for suicidal
behavior (Lieberman et al., 2008). In 2017, The CDC (2017b) reported
that the age-adjusted rate of suicide among American Indians/Alaska
Natives was 22.15 per 100,000 and among non-Hispanic whites it was
17.83. In contrast, lower and more similar rates were found among
Asian/Pacific Islanders (6.75%), Blacks (6.85%), and Hispanics
(6.89%). YRBSS’ data reveals that Black or African American students
reported the highest rate of suicide attempts (9.8%), followed by white
students at 6.1% (CDC, 2017a). Of note, YRBSS did not include Amer-
ican Indians/Alaska Natives as an option of ethnic identification; how-
ever, the CDC (2017b) reported that suicide rates peak during
adolescence and young adulthood among this population and then
decline. This pattern greatly differs from the general United States
population, where rates of suicide peak in mid-life.

The disproportionate level of risk for suicide in youth who identify as
American Indian and Alaska Native has been well researched, in which a
variety of contributing factors have been identified, e.g., high rates of
substance use, exposure to adverse early childhood experiences, limited
access to resources due to rural settings, and increased potential for
contagion effects of suicide (Leavitt et al., 2018). In light of these
complex vulnerabilities, researchers often recommend school involve-
ment in prevention and intervention to target the varied risk factors
present, especially as they relate to suicidal behavior. School program-
ming can typically reach larger populations, a dire need in rural areas in
which many of these young people reside (Leavitt et al., 2018; Lieber-
man et al., 2008). Specific recommendations within the school context
are offered across the relevant literature, which will be integrated into
clinical recommendations in later reading.

4. Legal implications of suicide in the school context

Suicide in the school context is a complex issue that can create sig-
nificant legal implications regarding the liability of the school district
and staff, especially administrators, support staff, and school psycholo-
gists. In the United States, there have been numerous legal battles in
which schools are sued in the aftermath of a death by suicide of a young
person. While this presents major concerns for school personnel, very
rarely do the parents of suicidal students succeed in court proceedings.
With the exception of the school’s failure to notify parents when there is
reason to suspect a student’s risk for suicide, courts have been reluctant
to find schools culpable (Stone, 2017).

Friedlander (2013) reported that parents as the plaintiffs face slim
chances when they file a lawsuit against the school or its officials after
the suicide of their child. Many factors contribute to this, including the
lack of resources, i.e., financial means, the lengthy trial periods, and
limited evidentiary documentation. Cases that cite bullying as a critical
factor in the youth’s suicide, for example, often lack the necessary
documentation of the parents’ concerns that are often reportedly shared
with school officials prior to their child’s death by suicide.

Moreover, Poland (Erbacher, Singer, & Poland, in press) reported
that only a small number of these cases make it to a jury trial. More
often, the school districts’ insurance companies decide to settle the cases
outside of court, as it can be a less costly and public matter, when
compared to the potential of a lengthy defense of the district in litiga-
tion. Moreover, public legal battles can generate a negative stigma
around the school and its district. However, MacIver (2011) suggested
that the number of court cases against schools may continue to rise in the
future, as courts are becoming more receptive to finding the defendants
liable for causing another person’s suicide. Further, suicide experts are
reported as having increased success in either proving or disproving a

specific cause of suicide.
In review of cases that have gone to trial, rulings are varied,

muddying the legal guidelines for school suicide prevention and related
liability. Dr. Scott Poland, one of the present authors and a leading
expert in youth suicide, discussed the complexity of these cases in his
chapter on Legal Issues for Schools (Erbacher et al., in press). In sum,
courts must primarily consider whether a student’s death by suicide was
a direct result of an inadequate response from the school personnel;
however, given the varied psychosocial risk factors associated with
youth suicide (e.g., mental health, and adverse childhood experiences),
it is highly difficult to prove that a school’s breach of duty is the sole
causal factor of the suicide, thereby making the personnel liable.

4.1. School liability: relevant legal cases

What then is the school’s liability in cases of student suicides? His-
torically, courts ruled that schools did not have a legal obligation to
prevent suicide (Stone & Zirkel, 2012). A 1991 appellate case, Eisel v.
Board of Education of Montgomery County, set new precedent on this
matter. The father of 13-year-old Nicole Eisel sued the school district
and two of its school counselors after they failed to report their learning
of an apparent murder-suicide pact with another peer. The father argued
that the special relationship the personnel maintained with his daughter
placed a duty upon them to share her reported suicidal ideation with her
parents. The Maryland Supreme Court held that the state’s Suicide
Prevention School Programs Act, the school’s own suicide prevention
policy, and the relationship between school, counselor, and youth gave
rise to a duty on the counselors’ part to use “reasonable means to
attempt to prevent a suicide when they are on notice of a child or
adolescent student’s suicidal intent” (Eisel v. Board of Education of
Montgomery County, 1991), including, at a minimum, a report to the
student’s parents. The Court listed “foreseeability of harm,” i.e., a
reasonable person would have been able to recognize that a student was
in an acute emotional state of distress and in danger of suicide, as the
prominent factor in determining whether school employees had a duty
to warn student’s parents (Eisel v. Board of Education of Montgomery
County, 1991; Friedlander, 2013).

While this was significant regarding the role of school professionals,
it did not create an absolute precedent of liability for schools. In fact, the
very same school district cited in the 1991 case was sued just a few years
later after another student’s suicide in Scott v. Montgomery County
Board of Education (1997), in which the court did not adhere to the
precedent of liability for school mental health professionals (SMHPs). A
federal appellate court upheld the dismissal of the lawsuit initiated by
the mother of a middle school student who had hanged himself. The
school psychologist met with the student approximately two months
prior to the student’s suicide and did not assess him as posing an im-
mediate danger of self-harm; furthermore, did not report the informa-
tion to the student’s parents. The court dismissed the mother’s claims of
negligence as educational malpractice, concluding that the alleged
causal linkage to the school psychologist was not sufficient (Scott vs.
Montgomery County Board of Education, 1997; Stone & Zirkel, 2012).

Court cases post Eisel (1991) in many states have continued to
consider school districts or personnel liability for student suicides.
Friedlander (2013) relayed that among these cases, claims of negligence
that are grounded in “statutory, regulatory, or district policy for suicidal
threats and suicide prevention” (Friedlander, 2013) are most promising
to plaintiffs. Negligence is a breach of duty owed to an individual
involving injury or damage (suicide) that finds a causal connection be-
tween a lack of or absence of duty to care for the student and his/her
subsequent suicide (Stone, 2017).

In Wyke v. Polk County School Board (1997), for example, the
Eleventh Circuit Court of Appeals concluded that the school board was
liable for the death of 13-year-old Shawn Wyke. Wyke hanged himself at
his home two days after two failed attempts were completed at school.
His mother, Carol Wyke utilized the “failure to train theory” arguing that

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the lack of suicide prevention/intervention training for the school
personnel demonstrated a direct indifference to their duty to care and
protect (Erbacher et al., in press). While the school board argued that
suicide is an intervening force, the jury found that the school was
“somewhat aware” of the attempts on campus and made no efforts to
intervene, i.e., hold the child in protective custody, recommend, pro-
vide, or obtain protective counseling for the student, or report the in-
cidents to his parents. Further, the Court concluded that given the
known attempts, the school personnel had strong reason to anticipate
the suicide which was thus, foreseeable (Erbacher et al., in press;
Friedlander, 2013; Wyke v. Polk County School Board, 1997).

Negligence and foreseeability are not the only factors that have been
identified in determining school liability in student suicides. Sovereign
immunity, for example, has been used in school related suicide cases.
Government entities are granted immunity if their conduct does not
clearly violate constitutional rights of which a reasonable person would
have known. There is a constitutional right of a duty to protect students
and state laws require compulsory attendance for students; however,
legal cases have failed to find that a child’s required attendance at school
creates a relationship that would mandate a school’s duty to protect
students. Immunity is based on state law; if the state deems schools an
arm of the state government, then schools within that state are granted
sovereign immunity (Erbacher et al., in press).

Additionally, a school can be found in violation of legal re-
sponsibility based on the constitutional rights of the victims, i.e., state
created danger. The school may be liable if it does not enact or follow
through with specific policies and procedures, thereby causing danger to
the student who died by suicide (Erbacher et al., in press; Sanford v.
Stiles, 2006). Lastly, many school attorneys use the “intervening force”
argument to defend the school and its personnel, stating that suicide is a
superseding and intervening force that breaks the direct connection
between the defendants’ actions, i.e., failure to notify parents, and the
suicide. In sum, the intervening force is the real reason for the suicide
that resulted and the longer the timeframe between the possible negli-
gence of the school and the suicide of a student, the more logical the
intervening force argument (Erbacher et al., in press).

4.2. Legislation

The major legal implications of youth suicide in the school context
certainly justify the need for state laws and mandates targeted at suicide
prevention and intervention in the school setting. In the past, district-
wide suicide prevention efforts oftentimes only occurred after the
occurrence of a tragic student death. Currently, a majority of states
require some type of suicide prevention training for their school
personnel. However, the programming, efforts, and quality vary state by
state (Kreuze et al., 2017; Singer et al., 2018).

The American Foundation of Prevention for Suicide (AFPS, 2019)
reviewed current state laws in the United States, finding varied policies
and procedures related to prevention programming. To date, 11 states
require mandated annual training; moreover, 20 states (40%) also
require mandated training, but without the yearly contingency. Many
states without mandated training are making efforts to encourage
training throughout school districts; further, many require the provision
of suicide prevention and intervention policies and procedures (AFPS,
2019).

The Garrett Lee Smith Memorial Act (2004) was the first bill signed
into law pertaining to suicide prevention among young people in the
United States. It affirmed suicide as national public health problem and
intended to provide funding to states, tribes, campuses, and behavioral
mental health services for grants that support prevention and inter-
vention efforts. In 2007, a hallmark piece of legislation, the Jason Flatt
Act, was passed in the state of Tennessee, requiring all educators in the
state to complete 2 h of youth suicide awareness and prevention training
each year in order to be able to be licensed to teach. The Tennessee
legislation now serves as the model to introduce the Jason Flatt Act

(2007) in other states. It’s founders, Jason Foundation Inc. (a non-profit
agency dedicated to bringing suicide prevention awareness and educa-
tion to schools), report that to date, 20 states have adopted the act
(although each state’s requirements vary [AFPS, 2019]) and have been
supported by the state’s Department of Education and the state’s
Teacher’s Association, highlighting the value observed in such preven-
tative training (Erbacher et al., in press; JasonFoundation, 2019).

AFPS (2019) is dedicating major advocacy efforts toward the adop-
tion of the Jason Flatt Act (2007) in states that are still lacking in legal
mandates for suicide prevention. For these states, AFPS has created a
model legislation that can be used as a guide for individuals who would
like to lobby for the passage of this type of training. Lobbyists and ad-
vocates report frustrations in their continued efforts, particularly
regarding the language used in the adoption of policies and procedures.
One critique, for example, is the state’s use of the word “recommended”
instead of “required” in suicide training for schools (Lieberman &
Poland, 2017). Nevertheless, ongoing pursuits for mandated prevention
programming and training for school personnel are imperative, as they
have been demonstrated as significant lifesaving and life changing
legislation.

5. Addressing youth suicide in the school context

The content reviewed thus far has set forth a solid foundation for the
argument that increased attention must be dedicated to youth suicide in
the school context. Comprehensive research on broad suicidality has
acted as a crucial guide to informing professionals and the general
public, creating more awareness and understanding surrounding the
topic. It has generated helpful statistics that shed light upon specific
factors that are associated with suicidal behaviors in children and ado-
lescents. The identified risk factors discussed are key findings that
inform suicide response practices in the school setting; best practices to
target youth suicide include health promotion, prevention, intervention,
and postvention (Gould et al., 2003; Katz et al., 2013).

5.1. Prevention

The World Health Organization (WHO, 2019) emphasizes the fact
that while suicide is a significant public health concern, it is one that is
preventable, with timely, evidence-based and at times, affordable in-
terventions. The conceptualization of youth suicide as a public health
problem prompted the United State to adopt a public health model of its
prevention. “The public-health approach focuses on identifying patterns
of suicide and suicidal behaviors in a group or population. It aims at
changing the environment to protect people against diseases and
changing the behaviors that put people at risk of getting them” (p. 118,
Yip, 2011). While suicide is not considered a “disease” in the traditional
sense, it is a significant public health concern. Moreover, given the legal
implications discussed and the very real preventability of such tragic
deaths, school personnel, specifically SMHPs, must understand the
importance implementing suicide prevention programs via the lens of
public health in order to reduce suicide risk and suicide rates among the
adolescent population (Lieberman et al., 2014).

Prevention strategies for this population are traditionally completed
in three domains, including community, healthcare systems, and school.
The primary goal of prevention programs is to reduce the prevalence of
suicidal behavior in the youth population (Katz et al., 2013). Ancillary
goals include identification of at-risk individuals and the completion of
appropriate referrals and treatment targeting risk factor reductions
(Gould & Kramer, 2001; Gould et al., 2003). Given the sheer amount of
time that youth spend in the school setting, school-based programs have
been suggested as being perhaps the most effective way to reach this
population (Calear et al., 2016; Miller et al., 2009).

5.1.1. School suicide prevention programs
A variety of school-based suicide prevention programs exist;

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however, systematic reviews reveal that the field has yet to find a
definitive, evidence-based, best practice guideline (Calear et al., 2016;
Gould et al., 2003; Katz et al., 2013). While prevention programming
varies across design, methods, and implementation, common recom-
mendations are observed across the literature. AFPS (2019) has devel-
oped four evidence-based frameworks for youth in the U.S. for ensuring
success of suicide prevention strategies, including gatekeeping (i.e.,
training those considered to be natural helpers to recognize signs and
symptoms of suicide [Katz et al., 2013]), psychoeducation, restriction to
access of lethal means, and provision of mental health treatment to
students with depression and/or anxiety disorders, or those at risk for
such disorders (Lieberman et al., 2014). Additionally, the U.S. Depart-
ment of Health and Human Services Substance Abuse and Mental Health
Services Administration (SAMHSA, 2012), has developed “Preventing
Suicide: A Toolkit for High Schools” that outlines a plan on how to
educate school personnel, students, and parents on youth suicide and
related behaviors. Lieberman et al. (2014) relayed that SAMHSA’s
guidelines are highly regarded methods that target the identification of
at-risk youth and the use of appropriate protocols for these students.
Additionally, the toolkit offers suggestions for evidence-based suicide
prevention programs that are well matched for the school setting
(SAMHSA, 2012).

Katz et al. (2013) comprehensive systematic literature review
examined a number of school-based suicide prevention programs,
including, but not limited to suicide awareness curricula, general skills
training, and peer leadership. Ultimately, the investigators concluded
that while there are numerous available programs, few are evidence
based; importantly, the research lacks randomized controlled trial (RCT)
studies that evaluate their effectiveness on the outcome of suicide.
Suggestions for best practices include the combined use of multiple
programs in order to address the varied and complex needs of youth
suicide in the school context.

Cooper et al. (2011) drew similar conclusions in their systematic
review of high school-based suicide prevention programs in the United
States, in which they recommended a hybrid approach that includes
elements from the various programs reviewed. Of note, the authors re-
ported that across the most commonly used programs, four types were
isolated, including enhancement of protective factors, screening tools,
gatekeeper trainings, and curriculum based. Programs that enhance
protective factors were described as those that aim to identify problem
solving skills, means to adaptively cope, and the promotion of devel-
opmentally appropriate mental health. As mentioned previously, gate-
keeping utilizes a training approach in which school personnel and
sometimes peers work to increase their skills related to the identification
of and response to suicidal behavior in the school environment. Addi-
tionally, screening methods, such as depression screening tools, are used
to gain objective measures of student self-report of suicidality and
related risk factors. Lastly, curriculum-based programs emphasize the
importance of addressing mental health factors, including the use of
training materials that educate school personnel on suicidality and at
risk-youth (Condron et al., 2015; Cooper et al., 2011). Kalafat (2006)
highlighted that while aspects of these programs are critical components
of effective suicide prevention planning, there is little evidence to prove
they are effective as stand-alone programs; however, these four cate-
gories warrant deeper review, including a brief discussion of existing
programs that fall within respective types of prevention programming.

5.1.2. Enhancement of protective factors
Common protective factors for at risk youth have been identified,

including family cohesion and stability, strong coping and problem-
solving skills, positive self-worth, connections to school and extracur-
ricular participation, academic success, and enhanced impulse control
(WHO, 2014). Self-esteem and social support are two critical protective
factors that buffer the risk of suicide. When the availability of peer and
family support is present, suicide risk decreases, as self-esteem increases
(Eisenberg & Resnick, 2006; Kleiman & Riskind, 2013; Sharaf et al.,

2009). Further, stronger levels of resiliency have been found in in-
dividuals with higher self-esteem (Sharaf et al., 2009). These factors are
significant in the conceptualization of youth suicide prevention plan-
ning and can be enhanced in programs that emphasize protective fac-
tors. Kalafat (2006) reported that research findings (Jessor et al., 1995)
have demonstrated that prevention strategies targeting the enhance-
ment of protective factors may be more effective than those that address
risk factors. Despite this, such programs are not recommended as lone
practices, as they do not fully account for the complex needs present in
youth suicidality.

Promoting CARE, for example, is a school and home-based program
that primarily targets the enhancement of protective factors (i.e., per-
sonal and social resources) in suicide-vulnerable high school youth. It
incorporates principles of behavior change maintenance as means to
increase skills acquisition, motivation, social support, and self-efficacy.
The program implements strategies aimed to decrease negative behav-
iors via the improvement of emotional management, interconnected-
ness, and coping skills. Its design is based on the empirical findings that
have demonstrated that interventions that emphasize motivation to
change, social support access, and self-efficacy (i.e., the confidence that
an individual is equipped with the ability to face life challenge and ac-
cess learned skills), increase the likelihood of skill acquisition, behav-
ioral change, and continued maintenance of change (Cooper et al., 2011;
Hooven et al., 2010; Hooven et al., 2012).

Hooven et al. (2010) analyzed the longitudinal data of the long-term
maintenance of achieved short-term changes of 615 high school youth
and their parents, all of whom had participated in the Promoting CARE
program in the United States. A review of the identified at-risk adoles-
cents in the short-term and up to eight years post engagement in the
program revealed a decrease in key risk factors, including suicidal be-
haviors, depression, and hopelessness, along with an increase in pro-
tective factors such as family connectedness, self-efficacy, and coping
skills. The most effective components of the program were found to be
two, two-hour home visits with parents paired with two expert-led
meetings with students that were held two and half months apart.
Parent meetings were psychoeducational in nature, along with the
development of specific strategies to utilize with their adolescent. The
student meetings included assessment and counseling, with an emphasis
on family connectedness and adequate preparation for school personnel.
Given these findings, Hooven and colleagues urged the field the broaden
their scope of research to further strengthen the evidence behind this
and other kinds of suicide prevention plans that enhance protective
factors. Moreover, these findings align with the ongoing mission of
schools to implement programs that focus on protective factors (Kalafat,
2006), albeit they present difficulties in implementation, i.e., consistent
involvement of outside parties (parents).

5.1.3. Screening tools
Among the prevention strategies reviewed, case-finding via direct

screening of youth, i.e., self-report screening tools, has received
increased attention (Gould et al., 2003; Singer et al., 2018). Self-report
and individual interviews have been demonstrated as being helpful aids
in the identification of youth who are at risk for suicide (Gould et al.,
2003; Reynolds, 1991; Shaffer & Craft, 1999; Singer et al., 2018;
Thompson & Eggert, 1999) and target the fluid nature of suicidality
(Pisani et al., 2016). Further, while it is commonly thought that suicide
is an impulsive action, research contradicts this, revealing that in-
dividuals considering suicide spend a range of time contemplating and
planning (Millner et al., 2017).

Screening is a method that involves screening either at-risk students
specifically, or all students at a school, in which those who are found to
be at increased risk are referred to treatment. Screening tools typically
examine specific risk factors such as substance use, depression, and past
suicidal behaviors. One of the most critical components of the screening
programs is the availability of adequate referral sources prior to the
screening taking place (Katz et al., 2013). This can present challenges in

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follow through. As discussed previously, there are often limited re-
sources available (particularly in rural areas), especially providers who
are competent to provide youth suicide intervention.

Additional limitations of screening programs include the fluctuating
nature of mental illness. A student who is screened in September, for
example, may report an entirely different experience of symptoms later
in the school year. Without multiple screenings, it is difficult to assess
risk factors that vary with time (Ciffone, 2007). Furthermore, critics
report concerns over the potential for generating both false positives and
negatives (Ciffone, 2007; Gould et al., 2005). However, Gould et al.
(2005) found that suicidal youth who were not asked about suicide were
more distressed than those who were asked about it via the screening
tools used, ultimately concluding that screening programs are a safe
method of suicide prevention in schools. These programs are further
supported in the literature (Lieberman et al., 2014; Scott et al., 2009).
For example, Peñta & Caine’s, 2006 systematic review of 17 screening
tools used to detect adolescents who were at-risk for suicidal behaviors
demonstrated improved identification; however, the positive predictive
value of any related suicidal behavior in school settings was low across
the reports (range 6–33% [Peñta & Caine, 2006; Zalsman et al., 2016]).

A variety of screening methods are available; however, consistent
with other prevention programming, there is not a clear consensus on
which tool should be primarily used. Cooper et al. (2011) cited three
well known screening tools that are most often used in school prevention
programs, including the Suicide Risk Screen (SRS), the Suicidal Ideation
Questionnaire (SIQ), and the Columbia Suicide Screen (CSS). Leading
experts in youth suicide, Lieberman et al. (2014) provided specific
recommendations for SMHPs that would enhance their ability to not
only identify potential suicidality in students, but also important risk
factors that may lead to a trajectory of suicidal behaviors. As such, while
several of the suggested screening tools target suicidal behavior directly
(e.g., The Columbia Suicide Severity Rating Scale [Posner et al., 2011],
MAPS: Measure for Adolescent Potential for Suicide [Eggert et al.,
1994], Brief Suicide Risk Assessment Questionnaire [Miller & McCo-
naughy, 2005]), the authors also include screeners that examine other
relevant factors, such as depression (e.g., Reynolds Adolescent Depres-
sion Scale-Second Edition (Osman et al., 2010)), and The Hopelessness
Scale for Children (Kazdin et al., 1986). Despite the multitude of rec-
ommendations, it is important comment on the fact that, consistent with
previous recommendations, screening tools should not be used as pre-
ventive methods alone; rather, in conjunction with other successful
programming.

5.1.4. Gatekeeper trainings
Gatekeeper training has become a broadly adapted model of suicide

prevention that has been integrated into other models, e.g., curriculum-
based programs. As mentioned earlier, gatekeepers are identified help-
ing adults, i.e., teachers, school counselors, coaches, clergy, etc., who
are in a position to both observe and intervene with at-risk adolescents.
The training emphasizes increased identification and response skills of
these adults (Stein et al., 2010). Within the school context, the use of
gatekeeper training is grounded in the concept that young people who
are at-risk for suicide are under identified and that by providing adults
with psychoeducation regarding suicide, identification can increase.
This training can enable school professionals to gain knowledge, atti-
tudes, and skills that aid in their identification of students who are at
risk, determine their levels of risk, and make appropriate referrals for
treatment as needed (Garland & Zigler, 1993; Gould et al., 2003; Kalafat
& Elias, 1995). Critics have discussed a few limitations to gatekeeping in
the school context, namely related to the availability of necessary adults
and the level of connectedness students who are at-risk may have,
thereby limiting the likelihood that they would share their SI with
friends (Kalafat, 2006).

As with the other domains of prevention, extensive empirical
research, including the necessary RTC studies, of Gatekeeper Trainings
are limited. However, some findings, inclusive of the above mentioned,

have suggested that it is an effective program to improve knowledge,
attitude, intervention skills, preparation for coping with a crisis, and
referral practices; moreover, reports indicate a general satisfaction with
the training (Gould et al., 2003; Katz et al., 2013). These factors are
thought to contribute to increased identification and adequate crisis
response to suicidal students on behalf of school personnel. Further, it
has been reported as a more widely accepted training by administrators
when compared to school-wide screening programs (Katz, 2013).

Among the commonly used gatekeeper training programs (e.g.,
LivingWorks, Yellow Ribbon International for Suicide Prevention, and
Suicide Options and Relief), Question Persuade Refer (QPR; Quinnet,
1995) has been repeatedly recommended in the literature (Burnette
et al., 2015; Gould et al., 2003; Kalafat, 2006; Tompkins et al., 2009). It
is a program that provides one to two-hour training sessions to in-
dividuals wherein they achieve the following objectives: (1) learning to
recognize warning signs, (2) question suicidal intent, (3) listen to
problems, and (4) refer for help (Tompkins et al., 2009). Tompkins et al.
(2009) empirical review of QPR resulted in a positive evaluation in
which significant gains in knowledge and attitudes related to suicide
were observed from pre- to post-test, providing support for the
continued use of QPR as a school-based prevention program.

5.1.5. Curriculum based programs
Curriculum-based programs have greatly evolved over the course of

the last two decades and are another popular method of suicide pre-
vention programming. Such programs aim to provide psychoeducation
and increased awareness regarding suicide via school curriculum. Thus
far, the curriculum is largely geared for the middle and high school
populations (Cooper et al., 2011). Currently, the majority of these pro-
grams are part of the comprehensive universal school-based prevention
programs (i.e., those that target an entire population vs. selected in-
dividuals/populations [Kalafat, 2006; Singer et al., 2018]).They are
designed to reflect a hybrid model (in line with previously discussed
recommendations), in which screening and gatekeeping aspects are
included, thereby increasing the likelihood of identifying at-risk stu-
dents (Katz et al., 2013). Kalafat (2006) cites the empirical base for these
programs as that there is a higher likelihood that at-risk youth will tell a
peer about their thoughts or plans and that most of these peer confidants
do not relay this information to an adult. Moreover, school-based adults
have been cited as the last choice for youth to turn to for their diffi-
culties. As such, these programs are developed to increase the likelihood
that gatekeepers and peers are more readily able to identify at-risk
students and can subsequently provide appropriate interventions and
referrals (Kalafat, 2006).

Ciffone (2007) provided a thorough review of curriculum based
programs and recommended the use of two tier program model, in
which the primary strategy includes an “authoritative delivery of a well-
designed curriculum-based prevention message” (p.42, Ciffone, 2007)
followed by the secondary strategy of screening that will aid the school
personnel in identifying students who are at-risk for suicidal behaviors.
Curriculum-based programs have been cited as being beneficial in
improving suicide and mental health related knowledge and attitudes
(Guo & Harstall, 2002; York et al., 2012); however, there is limited
evidence for the prevention of suicidal behavior (Mann et al., 2005).
Critics shed light on the fact that changes in knowledge and attitude are
not necessarily correlated with changes in behavior. (Katz et al., 2013).
Despite this, curriculum-based programs in the school context are a
promising direction for prevention and, unlike most of the other models,
have some empirical evidence behind specific program models.

Signs of Suicide (SOS; Mindwise Interventions, 2019) is a long-
standing, school-based suicide prevention program that includes both
curriculum and screening (Singer et al., 2018). A variety of national
organizations that specialize in youth mental health and suicide pre-
vention have served as sponsors of the SOS program, ranging from the
National Association of School Psychologists (NASP), to the National
Association of Secondary School Principals. This prevention plan

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integrates two frameworks: (1) heightened awareness via psycho-
education for students and school staff about recognition of warning
signs of depression and suicide, along with avenues for intervention, and
(2) a self-report measure that screens for the presence of depression and
suicide risk (Lieberman et al., 2014). A key factor to implementation
includes the training of students to be gatekeepers, in which they are
taught that suicidal behaviors are not a normal response to life stressors
(as historically conceptualized), rather, an emergency that should be
shared with a responsible adult (Cooper et al., 2011). Additionally, SOS
includes a kit of materials per grade groups, beginning with eighth
grade. The kit includes teaching materials (a video and discussion
guide), along with the Brief Screen for Adolescent Depression (Lieber-
man et al., 2014; Mindwise Interventions, 2019).

SOS has been proven as an effective method of prevention in the
school context. Drs. Aseltine and Demartino (2004) completed a large-
scale RCT examining the effectiveness of SOS in reducing suicidal be-
haviors. The subsequent study (Aseltine et al., 2007) expanded upon this
analysis, including a second year of data and an additional examination
of efficacy variation among different types of students. Both studies
found that students involved in SOS demonstrated significantly
decreased rates of SAs, along with increased knowledge and a more
adaptive attitude regarding depression and suicide. Further, specific
factors such as race/ethnicity, grade, and gender did not impact the
intervention outcomes evaluated (Aseltine et al., 2007; Aseltine &
DeMartino, 2004). While this curriculum prevention program has been
proven effective, researchers acknowledge their lack of knowledge
regarding the long-term effectiveness of models like SOS (Aseltine et al.,
2007). Regardless, it is still a prominent recommendation among experts
(Aseltine et al., 2007; Aseltine & DeMartino, 2004; Gould et al., 2005;
Lieberman et al., 2014) and incorporates a variety of the recommended
program components (e.g., screening, gatekeeping, psychoeducation)
into one comprehensive school suicide prevention program.

5.1.6. Peer leadership
While not included in the above domains, it is important to highlight

another area of school-based suicide prevention that is gaining more
attention in the recent years. Peer leadership programs are founded
upon the associations between suicidal behavior and adolescents’ social
ties and norms. Suicidal adolescents are found to have increased con-
nections to other suicidal youths; moreover, adolescents who have a
friend who attempts suicide are 2 to 3 times more likely to make an
attempt themselves (Bearman & Moody, 2004; May et al., 2012).
Exposure to peer suicidal behavior may result in the promotion of a
perceived norm that a common response to distress is suicidal behavior,
thereby increasing a student’s susceptibility to suicide imitation.
Acceptance of suicide has been associated with increased suicidal be-
haviors and planning (Wyman et al., 2010).

Peer leadership programs enact changes from within the student
population, in which socioecological protective influences are learned
and translated across the student body. Given the fact that students are
more likely to discuss their suicidal thoughts with peers rather than
adults (Katz et al., 2013), placing preventing in the hands of students is a
logical route. These programs often aim to revise the norms that are
perpetuated among peer groups in order to alter perceptions of what is
typical behavior and of the consequences for positive coping behaviors
(Wyman et al., 2010). The framework is centered on the training of
diverse student representation, in which students are taught how to
respond appropriately to a friend’s report of suicidal thoughts, including
when to seek a trusted adult. Additionally, a key goal is to aid in
implementing positive coping norms within the school setting and a
culture of prosocial and help seeking behaviors.

HOPE Squad (2018), is a “peer to peer” based program that partners
with local community and mental health agencies to train students to be
empowered to take action to prevent suicide. Students are nominated by
their classmates as trustworthy peers and are then trained to recognize
the signs of suicide, be active listeners, provide friendships, and seek

assistance from a trusted adult when necessary. The goals of HOPE
Squad are to prevent suicide and reduce behaviors by creating an
environment that promotes positive relationships among students and
culture of openness to talk about suicide and acceptance to seek help
across schools and communities. The HOPE Squad Program originated
in the state of Utah, the nation’s 5th leading state for youth suicide and
has been successfully implemented in three different school districts.
Moreover, it has been determined by the Utah Evidence-Based Work
group to be a Level 3, Supported Program and Practices. HOPE Squads
are on the Utah State Office of Education approved suicide prevention
programs list and have support from the Utah legislature (Hope Squad,
2018).

Sources of Strength is another peer-based suicide prevention pro-
gram that has garnered increased attention and research in the last
several years (Singer et al., 2018). The program attempts to generate a
diverse group of peer leaders who can positively affect a broad range of
cliques within a school or community. Student leaders are recruited
through teacher, staff, and peer nominations and are trained to model
and encourage other peers to “(1) name and engage ‘trusted adults’ to
increase youth–adult communication ties; (2) reinforce and create an
expectancy that friends ask adults for help for suicidal friends, thereby
reducing implicit suicide acceptability; and (3) identify and use inter-
personal and formal coping resources” (Sources of Strength, n.d.;
Wyman et al., 2010). Wyman et al. (2010) completed one of the nation’s
largest studies on peer leaders and their impact on suicide prevention,
focusing on the implementation of Sources of Strength. The results were
in favor of the program, demonstrating an increase in both peer leaders’
connectedness to adults and in school engagement, along with an in-
crease in positive perceptions of adult support for suicidal youth and the
acceptability of seeking help. Further, peer leaders in larger schools
were found to be four times more likely to refer a suicidal friend to an
adult, fulfilling the primary goal of prevention in the context of youth
suicide.

5.2. Intervention

The majority of research regarding suicide in the school context
primarily focuses on prevention as the means for intervention, especially
given the reported preventability of these tragic deaths. Experts
emphasize the importance of early identification and intervention.
However, the literature has demonstrated that despite the broad avail-
ability of school-based suicide prevention programs, few are evidenced
based and there has yet to be a national consensus of specific pro-
gramming to use. Moreover, given the trends reviewed earlier, youth
suicide during school months continues to be a major public health
concern that school personnel may have to address at some point in their
careers.

Comprehensive intervention policies and procedures ensure that
school personnel have specific guidance around and are supported in
intervening with students experiencing SI or who have engaged in a SA.
AFPS (2019) reports that such policies will enhance clarity regarding
educators’ roles and empower them to effectively intervene in the face
of student suicidal behavior. The SAMHSA (2012) toolkit strongly rec-
ommends for the placement of protocols in every school in order to
specify which individual(s) will handle each of the tasks in the event of a
suicide risk, suicide attempt, or completed suicide. Two key components
that must be in place even if the school does not provide further suicide
prevention strategies include, “protocols for helping students at possible
risk of suicide” and “protocols for responding to a suicide death (and
thus preventing additional suicides)” (p. 17, U.S. Department of Health
and Human Services Substance Abuse and Mental Health Services
Administration, 2012).

Collaborative efforts of the American Foundation for Suicide Pre-
vention, the American School Counselor Association, the National As-
sociation of School Psychologists, and The Trevor Project resulted in the
development of the “Model School District Policy on Suicide Prevention”

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(AFPS et al., 2019). The model is not a specific program, rather a guide
for the development and implementation of comprehensive school dis-
trict policies on suicide prevention. It offers recommended language for
school district policies that target suicide risk, prevention, intervention,
and response in young people. Further, it includes suggestions for best
practices, commentary, and resources pertaining to youth suicide pre-
vention. Leading experts in the field, such as Drs. Lieberman et al.
(2014) and the National Association for School Psychologists (2015)
have provided recommendations for best practices in suicide prevention
and intervention, much of which aligned with those offered in the Model
Policy (AFPS et al., 2019). Key factors are consistently identified across
the literature, including (1) prevention via early identification, (2)
proper risk assessment, (3) appropriate referrals (e.g., notification of
parents and SMHPs, treatment resources), and (4) re-entry procedures.

5.2.1. Identification of at-risk youth
It has been well established that the school and its personnel play a

critical role in suicide prevention for students. AFPS et al. (2019) rec-
ommends that school districts assign a suicide prevention coordinator
that provides assistance in planning and implementing prevention pol-
icies at the district and school levels. Given the limited availability of
staffing and resources in many districts, alternative recommendations
include the incorporation of SMHPs (e.g., school counselors, social
workers, or preferably school psychologists—as they are trained in
psychological assessment) or other school personnel that can be prop-
erly trained (Lieberman et al., 2014). These individuals should serve as
the point of contact when there is concern regarding an at-risk student
(AFPS et al., 2019).

Of utmost importance, is the training of these individuals and the
broader school personnel in early identification of common warning
signs (Singer et al., 2018). While many youths who are at-risk for sui-
cidal behavior go unnoticed, the majority of them demonstrate clues to
their distress in some form. These warning signs are the foundational
concept to the need for gatekeepers and it is recommended that these
individuals are trained to identify and respond appropriately to them
(Lieberman et al., 2014). There are various warning signs of youth sui-
cide (Poland & Lieberman, 2002; U.S. Department of Health and Human
Services SAMHSA, 2012) including (1) threats that can be passive (e.g.,
what’s the use?) or direct (e.g., “I want to die”) in nature, (2) plan/
method/access—the presence of a plan, availability of a method, and
access to means increases the risk of suicidal behavior, (3) making final
arrangements (e.g., giving away possessions, writing goodbye notes,
reporting sense of purposelessness) and (4) observed sudden changes (e.
g., in behavior—social withdrawal, mood, personality, friends). Any
recognition of such clues for potential at-risk behavior should never go
unaddressed as they are strong predictors for suicide.

5.2.2. Risk assessment
Identification of at-risk youth is of utmost important in the preven-

tion of youth suicide. Suicide screeners are often used as means to
identify students who are in need of more in depth risk assessment.
Erbacher, Singer, and Poland (2015) developed a formatted suicide
screener, Suicide Risk Screening Form, that included five direct questions
for a student in which suicidality is suspected: 1) Have you wished you
were dead?, 2) Have you felt that you, your friends, or your family
would be better off if you were dead?, 3) Have you had thoughts about
killing yourself?, 4) Do you intent to kill yourself?, 5) Have you tried to
kill yourself? (p. 95).

Upon identifying at-risk youth, a thorough risk assessment must be
completed. There should be at least one professional in the school setting
that is trained to complete a thorough risk assessment. AFPS et al. (2019)
describes risk assessment as an evaluation aimed to elicit specific in-
formation related to a student’s intent to die by suicide—inclusive of a
plan and level of lethality and availability, along with his/her previous
history of SI, mental status, presence of support systems and other risk
factors, and levels of helplessness. Kennebeck and Bonin (2019)

expanded upon this description to incorporate specific elements that
should be addressed in the assessment, including content and chronicity
of the SI, limited developmental progress, functional impairments, and
substance abuse. Lieberman et al. (2014) recommends a multi-stage
model of risk assessment that aids in early detection through the utili-
zation of screenings and clinical interviews (Reynolds, 1991). The
screenings should be brief, well-validated, and reliable; the follow-up
clinical interview(s) with the individual and his/her support system,
on the other hand, should be thorough in assessing ideation, plan, intent,
risk factors, warning signs, and protective factors. Poland (1995)
emphasized the importance of directly querying the student whether s/
he is actively thinking about death. He provided specific guidelines for
SMHPs when assessing a student’s risk in Table 5.2.1 below.

Best practices for risk assessment include a step by step procedure
that guide SMHPs to review and assess for all of the critical items dis-
cussed previously. The Montana Crisis Action School Toolkit on Suicide
(CAST-S), a suicide prevention program that was developed in a
collaboration between the Big Sky Council and National Alliance for
Mental Illness (NAMI) Montana to support Montana school communities
in response to state legislation for school suicide prevention program-
ming (Poland & Poland, 2017). The Montana CAST-S program’s steps
include the identification of risk factors through the use of suicidal
ideation severity scales, such as the Columbia Suicide Severity Rating
Scale (C-SSRS, Posner et al., 2011), along with a detailed collection of
family history, psychiatric concerns, precipitating stressors, presenting
symptoms, and access to lethal means. Protective factors, both internal
(e.g., fear of death, ability to cope with stress) and external (e.g., beloved
pets, engaged in work or school) should be identified, followed by
specific questioning about thoughts, plans, and suicidal intent. The
CAST-S recommends utilizing the C-SSR’s Suicidal Ideation Intensity, as
it includes direct and specific language that is necessary to determine the
level of risk involved (see Montana CAST-S, Tool 14B: SAFE-T Protocol
for the step-by-step recommendations [Poland & Poland, 2017, p.
79–83]).

It is important to highlight a specific factor of risk assessment that
may be not specifically considered: language. The use of specific lan-
guage is highly important in the course of proper suicidal assessment for
an at-risk student. The use of phrases such as “kill yourself,” “suicide,”
and “take your own life” is critical in the assessment process, as it aids in
the differentiation of the type of self-harm the youth may be engaging in
or intend to engage in. For example, a teen who engages in nonsuicidal
self-injurious behaviors (e.g., cutting) as means to cope with over-
whelming emotions or the absence of emotions may respond “yes” to a
question that is less direct such as, “have you had thoughts of hurting
yourself?” Additionally, most adolescents will respond “yes” to the
question “have you had thoughts of dying?” given the developmental
appropriateness of the consideration of mortality. Asking a student
directly about having thoughts or desires to kill themselves not only
creates a clearer path for querying, but also demonstrates an attitude of
openness to discuss suicide with the youth (Erbacher et al., in press). The
questions in Table 5.2.2 below can be found on the C-SSRS (Posner et al.,
2011) and within the CAST-S′ toolkit; they showcase the direct nature of

Table 5.2.1
Suicide assessment recommendations for SMHPs.

Best practices: suicide assessment for SMHPs

▸ Connect with student through providing empathy, support, and trust.
▸ Reflect feelings, remain nonjudgmental, and do not minimize the problems.
▸ Respect student’s developmental, cultural, and sexuality issues while collecting
necessary information considering appropriate community referrals.
▸ Utilize an assessment worksheet.
▸ Be direct in questioning the student, staff member, and/or parents when collecting
information.
▸ Never promise confidentiality.
▸ Ensure that you are maintaining the chain of supervision at all times (Poland,
1995).

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the language recommended in best practices for risk assessment.

5.2.3. Safety plan
No-harm/no-suicide contracts are used broadly in suicide interven-

tion, serving as a written documentation of the student promising not to
act on thoughts of self-harm or suicide and to instead reach out to
appropriate resources, e.g., loved ones, police. Despite their widespread
use, no-harm/no-suicide contracts have become a controversial topic
related to their effectiveness, especially due to the fact that there are no
data to support their impact on the reduction of suicide (Rudd et al.,
2005; Erbacher et al., in press). An alternate approach to no-harm/no-
suicide contracts, and the current best practice standard of care, is to
create a safety plan.

A collaborative creation of a safety plan between the student and
SMHP is essential in the face of suspected suicidality and/or a reentry to
school from a hospitalization. The design of this plan is flexible and can
include a variety of components (Brent et al., 2011; King et al., 2013;
Stanley & Brown, 2012). The goal of the safety plan is to provide a
document that students can reference when experiencing suicidal
ideation. Component of a safety plan include predetermined coping
strategies, peer and adult supports, and professional resources; all of
which can aid the student in working through the crisis. Specific rec-
ommended elements include identified triggers and related thoughts,
emotions, and behaviors, internal and external coping resources, a plan
of how to access such resources in times of distress, an agreement to
remove lethal means, and the contact number of appropriate crisis
hotlines. As mentioned, this plan should be developed collaboratively
with the student and shared with the parents or guardians. Lastly, the
student must ensure that the plan is readily accessible when in need
(Erbacher et al., in press).

Among the discussed components of a safety plan, it is important to
expand upon a few items further. An agreement to remove lethal means
is a critical aspect that can have a major impact on the trajectory of the
student’s future decision making when in crisis. A common myth often
pandered regarding restriction of means is that individuals whose access
to lethal means has been removed will pursue an alternative method. In
fact, research has documented quite the opposite, finding that if a spe-
cific method is removed and unavailable, suicidal individuals are very
unlikely to seek another method (Poland & Poland, 2017). The Means
Matter website at Harvard University (Harvard Injury Control Research
Center, 2019) provides comprehensive research that removing the lethal
means, such as a gun, or raising the barrier on bridges, have decreased
suicides.

An additional important aspect that requires further review is the

provision of both local and national suicide/crisis hotlines. This is an
essential part of not only a safety plan, but general suicide prevention
and intervention planning. As mentioned, this information should be
made available during safety planning either during the risk assessment
phase or after reentry from a hospitalization. Additionally, it should be
made available to students and staff throughout the school environment.
Students should be provided with the number for the National Suicide
Prevention Lifeline 1-800-273-TALK (8255) and 911 (Suicide Preven-
tion Lifeline, 2019).

Relatedly, students should be alerted to the alternate technical re-
sources at their disposal, such as the Crisis Text Line (2013), in which at-
risk students can text “HOME” to 741741 to receive 24/7 crisis support
via text. Other options include Apple’s “Siri,” the application that en-
ables users to complete tasks by speaking to their phone, which has
recently undergone major changes in its response to suicidal behavior.
Prior to June 2013, if an iPhone user told Siri that s/he wanted to jump
off a bridge, Siri would provide a list of bridge locations. However, Apple
has since reprogrammed Siri to return to such requests and others
related to suicidality with the phone number for the National Suicide
Prevention Lifeline. Further, Siri is prompted to then ask if the user
would like her to call the number or provide a more detailed list of local
suicide prevention centers on a map (Erbacher et al., in press; Stern,
2013). These avenues for help are invaluable resources for students in
crisis and should be widely publicized in the school setting.

5.2.4. Referrals
The notification of at-risk students to individuals who are in a posi-

tion to intervene has been reiterated throughout this paper, particularly
in relation to the vital importance of gatekeepers in suicide prevention
programs. As mentioned, appropriately trained individuals (e.g., peers,
professionals) should be able to recognize warning signs of suicide and/
or be able to respond adequately to any observed suicidal behavior of
students. Identification should prompt proper referrals to school
personnel who are equipped with the skills to intervene (e.g., SMHPs). If
SMHPs are not available, the Model Policy (AFPS et al., 2019) advises
that the administrator or school nurse should provide care for the stu-
dent until a SMHP or outside professional can be reached to complete a
thorough risk assessment. As a reminder, the student should never be left
alone once at-risk behavior is identified.

An additional and highly critical notification that must be completed
is the notification of the parents or guardians. As discussed earlier,
failure to notify parents has been cited as a major factor of negligence in
numerous legal cases after a student’s suicide. As a result, it has been
determined that a SMHP has an obligation to report any student who
may be suspected for at-risk suicidal behavior based on foreseeability. It
is important to note that often students will deny being suicidal; how-
ever, even if a student denies SI, if he has been referred to a SMHP for
suspected suicidality, it is the onus of the school to notify the parents or
guardians. This should be the case for all students, elementary to high
school. This is even the case for students over 18 years of age. Addi-
tionally, any notifications should be completed in writing. If SMHPs do
not follow through on this duty, it can be considered negligent in a court
of law (Eisel v. Board of Education Montgomery County, 1991; Lieber-
man et al., 2014). Notification to parents and guardians of a student who
is suspected of being suicidal (unless abuse is suspected, in such cases
protective services should be notified) is crucial, not only because of the
possible legal implications, but also to ensure that they are alerted to the
need to provide best care for the student’s safety.

Of note, should the tragic incident of a SA on campus be made, the
Model Policy (AFPS et al., 2019) recommends that all students should be
removed from surrounding areas as soon as possible and that the pri-
mary concern should be for the suicidal student. Medical treatment
should be provided, per district emergency medical policies and SMHPs
or suicide prevention coordinators and parents and guardians should be
immediately notified. Steps should then be taken to ensure the safety
and well-being of students who have been exposed and/or impacted by

Table 5.2.2
Best practices: direct language for suicide assessment.

Severity of ideation

▸ Have you wished you were dead or wished you could go to sleep and not wake?
▸ Have you actually had any thoughts of killing yourself?
▸ Have you been thinking about how you might do this?
▸ Have you had these thoughts and had some intention of acting on them?
▸ Have you started to work out or worked out the details of how to kill yourself?
▸ Do you intend to carry out this plan?
▸ Have you ever done anything, started to do anything, or prepared to do anything
to end your life? (C-SSRS, Posner et al., 2011)

Thoughts, plans, and suicidal intent

▸ Frequency: How many times have you had these thoughts?
▸ Duration: When you have the thoughts, how long do they last?
▸ Controllability: Could/can you stop thinking about killing yourself or wanting to
die if you want to?
▸ Deterrents: Are there things—anyone or anything (e.g., family, religion, pain of
death)—that stopped you from wanting to die or acting on thoughts of suicide?
▸ Reasons for Ideation: What sort of reasons did you have for thinking about
wanting to die or killing yourself?
(C-SSRS, Posner et al., 2011)

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the SA, albeit such methods may vary from district to district (Vaillan-
court & Gibson, 2014).

Once risk is assessed and parents have been notified, an action plan
should be collaboratively developed with school personnel, family
members, and outside professionals. Referrals for treatment should
occur. Lieberman et al. (2014) recommended that SMPHs maintain a
current list of community mental health resources to use as referrals for
at-risk students. Of importance, both the SAMHSA (2012) toolkit and the
Montana CAST-S (Poland and Poland, 2017) advise schools to complete
pre-screenings of said resources. Specific questions should be asked to
private providers prior to completing referrals related to professional
qualifications (e.g., Do you have experience working with LGBTQ stu-
dents and other groups that are disproportionately at risk for suicide?,
What process do you follow in the event of a suicide crisis?) and business
logistics (e.g., do you offer a sliding scale fee?, What is your typical wait
time to see a new client? [see p. 119 Tool 28: Screening Mental Health
Providers, Montana CAST-S, 2017]). Once an action plan is in place for
the student and his/her parent/guardian has secured treatment, the
authors recommend that the designated reporters or SMPHs make con-
tact with the referral provider in to provide a comprehensive review of
what took place. Moreover, various factors such as developmental,
cultural, socioeconomic (potential need for provider who offers sliding
scale rates), and sexuality issues should be considered when making
such referrals (Lieberman et al., 2006; Lieberman et al., 2014).

Lastly, it is important to comment on a critical component of re-
ferrals: the need for thorough and clear written documentation on behalf
of the SMHPs and related school personnel. It should be completed on
the day of the assessment/incident and content collected through in-
terviews and assessments should be written down verbatim. Documen-
tation such as this is essential in the referral of a student to both crisis
response teams and related mental health professionals. School districts
should provide specific forms for documenting in order to guarantee that
proper records are kept of their responses, actions taken, recommen-
dations, and referrals made to a suicidal student and/or the individual’s
parents (Lieberman et al., 2008).

5.2.5. Re-entry
The implementation of specific policies for handling students who

return to school after engaging in suicidal behaviors is consistently
recommended. While each school and district’s procedures may vary,
The Model Policy (AFPS et al., 2019) has identified key aspects of a re-
entry plan, including:

▪ A designated SMHP will coordinate with the student, family,
and any outside mental health providers (if permission was
granted).

▪ The parent or guardian will provide sufficient medical docu-
mentation that the student is no longer a danger to themselves
or others.

▪ The designated SMHP will determine what supports are needed
to help the student readjust to the school community and meet
with him or her periodically to address any concerns (Vaillan-
court & Gibson, 2014).

Lieberman et al. (2014) expanded upon these recommendations,
reporting that it is essential to facilitate the student’s re-entry in a
“careful [and] precise manner” (p. 282, Lieberman et al., 2014). They
recommended a multidisciplinary meeting between any and all in-
dividuals (e.g., parents, teachers, SMHPs, administrators, outside mental
health professionals, medical staff) that can aid in mediating a successful
reintegration into the school environment. As mentioned previously, a
safety plan should be collaboratively created if one was not already done
so in outside care. The Montana CAST-S (2017) provides a useful
checklist for school reentry for administrators, SMHPs, and staff mem-
bers. It includes a step by step guide for how each professional should
approach the reintegration process for a suicidal student (see p. 101,

Tool 20: Checklist for School Reentry of Suicidal Student). The authors
caution individuals who are wary to return to school, as it has been
found that a depressed child is safer in school than not. Of note, while
these are guidelines for best practice for re-entry procedures, it is always
imperative that SMPHs review and adhere to their individual districts
policies.

5.3. Postvention

Specific and consistent guidelines have been provided by experts for
the coordinated response schools should take following a death by sui-
cide in the school community, i.e., postvention (AFPS, 2019). Postvention
is a term unique to the literature related to suicidality and encompasses
specific activities or events that are planned for schools to implement
following a suicide in order to evaluate the overall impact, identify at-
risk individuals, prevent a contagion effect from occurring, and sup-
port survivors who are emotionally affected by the death to cope
effectively (Lieberman et al., 2014). Just as important as prevention,
postvention is a critical aspect of adequately addressing suicidality in
the school context. The rationale behind this is that a timely response to
suicide in the school community aids in a reduction of potential subse-
quent morbidity and mortality among exposed students, inclusive of the
onset of symptomology related to depression, posttraumatic stress dis-
order, and bereavement, along with suicidal behaviors (Gould et al.,
2003; Singer et al., 2018; Talbott & Bartlett, 2012). Postvention pro-
grams are designed to target the goals of assisting survivors in the grief
process, identifying and referring at risk individuals, providing accurate
information about the suicide while attempting to minimize suicide
contagion, and coordinating a plan for continued prevention efforts
(Gould et al., 2003; Hazell, 1993; Lieberman et al., 2014; Underwood &
Dunne-Maxim, 1997).

Vaillancourt and Gibson (2014) provided an integrated guideline for
postvention strategies based upon The Model Policy (AFPS et al., 2019)
and resources from The National Association of School Psychologists
(NASP). Postvention programs that follow these guidelines will ensure
comprehensive follow up and support in response to a tragic loss in the
school community and buffer against suicide contagion among students.
The contagion effect of suicide is a major concern in the realm of youth
suicidality. Rooted in social learning theory, contagion effects in the
context of suicidal behaviors refer to the idea that upon being exposed to
suicide (via peers, family members, celebrities, the media), young peo-
ple may learn that it is the only permanent solution to their difficulties,
creating higher risk for SI/SA (Lieberman et al., 2014).

Youth have been found to be especially vulnerable to the contagion
effect, creating suicide point clusters (suicides are contiguous in time
and space) in schools and communities across the nation, such as Palo
Alto, CA (2002, 2009, 2014), Fairfax County, Virginia (2014), Colorado
Springs, Colorado (2017), and Salt Lake City, Utah (2018 [Poland et al.,
2019]). A review of point clusters revealed specific risk factors including
male gender, mental health issues, history of suicidal ideation or suicide
attempt, substance abuse issues, relationship problems, a recent crisis,
cutting behavior, parents not recognizing the severity of the mental
health needs of their child, sleep deprivation, academic pressure, sexual
orientation, and intimate partner violence (Annor et al., 2017; Garcia-
Williams et al., 2016; Poland et al., 2019; Spies et al., 2014). Such factors
are vital pieces of information to school personnel in the wake of a
student suicide, providing increased awareness to at risk youth.

While individual circumstances surrounding a suicide will guide the
school and community response, it is important that schools obtain
reliable information in order to help their students cope with and
respond to the loss. An action plan should be developed in which several
steps are taken: (1) details of the student’s death are verified by the local
police department or coroner’s office, (2) the impact of the suicide on
the students and community is assessed by the school/district crisis team
and appropriate resources for individual and universal student needs are
identified, (3) factual information is shared to school personnel,

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students, and their families, inclusive of the resources and supports
available in the school and community, (4) high risk students, e.g., close
friends of the student who died, are identified in order to decrease sui-
cide contagion, (5) further risk assessment of students is completed and
provision of support services is offered, and (6) creation a memorial plan
with the student’s friends and family that is both a safe and meaningful
approach to acknowledging the loss without any glamorization or
perpetuation of the stigma of suicide (Vaillancourt & Gibson, 2014).

Poland et al. (2019) further support these recommendations for ac-
tion planning in postvention and provide a more current and detailed
review of each step that should be taken. Furthermore, they introduce a
valuable resource for postvention planning: “After a Suicide: Toolkit for
Schools Second Edition” (AFPS & SPRC, 2018). The toolkit is recom-
mended as an appropriate postvention guideline for addressing a suicide
among the community. Best practice guidelines in the aftermath of a
suicide are offered, including crisis response, helping students and
school personnel cope, collaborative efforts with the community (e.g.,
government agencies, mental health providers) and media (a necessary
relationship in order to appropriately report on the suicide and minimize
contagion [Lieberman et al., 2014]), memorialization, social media, and
buffering suicide contagion. An overarching recommendation from the
AFPS Toolkit is that all deaths should be treated in the same way.
Schools are encouraged to develop a memorialization policy and to do
the same thing after a death regardless of cause of death, popularity, or
socioeconomic level of the deceased. In order to provide the best care to
the school/community, this toolkit outlines very specific courses of both
appropriate and inappropriate actions to take after a completed suicide
in the school community.

Even more sparse than the existing research on school-based pre-
vention programs, is that on school-based postvention programs. Rob-
inson et al. (2013) systematic literature review of school-based suicide
prevention programs discussed the significant gap in the research
regarding reviewed postvention programs, noting that majority of the
literature includes case studies and anecdotal information. Gould et al.
(2003) similarly lamented to paucity of research in this area, finding
only two studies that examined the efficacy of school-based postvention
programs in the reduction of student suicidal behavior. The first, Hazell
and Lewin (1993) revealed no differences in their comparison outcomes
of the intervention group vs. the control group. Poijula et al. (2001)
small scale study, on the other hand, did demonstrate interesting results,
finding that in a 4-year-follow-up, no new suicides took place in schools
that incorporated appropriate interventions, whereas in schools that did
not have interventions, suicides increased significantly. The present
authors echo historical concerns regarding the lack of research in this
area, given the serious risks of exacerbation of distress for survivors and
the potential of contagion.

6. Conclusion

The aim of this paper was to provide a critical review of youth suicide
in the school context. The information reviewed was gathered from a
variety of sources, including empirical findings, systematic literature
reviews, expert recommendations, and government generated content.
This review covered the important areas related to suicide in the school
setting, including current trends, relevant risk and protective factors,
legal issues, prevention, intervention and postvention, along with spe-
cific guidelines for best practices. The in-depth exploration is a helpful
map for generating a comprehensive conceptualization of youth suici-
dality in the school environment.

Given the ongoing public health concern that youth suicide presents,
along with the demonstrated findings of seasonal variations and asso-
ciated risk factors related to the school milieu, continued examination of
suicidality in the school context is imperative. While this is generally
acknowledged across both school and mental health professionals, there
is still a lack of consistent implementation nationwide. Dr. Scott Poland
noted specific roadblocks that he has encountered in his professional

collaborations, including a lack of awareness of the problem, lack of
training and acceptance of shared responsibility, the presence of
competing demands at the school, fear to openly talk about suicide,
failure to recognize legislative requirements for training and utilization
of prevention programming, and limited or no collaboration with
community services and prevention initiatives (Erbacher et al., in press).
AFPS (2019) is dedicated to broadening the scope of prevention prac-
tices in the school setting and will need support from professionals,
families, and organizations to further their mission.

As discussed, school personnel play a critical role in targeting youth
suicide in a myriad of ways. It is imperative that they receive appro-
priate training in the identification of at-risk youth. As a reminder, lack
of training has been connected to significant legal implications, some of
which have generated clarity on the school’s role in this matter. Lia-
bility, however, remains to be considered a distinct precedence across
states. Prevention programs should be in place in every school nation-
wide, in which a hybrid approach is utilized, incorporating helpful
screening methods, gatekeeping, and psychoeducation for students,
staff, and parents. When making decisions on program choice, schools
should utilize evidence-based resource databases, such as those com-
plied by both SPRC and SAMSHA, in which many of the resources and
programs discussed can be reviewed. Trained SMHPs who can complete
appropriate risk assessments and necessary interventions must be
incorporated. Notification of the parents or guardians is a critical factor
of school-based suicide intervention and failure to so do can result in
serious legal consequences. Identification of appropriate referral re-
sources for mental health treatment is recommended and ongoing
collaboration with such providers can be helpful. Lastly, postvention
efforts must be made in order to properly meet the needs of grieving
survivors and to minimize the potential of a suicide contagion.

A variety of programs, organizations, materials, and resources have
been discussed throughout this paper and are key contributors to the
ongoing research in this field. A list of pertinent resources to address
suicide in the school context can be found below:

▪ Centers for Disease and Control: “Youth Risk Behavior Sur-
veillance Survey” (2017) (Centers for Disease Control and
Prevention (CDC), 2017a).

▪ American Foundation for Suicide Prevention (AFPS): “Model
School District Policy on Suicide Prevention” (2019) (American
Foundation of Prevention for Suicide (AFPS) et al., 2019)

▪ The National Association of School Psychologists (NASP):
“Guidelines for Administrators and Crisis Teams” (National
Association of School Psychologists, 2015)

▪ Suicide Prevention Resource Center (SPRC): “Preventing Sui-
cide: The Role of High School Mental Health Providers” &
“Preventing Suicide: The Role of High School Teachers” (Sui-
cide Prevention Resource Center, 2019)

▪ AFPS & SPRC: “After a Suicide, a Toolkit for Schools Second
Edition” (2018) (American Foundation of Prevention for Sui-
cide (AFPS) and Suicide Prevention Resource Center (SPRC),
2018)

▪ Substance Abuse and Mental Health Services Administration
(SAMHSA): “Preventing Suicide: A Toolkit for High School”
(Substance Abuse and Mental Health Administration
(SAMHSA), 2019)

▪ Poland & Poland in collaboration with Montana OPI, SAM,
DPHHS, Big Sky AACAP, and NAMI Montana: “Montana Crisis
Action School Toolkit on Suicide”(CAST-S) (Poland and Poland,
2017)

▪ SPRC: Resources and Programs Database (Suicide Prevention
Resource Center, 2019c)

▪ SAMSHA: Evidence Based Practices Resource Center (Sub-
stance Abuse and Mental Health Administration (SAMHSA),
2019)

S. Poland and S. Ferguson

Aggression and Violent Behavior xxx (xxxx) xxx

13

▪ President and Fellows of Harvard College: Means Matter
(Harvard Injury Control Research Center, 2019)

7. Future directions and additional recommendations

An important aspect of this review is the consistent finding of limited
evidence-based programming for prevention, intervention, and post-
vention. While some empirical findings are present across the literature,
researchers criticize the lack of RCTs and repeated trials examining
school-based program effectiveness on youth suicide outcomes. As such,
the present authors join other critics in the field and encourage re-
searchers to focus their efforts on empirically examining suicidality in
the school context. Despite the limited availability of evidence-based
programs, a wealth of recommendations for best practices is present
across the literature, all of which are grounded in scientific findings and
expert knowledge.

A variety of programs and toolkits have been reviewed; as
mentioned, while these are comprehensive resources, they are limited to
middle and high school populations. However, recall the CDC’s (2017b)
finding that suicide is the second leading cause of death for ages 10–34,
indicating that students in elementary grades are engaging in suicidal
behaviors. Moreover, recent studies that have investigated common risk
factors and trends related to risk factors and trends in suicidal behavior
in elementary-aged students have suggested the need for suicide pre-
vention efforts that are adapted to be developmentally appropriate for
this population (Bridge et al., 2015; Sheftall et al., 2016; Singer et al.,
2018). As such, the authors call for further research related to this
population and the creation or adaption of additional resources for
elementary grade levels.

The presence of school-based programming continues to grow;
however, schools are faced with the challenge of finding evidence-based
and best practice programs given the limited unified support in legis-
lation. Many states are still operating without specific legislative guid-
ance or requirements for prevention efforts. While there is guidance
available on this matter, the variation due to individual school districts
and policies can create challenges in broad implementation. Continued
lobbying for government and legal changes for better practices are
necessary and can be further pursued through organizations like ASFP.

The authors recommend that all states enact legislation that requires
suicide prevention in schools. Included in this prevention should be a
one-hour (at minimum) annual training for all school personnel who
interact with students, including support staff such bus drivers, cafeteria
staff, administrative assistants, and paraprofessionals. In states in which
legislative requirements have been set forth, it is imperative that the
Department of Education has procedures in place to assess whether or
not the legislation is being implemented. Given the wealth of informa-
tion reviewed related to suicide in the school context, it is vital that
professionals across fields (school, legal, clinical, community) continue
to push for increased attention, research, and programming to aid in the
prevention and reduction of youth suicide.

Declaration of competing interest

None.

References

Almeida, J., Johnson, R. M., Corliss, H. L., Molnar, B. E., & Azrael, D. (2009). Emotional
distress among LGBT youth: The influence of perceived discrimination based on
sexual orientation. Journal of Youth and Adolescence, 38(7), 1001–1014. https://doi.
org/10.1007/s10964-009-9397-9

American Foundation of Prevention for Suicide (AFPS). (2019). Retrieved from https://
afsp.org/. (Accessed 30 June 2019).

American Foundation of Prevention for Suicide (AFPS), American School Counselor
Association, the National Association of School Psychologists, & The Trevor Project.
(2019, October 22). Model school policy on suicide prevention. Retrieved from
https://afsp.org/our-work/education/model-school-policy-suicide-prevention/.
(Accessed 10 August 2019).

American Foundation of Prevention for Suicide (AFPS), & Suicide Prevention Resource
Center (SPRC). (2018). After a suicide, a toolkit for schools second edition. Retrieved
from https://afsp.org/our-work/education/after-a-suicide-a-toolkit-for-schools/.
(Accessed 31 July 2019).

Annor, F., Wilkinson, A., & Zwald, M. (2017). Epi Aid #2012-019: Undetermined risk
factors for suicide among youth aged 10–17 years Utah 2017. Retrieved from htt
ps://health.utah.gov/wp-content/uploads/Final-Report-UtahEpiAid . (Accessed
16 August 2019).

Aseltine, R. H., & Demartino, R. (2004). An outcome evaluation of the SOS suicide
prevention program. American Journal of Public Health, 94(3), 446–451. https://doi.
org/10.2105/ajph.94.3.446

Aseltine, R. H., James, A., Schilling, E. A., & Glanovsky, J. (2007). Evaluating the
SOSsuicide prevention program: A replication and extension. BMC Public Health, 7
(1). https://doi.org/10.1186/1471-2458-7-161

Bearman, P. S., & Moody, J. (2004). Suicide and friendships among American
adolescents. American Journal of Public Health, 94(1), 89–95. https://doi.org/
10.2105/ajph.94.1.89

Birkett, M., Newcomb, M. E., & Mustanski, B. (2015). Does it get better? A longitudinal
analysis of psychological distress and victimization in lesbian, gay, bisexual,
transgender, and questioning youth. Journal of Adolescent Health, 56(3), 280–285.
https://doi.org/10.1016/j.jadohealth.2014.10.275

Brent, D. A., Poling, K. D., & Goldstein, T. R. (2011). Treating depressed and suicidal
adolescents: A clinicians guide. New York: Guilford Press.

Bridge, J. A., Asti, L., Horowitz, L. M., Greenhouse, J. B., Fontanella, C. A., Sheftall, A. H.,
& Campo, J. V. (2015). Suicide Trends Among Elementary School–Aged Children in
the United States From 1993 to 2012. JAMA Pediatrics, 169(7), 673. https://doi.
org/10.1001/jamapediatrics.2015.0465.

Burnette, C., Ramchand, R., & Ayer, L. (2015). Gatekeeper training for suicide prevention
a theoretical model and review of the empirical literature. Retrieved from https
://www.rand.org/pubs/research_reports/RR1002.html. (Accessed 26 July 2019).

Burstein, B., Agostino, H., & Greenfield, B. (2019). Suicidal attempts and ideation among
children and adolescents in US emergency departments, 2007–2015. JAMA
Pediatrics, 173(6), 598. https://doi.org/10.1001/jamapediatrics.2019.0464

Calear, A. L., Christensen, H., Freeman, A., … Donker, T. (2016). A systematic review of
psychosocial suicide prevention interventions for youth. European Child & Adolescent
Psychiatry, 25, 467–482. https://doi.org/10.1007/s00787-015-0783-4

Centers for Disease Control and Prevention (CDC). (2011). Connectedness as a strategic
direction for the prevention of suicidal behavior. Retrieved from http://www.cdc.
gov/violenceprevention/pdf/Suicide_.

Centers for Disease Control and Prevention (CDC). (2017a). Youth risk behavior survey
data. Retrieved from www.cdc.gov/yrbs.

Centers for Disease Control and Prevention (CDC). (2017b). Web-based injury statistics
query and reporting system. Retrieved from https://www.cdc.gov/injury/images/
lc-charts/leading_causes_of_death_by_age_group_2017_1100w850h .

Centers for Disease Control and Prevention (CDC). (2018). Suicide rising across the US.
Retrieved from https://www.cdc.gov/vitalsigns/suicide/index.html.

Ciffone, J. (2007). Suicide prevention: An analysis and replication of a curriculum-based
high school program. Social Work, 52, 41–49.

Condron, D. S., Garraza, L. G., Walrath, C. M., McKeon, R., Goldston, D. B., &
Heilbron, N. S. (2015). Identifying and referring youths at risk for suicide following
participation in school-based gatekeeper training. Suicide and Life-Threatening
Behavior, 45(4), 461–476. https://doi.org/10.1111/sltb.12142

Cooper, G. D., Clements, P. T., & Holt, K. (2011). A review and application of suicide
prevention programs in high school settings. Issues in Mental Health Nursing, 32,
696–702. https://doi.org/10.3109/01612840.2011.597911

Crisis Text Line. (2013). Retrieved from https://www.crisistextline.org/. (Accessed 16
August 2019).

Curtin, S., Warner, M., & Hedegaard, H. (2016). Increase in Suicide in the United States,
1999–2014. Hyattsville, MD: National Center for Health Statistics. Retrieved from
www.cdc.gov/nchs/data/databriefs/db241 .

Curtin, S. C., Heron, M., Miniño, A. M., & Warner, M. (2018). Recent increases in injury
mortality among children and adolescents aged 10–19 years in the United States:
1999–2016 (Retrieved from https://www.cdc.gov〉nchs〉data〉nvsr〉nvsr67〉nvsr67_
04).

Dahl, A. L., & Galliher, R. V. (2012). LGBTQ adolescents and young adults raised within a
Christian religious context: Positive and negative outcomes. Journal of Adolescence,
35(6), 1611–1618. https://doi.org/10.1016/j.adolescence.2012.07.003

Eggert, L. L., Thompson, E. A., & Herting, J. R. (1994). A measure of adolescent potential
for suicide (MAPS): Development and preliminary findings. Suicide and Life-
threatening Behavior, 24, 359–381.

Eisel v. Board of Education of Montgomery County 597 A.2d 447 (Md. 1991).(1991).
Eisenberg, M. E., & Resnick, M. D. (2006). Suicidality among gay, lesbian and bisexual

adolescents: The role of protective factors. Journal of Adolescent Health, 39, 662–668.
Erbacher, T. A., Singer, J. B., & Poland, S. (2015). Suicide in schools: a practitioner’s guide

to multi-level prevention, assessment, intervention, and postvention. New York:
Routledge.

Erbacher, T. A., Singer, J. B., & Poland, S. (2021). Suicide in schools: A practitioners guide
to multi-level prevention, assessment, intervention, and postvention. New York: Routledge
(in press).

Evans, R., & Hurrell, C. (2016). The role of schools in children and young people’s self-
harm and suicide: Systematic review and meta-ethnography of qualitative research.
BMC Public Health, 16(1). https://doi.org/10.1186/s12889-016-3065-2

Friedlander, W. (2013). Student suicide and school liability. American Association for
Justice., 49(12), 55–64.

Garcia-Williams, A., O’Donnel, J., Spies, E., Zhang, X., Young, R., Azofeifa, A., & Vagi, K.
(2016). Epi Aid 2016-018: Undetermined risk factors for suicide among youth ages

S. Poland and S. Ferguson

https://doi.org/10.1007/s10964-009-9397-9

https://doi.org/10.1007/s10964-009-9397-9

https://afsp.org/

https://afsp.org/

https://afsp.org/our-work/education/model-school-policy-suicide-prevention/

https://afsp.org/our-work/education/after-a-suicide-a-toolkit-for-schools/

https://health.utah.gov/wp-content/uploads/Final-Report-UtahEpiAid

https://health.utah.gov/wp-content/uploads/Final-Report-UtahEpiAid

https://doi.org/10.2105/ajph.94.3.446

https://doi.org/10.2105/ajph.94.3.446

https://doi.org/10.1186/1471-2458-7-161

https://doi.org/10.2105/ajph.94.1.89

https://doi.org/10.2105/ajph.94.1.89

https://doi.org/10.1016/j.jadohealth.2014.10.275

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0050

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0050

https://doi.org/10.1001/jamapediatrics.2015.0465

https://doi.org/10.1001/jamapediatrics.2015.0465

https://www.rand.org/pubs/research_reports/RR1002.html

https://www.rand.org/pubs/research_reports/RR1002.html

https://doi.org/10.1001/jamapediatrics.2019.0464

https://doi.org/10.1007/s00787-015-0783-4

http://www.cdc.gov/violenceprevention/pdf/Suicide_

http://www.cdc.gov/violenceprevention/pdf/Suicide_

http://www.cdc.gov/yrbs

https://www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_by_age_group_2017_1100w850h

https://www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_by_age_group_2017_1100w850h

https://www.cdc.gov/vitalsigns/suicide/index.html

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0090

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0090

https://doi.org/10.1111/sltb.12142

https://doi.org/10.3109/01612840.2011.597911

https://www.crisistextline.org/

http://www.cdc.gov/nchs/data/databriefs/db241

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf01

15

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0115

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0115

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0115

https://doi.org/10.1016/j.adolescence.2012.07.003

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0125

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0125

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0125

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0130

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0135

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0135

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf9040

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf9040

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf9040

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0140

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0140

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0140

https://doi.org/10.1186/s12889-016-3065-2

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0150

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0150

Aggression and Violent Behavior xxx (xxxx) xxx

14

10–24—Santa Clara County, CA. Retrieved from https://www.sccgov.org/sites/
phd/hi/hd/epi-aid/Documents/epi-aid-report .

Garland, A. F., & Zigler, E. (1993). Adolescent suicide prevention: Current research and
social policy implications. The American Psychologist, 48, 169–182.

Garrett Lee Smith Memorial Act. (2004). S. 118 Stat. 1404, 108th Cong., 2nd session.
Gould, M. S., Greenberg, T., Velting, D. M., & Shaffer, D. (2003). Youth suicide risk and

preventive interventions: A review of the past 10 years. Journal of the American
Academy of Child & Adolescent Psychiatry, 42(4), 386–405. https://doi.org/10.1097/
01.chi.0000046821.95464.cf

Gould, M. S., & Kramer, R. A. (2001). Youth suicide prevention. Suicide & Life-Threatening
Behavior, 31(suppl), 6–31.

Gould, M. S., Marrocco, F. A., Kleinman, M., Thomas, J. G., Mostkoff, K., Cote, J., &
Davies, M. (2005). Evaluating iatrogenic risk of youth suicide screening programs.
Jama, 293(13), 1635. https://doi.org/10.1001/jama.293.13.1635

Guo, B., & Harstall, C. (2002). Efficacy of suicide prevention programs for children and
youth. Edmonton, Alberta: Alberta Heritage Foundation for Medical Research.

Hansen, B., & Lang, M. (2011). Back to school blues: Seasonality of youth suicide and the
academic calendar. Economics of Education Review, 30(5), 850–861. https://doi.org/
10.1016/j.econedurev.2011.04.012

Harris, E. C., & Barraclough, B. (1997). Suicide as an outcome for mental disorders.
British Journal of Psychiatry, 170(3), 205–228. https://doi.org/10.1192/
bjp.170.3.205

Harvard Injury Control Research Center. (2019). Means matter. Retrieved from htt
ps://www.hsph.harvard.edu/means-matter/. (Accessed 11 August 2019).

Hatzenbuehler, M. L. (2011). The social environment and suicide attempts in lesbian,
gay, and bisexual youth. Pediatrics, 127(5), 896–903. https://doi.org/10.1542/
peds.2010-3020

Hazell, P. (1993). Adolescent suicide clusters: Evidence, mechanisms and prevention. The
Australian and New Zealand Journal of Psychiatry, 27, 653–665.

Hazell, P., & Lewin, T. (1993). An evaluation of postvention following adolescent suicide.
Suicide & Life-Threatening Behavior, 23, 101–109.

Hinduja, S., & Patchin, J. W. (2012). Cyberbullying: Neither an epidemic nor a rarity.
European Journal of Developmental Psychology, 9(5), 539–543. https://doi.org/
10.1080/17405629.2012.706448

Holt, M. K., Vivolo-Kantor, A. M., Polanin, J. R., Holland, K. M., Degue, S.,
Matjasko, J. L., … Reid, G. (2015). Bullying and suicidal ideation and behaviors: A
meta-analysis. Pediatrics, 135(2). https://doi.org/10.1542/peds.2014-1864

Hooven, C., Herting, J. R., & Snedker, K. A. (2010). Long-term outcomes for the
promoting CARE suicide prevention program. American Journal of Health Behavior,
34(6), 721–736.

Hooven, C., Walsh, E., Pike, K. C., & Herting, J. R. (2012). Promoting CARE: Including
parents in youth suicide prevention. Family & Community Health, 35, 225–235.

Hope Squad. (2018). Home. Hope Squad. Retrieved from https://hopesquad.com/. 22
August, 2019.

JasonFoundation. (2019). Retrieved from http://jasonfoundation.com/. 12 August,
2019.

Jason Flatt Act. (2007). 45 State of Tennessee & 57.
Jessor, R., Van Den Bos, J., Vanderryn, J., Costa, F. M., & Turbin, M. S. (1995). Protective

factors in adolescent problem behavior: Moderator effects and developmental
change. Developmental Psychology, 31, 923–933.

Joiner, T. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.
Kalafat, J. (2006). Youth suicide prevention programs. PsycEXTRA Dataset.. https://doi.

org/10.1037/e530102006-003
Kalafat, J., & Elias, M. (1995). Suicide prevention in an educational context: Broad and

narrow foci. Suicide & Life-Threatening Behavior, 25, 123–133.
Katz, C., Bolton, S.-L., Katz, L. Y., Isaak, C., Tilston-Jones, T., & Sareen, J. (2013).

A systematic review of school-based suicide prevention programs. Depression and
Anxiety.. https://doi.org/10.1002/da.22114

Kazdin, A. E., Rodgers, A., & Colbus, D. (1986). The Hopelessness Scale for Children:
Psychometric characteristics and concurrent validity. Journal of Consulting and
Clinical Psychology, 54(2), 241–245. https://doi.org/10.1037//0022-006x.54.2.241

Kennebeck, S., & Bonin, L. (2019). Suicidal behavior in children and adolescents:
Epidemiology and risk factors. Retrieved from Wolters Kluwer Health UpToDate
website https://www.uptodate.com/contents/suicidal-behavior-in-children-and-ado
lescents-epidemiology-and-risk-factors. (Accessed 10 August 2019).

King, C. A., Foster, C. E., & Rogalski, K. M. (2013). Teen suicide risk: A practitioner guide to
screening, assessment, and management. New York: The Guilford Press.

Kleiman, E. M., & Riskind, J. H. (2013). Utilized social support and self-esteem mediate
the relationship between perceived social support and suicide ideation. Crisis, 34(1),
42–49. https://doi.org/10.1027/0227-5910/a000159

Kosciw, J. G., Greytak, E. A., Bartkiewicz, M. J., Boesen, M. J., & Palmer, N. A. (2012).
The 2011 National School Climate Survey: The experiences of lesbian, gay, bisexual and
transgender youth in our nation’s schools. New York: GLSEN.

Kreuze, E., Stecker, T., & Ruggiero, K. J. (2017). State requirements for school personnel
suicide prevention training: Where do we go from here? Adolescent Research Review.
https://doi.org/10.1007/s40894-017-0057-0

Leavitt, R. A., Ertl, A., Sheats, K., Petrosky, E., Ivey-Stephenson, A., & Fowler, K. A.
(2018). Suicides among American Indian/Alaska natives — National violent death
reporting system, 18 states, 2003–2014. MMWR Morbidity Mortality Weekly Report,
67, 237–242. https://doi.org/10.15585/mmwr.mm6708a1externalicon, 2018.

Lieberman, R., & Poland, S. (2017, November). Suicide prevention legislation: What school
psychologists need to know and do (p. 8). Communique.

Lieberman, R., Poland, S., & Cassel, R. (2008). Best practices in suicide intervention. In
A. Thomas, & J. Grimes (Eds.), Best practices in school psychology V. Bethesda, MD:
National Association of School Psychologists.

Lieberman, R., Poland, S., & Cowan, K. (2006). Suicide prevention in the schools.
Principal Leadership, 7(2), 11–15.

Lieberman, R., Poland, S., & Kornfeld, C. (2014). Best practices in suicide intervention. In
P. L. Harrison, & A. Thomas (Eds.), Best practices in school psychology: Systems-level
services (pp. 273–288). Bethesda, MD: National Association of School Psychologists.

Lueck, C., Kearl, L., Lam, C. N., & Claudius, I. (2015). Do emergency pediatric psychiatric
visits for danger to self or others correspond to times of school attendance? The
American Journal of Emergency Medicine, 33(5), 682–684. https://doi.org/10.1016/j.
ajem.2015.02.05

MacIver, A. (2011). Suicide causation exerts in teen wrongful death claims: Will they
assist the trier of fact? John Marshall Law Review, 45, 51–83.

Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., Haas, A.,… Hendin, H.
(2005). Suicide prevention strategies: A systematic review. Journal of the American
Medical Association, 294, 2064 –2074. https://doi.org/10.1001/jama.294.16.2064.

May, A. M., Klonsky, E. D., & Klein, D. N. (2012). Predicting future suicide attempts
among depressed suicide ideators: A 10-year longitudinal study. Journal of
Psychiatric Research, 46(7), 946–952. https://doi.org/10.1016/j.
jpsychires.2012.04.009

Miller, D. N., Eckert, T. L., & Mazza, J. J. (2009). Suicide prevention programs in the
schools: A review and public health perspective. School Psychology Review, 38(2),
168–188.

Miller, D. N., & McConaughy, S. H. (2005). Assessing risk for suicide. In
S. H. McConaughy (Ed.), Clinical interview for children and adolescents: Assessment to
intervention (pp. 184–199). New York: Guilford Press.

Millner, A. J., Lee, M. D., & Nock, M. K. (2017). Describing and measuring the pathway to
suicide attempts: A preliminary study. Suicide & Life-Threatening Behavior, 47(3),
353–369. https://doi.org/10.1111/sltb.12284

MindWise Innovations. (2019). Suicide prevention programs overview. Retrieved from
https://www.mindwise.org/what-we-offer/suicide-prevention-programs/.
(Accessed 10 August 2019).

National Association for School Psychologists. (2015). Preventing youth suicide.
Retrieved from https://www.nasponline.org/resources-and-publications/resou
rces-and-podcasts/school-climate-safety-and-crisis/mental-health-resources/prevent
ing-youth-suicide. (Accessed 3 August 2019).

National Association of School Psychologists. (2015). Preventing suicide: Guidelines for
administrators and crisis teams. Retrieved from https://www.nasponline.org/res
ources-and-publications/resources-and-podcasts/school-climate-safety-and-crisis
/mental-health-resources/preventing-youth-suicide/preventing-suicide-guidelines
-for-administrators-and-crisis-teams. (Accessed 16 August 2019).

National Center for Education Statistics and the Bureau of Justice Statistics. (2018). 2017
school crime supplement (Retrieved from https://nces.ed.gov 〉 pubs2018. Accessed 01
August 2019).

Olweus, D. (1993). Bullying at school: What we know and what we can do. Oxford:
Blackwell.

Osman, A., Gutierrez, P. M., Bagge, C. L., Fang, Q., & Emmerich, A. (2010). Reynolds
adolescent depression scale-second edition: A reliable and useful instrument. Journal
of Clinical Psychology, 66(12), 1324–1345. https://doi.org/10.1002/jclp.20727

Peñta, J. B., & Caine, E. D. (2006). Screening as an approach for adolescent suicide
prevention. Suicide and Life-Threatening Behavior, 36(6), 614–637. https://doi.org/
10.1521/suli.2006.36.6.614

Pisani, A. R., Murrie, D. C., & Silverman, M. M. (2016). Reformulating suicide risk
formulation: From prediction to prevention. Academic Psychiatry, 40, 623–629.
https://doi.org/10.1007/s40596-015-0434-6

Plemmons, G., Hall, M., Doupnik, S., Gay, J., Brown, C., Browning, W., … Williams, D.
(2018). Hospitalization for suicide ideation or attempt: 2008–2015. Pediatrics, 141
(6). https://doi.org/10.1542/peds.2017-2426

Poijula, S., Wahlberg, K. E., & Dyregrov, A. (2001). Adolescent suicide and suicide
contagion in three secondary schools. International Journal of Emergency Mental
Health, 3, 163–168.

Poland, S. (1995). Best practices in suicide intervention. In A. Thomas, & J. Grimes
(Eds.), Best practices in school psychology III (pp. 155–166). Washing, DC: National
Association of School Psychologists.

Poland, S., & Lieberman, R. (2002). Best practices in suicide intervention. In A. Thomas,
& J. Grimes (Eds.), Best practices in school psychology IV (pp. 1151–1167). Bethesda,
MD: National Association of School Psychologists.

Poland, S., Lieberman, R., & Niznik, M. (2019). Suicide contagion and clusters—Part 1:
What school psychologists should know. Communiqué, 47(5), 21–23, 1.

Poland, S., & Poland, D. (2017). The Montana crisis action school toolkit on suicide
[CreateSpace independent publishing platform]. Retrieved from https://saom.me
mberclicks.net/assets/SAM_unpublished_links/CAST-S 2017 FINAL_revised .

Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., …
Mann, J. J. (2011). The Columbia–Suicide Severity Rating Scale: Initial validity and
internal consistency findings from three multisite studies with adolescents and
adults. American Journal of Psychiatry, 168(12), 1266–1277. https://doi.org/
10.1176/appi.ajp.2011.10111704

Quinnet, P. (1995). QPR for suicide prevention. Spokane (WA): QPR Institute.
Ryan, C., Russell, S. T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family acceptance in

adolescence and the health of LGBT young adults. Journal of Child and Adolescent
Psychiatric Nursing, 23(4), 205–213. https://doi.org/10.1111/j.1744-
6171.2010.00246.x

Reynolds, W. M. (1991). A school-based procedure for the identification of adolescents at
risk for suicidal behaviors. Family & Community Health, 14, 64–75.

Robinson, J., Cox, G., Malone, A., Williamson, M., Baldwin, G., Fletcher, K., &
O’Brien, M. (2013). A systematic review of school-based interventions aimed at
preventing, treating, and responding to suicide- related behavior in young people.
Crisis, 34(3), 164–182. https://doi.org/10.1027/0227-5910/a000168

S. Poland and S. Ferguson

https://www.sccgov.org/sites/phd/hi/hd/epi-aid/Documents/epi-aid-report

https://www.sccgov.org/sites/phd/hi/hd/epi-aid/Documents/epi-aid-report

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0160

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0160

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0165

https://doi.org/10.1097/01.chi.0000046821.95464.cf

https://doi.org/10.1097/01.chi.0000046821.95464.cf

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0175

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0175

https://doi.org/10.1001/jama.293.13.1635

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0185

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0185

https://doi.org/10.1016/j.econedurev.2011.04.012

https://doi.org/10.1016/j.econedurev.2011.04.012

https://doi.org/10.1192/bjp.170.3.205

https://doi.org/10.1192/bjp.170.3.205

https://www.hsph.harvard.edu/means-matter/

https://www.hsph.harvard.edu/means-matter/

https://doi.org/10.1542/peds.2010-3020

https://doi.org/10.1542/peds.2010-3020

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0210

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0210

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0215

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0215

https://doi.org/10.1080/17405629.2012.706448

https://doi.org/10.1080/17405629.2012.706448

https://doi.org/10.1542/peds.2014-1864

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0230

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0230

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0230

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0235

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0235

https://hopesquad.com/

http://jasonfoundation.com/

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0240

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0245

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0245

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0245

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0250

https://doi.org/10.1037/e530102006-003

https://doi.org/10.1037/e530102006-003

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0260

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0260

https://doi.org/10.1002/da.22114

https://doi.org/10.1037//0022-006x.54.2.241

https://www.uptodate.com/contents/suicidal-behavior-in-children-and-adolescents-epidemiology-and-risk-factors

https://www.uptodate.com/contents/suicidal-behavior-in-children-and-adolescents-epidemiology-and-risk-factors

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0280

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0280

https://doi.org/10.1027/0227-5910/a000159

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf9000

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf9000

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf9000

https://doi.org/10.1007/s40894-017-0057-0

https://doi.org/10.15585/mmwr.mm6708a1externalicon

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0300

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0300

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0305

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0305

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0305

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0310

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0310

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0315

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0315

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0315

https://doi.org/10.1016/j.ajem.2015.02.05

https://doi.org/10.1016/j.ajem.2015.02.05

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0325

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0325

https://doi.org/10.1001/jama.294.16.2064

https://doi.org/10.1016/j.jpsychires.2012.04.009

https://doi.org/10.1016/j.jpsychires.2012.04.009

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0335

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0335

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0335

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0340

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0340

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0340

https://doi.org/10.1111/sltb.12284

Suicide Prevention Programs Overview

https://www.nasponline.org/resources-and-publications/resources-and-podcasts/school-climate-safety-and-crisis/mental-health-resources/preventing-youth-suicide

https://www.nasponline.org/resources-and-publications/resources-and-podcasts/school-climate-safety-and-crisis/mental-health-resources/preventing-youth-suicide

https://www.nasponline.org/resources-and-publications/resources-and-podcasts/school-climate-safety-and-crisis/mental-health-resources/preventing-youth-suicide

https://www.nasponline.org/resources-and-publications/resources-and-podcasts/school-climate-safety-and-crisis/mental-health-resources/preventing-youth-suicide/preventing-suicide-guidelines-for-administrators-and-crisis-teams

https://www.nasponline.org/resources-and-publications/resources-and-podcasts/school-climate-safety-and-crisis/mental-health-resources/preventing-youth-suicide/preventing-suicide-guidelines-for-administrators-and-crisis-teams

https://www.nasponline.org/resources-and-publications/resources-and-podcasts/school-climate-safety-and-crisis/mental-health-resources/preventing-youth-suicide/preventing-suicide-guidelines-for-administrators-and-crisis-teams

https://www.nasponline.org/resources-and-publications/resources-and-podcasts/school-climate-safety-and-crisis/mental-health-resources/preventing-youth-suicide/preventing-suicide-guidelines-for-administrators-and-crisis-teams

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0365

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0365

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0365

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0370

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0370

https://doi.org/10.1002/jclp.20727

https://doi.org/10.1521/suli.2006.36.6.614

https://doi.org/10.1521/suli.2006.36.6.614

https://doi.org/10.1007/s40596-015-0434-6

https://doi.org/10.1542/peds.2017-2426

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0395

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0395

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0395

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0400

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0400

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0400

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0405

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0405

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0405

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0410

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0410

https://saom.memberclicks.net/assets/SAM_unpublished_links/CAST-S%202017%20FINAL_revised

https://saom.memberclicks.net/assets/SAM_unpublished_links/CAST-S%202017%20FINAL_revised

https://doi.org/10.1176/appi.ajp.2011.10111704

https://doi.org/10.1176/appi.ajp.2011.10111704

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0425

https://doi.org/10.1111/j.1744-6171.2010.00246.x

https://doi.org/10.1111/j.1744-6171.2010.00246.x

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0430

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0430

https://doi.org/10.1027/0227-5910/a000168

Aggression and Violent Behavior xxx (xxxx) xxx
15

Rudd, M. D., Mandrusiak, M., & Joiner, T. (2005). The case against no-suicide contracts:
The commitment to treatment statement as a practice alternative. Journal of Clinical
Psychology, 62(2), 243–251. https://doi.org/10.1002/jclp.20227

Sanford v. Stiles. (2006). 456 F.3d 298 (3rd Cir. 2006).
Scott, M. A., Wilcox, H. C., Schonfeld, I. S., Davies, M., Hicks, R. C., Turner, J. B., &

Shaffer, D. (2009). School-based screening to identify at-risk students not already
known to school professionals: The Columbia suicide screen. American Journal of
Public Health, 99(2), 334–339. https://doi.org/10.2105/ajph.2007.127928

Scott v. Montgomery County Board of Education. (1997). No. 96-2455 U.S. App LEXIS
21258 (4th Cir.1997).

Shaffer, D., & Craft, L. (1999). Methods of adolescent suicide prevention. The Journal of
Clinical Psychiatry, 60, 70–74.

Sharaf, A. Y., Thompson, E. A., & Walsh, E. (2009). Protective effects of self-esteem and
family support on suicide risk behaviors among at-risk adolescents. Journal of Child
and Adolescent Psychiatric Nursing, 22(3), 160–168.

Sheftall, A. H., Asti, L., Horowitz, L. M., Felts, A., Fontanella, C. A., Campo, J. V., &
Bridge, J. A. (2016). Suicide in Elementary School-Aged Children and Early
Adolescents. PEDIATRICS, 138(4). https://doi.org/10.1542/peds.2016-0436.

Singer, J. B., Erbacher, T. A., & Rosen, P. (2018). School-based suicide prevention: A
framework for evidence-based practice. School Mental Health, 11(1), 54–71. https://
doi.org/10.1007/s12310-018-9245-8

Sources of Strength. (n.d.). Retrieved from https://sourcesofstrength.org/. Accessed 10
August 2019.

Spies, E., Ivey-Stephenson, A., VanderEnde, K., Lynch, S., Dean, D., & Gleason, B. (2014).
Epi Aid 2015-003: Undetermined risk factors for suicide among youth, ages 10–24
Fairfax County, VA, 2014. Retrieved from https://www.fairfaxcounty.gov/health/sit
es/health/files/assets/images/suicide-epi-aid-final-report . (Accessed 16 August
2019).

Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to
mitigate suicide risk. Cognit Behav Pract, 19, 256–264.

Stein, B. D., Katoaka, S. H., Hamilton, A. B., Schultz, D., Ryan, G., & Vona, P.,& Wond,
M.. (2010). School personnel perspectives on their school’s implementation of a
school-based suicide prevention program. The Journal of Behavioral Health Services &
Research, 37(3), 338–349. https://doi.org/10.1007/s11414-009-9174-2

Stern, J. (2013). June 24. In Apple’s Siri can be first call for users thinking of suicide.
Retrieved from http://abcnews.go.com/Technology/apples-siri-now-prevent-suic
ides/sotry?id=19438495. (Accessed 16 August 2019).

Stone, C. (2017). Ethics and the law (4th ed.). American School Counselor Association:
Alexandria, VA.

Stone, C., & Zirkel, P. A. (2012). Student suicide: Legal and ethical implications. ASCA
SchoolCounselor, 49(5), 24–30.

Substance Abuse and Mental Health Administration (SAMHSA). (2019). EBP Resource
Center. Retrieved from https://www.samhsa.gov/ebp-resource-center. (Accessed 19
August 2019).

Substance Abuse and Mental Health Services Administration (SAMHSA). (2012).
Preventing suicide: A toolkit for high schools. (HHS publication no. SMA-12-4669).
Rockville, MD: Author. Retrieved from https://store.samhsa.gov/product/Preventi
ng-Suicide-A-Toolkit-for-High-Schools/SMA12-4669. (Accessed 6 July 2019).

Suicide Prevention Lifeline. (2019). Home. Retrieved from https://suicidepreventionlife
line.org/. (Accessed 16 August 2019).

Suicide Prevention Resource Center. (2019). “Preventing suicide”: The role of high
school teachers. Retrieved from https://www.sprc.org/settings/schools. (Accessed
16 August 2019).

Suicide Prevention Resource Center. (2019c). Resources and programs. Retrieved from
http://www.sprc.org/resources-programs. (Accessed 16 August 2019).

Suicide Prevention Resource Center (SPRC). (2011). Suicide and bullying issue brief.
Retrieved From https://www.sprc.org/sites/default/files/migrate/library/Suicide
BullyingIssueBrief . (Accessed 27 July 2019).

Talbott, L. L., & Bartlett, M. L. (2012). Youth suicide postvention: Support for survivors
and recommendations for school personnel. Alabama Counseling Association Journal,
38(2), 104–119.

Thompson, E. A., & Eggert, L. L. (1999). Using the suicide risk screen to identify suicidal
adolescents among potential high school dropouts. Journal of the American Academy
of Child and Adolescent Psychiatry, 38, 1506–1514.

Tompkins, T. L., Witt, J., & Abraibesh, N. (2009). Does a gatekeeper suicide prevention
program work in a school setting? Evaluating training outcome and moderators of
effectiveness. Faculty Publications. Submitted Version. Submission 1. Retrieved from
https://digitalcommons.linfield.edu/psycfac_pubs/1.

U.S. Department of Health and Human Services. (2019, May 30). StopBullying.gov.
Retrieved from https://www.stopbullying.gov/cyberbullying/what-is-it/index.html.
(Accessed 1 August 2019).

Underwood, M. M., & Dunne-Maxim, K. (1997). Managing sudden traumatic loss in the
schools. University of Medicine and Dentistry of New Jersey. New Jersey Adolescent
Suicide Prevention Project, 1–134.

Vaillancourt, K. M., & Gibson, N. A. (2014). Model school district policy for suicide
prevention. Communique, 43(2), 24–27.

World Health Organization. (2014). Suicide prevention: a global imperative. Geneva,
Switzerland: WHO Press.

World Health Organization. (2019, September). Suicide. Retrieved from https://www.
who.int/news-room/fact-sheets/detail/suicide. (Accessed 6 July 2019).

Wyke v. Polk County School Board. (1997). U.S. Middle District Court Florida. No.91-1457-
CIV-T-24C.

Wyman, P. A., Brown, C. H., Lomurray, M., Schmeelk-Cone, K., Petrova, M., Yu, Q., …
Wang, W. (2010). An outcome evaluation of the sources of strength suicide
prevention program delivered by adolescent peer leaders in high schools. American
Journal of Public Health, 100(9), 1653–1661. https://doi.org/10.2105/
ajph.2009.190025

Yip, P. S. (2011). Towards evidence-based suicide prevention programs. Crisis: The
Journal of Crisis Intervention and Suicide Prevention, 32, 117–120 (Doi: 10.027/0227-
5910/a00010).

York, J., Lamis, D. A., Friedman, L., Berman, A. L., Joiner, T. E., Mcintosh, J. L., …
Pearson, J. (2012). A Systematic Review Process to Evaluate Suicide Prevention
Program: A Sample Case OF Community-based Programs. Journal of Community
Psychology, 41(1), 35–51. https://doi.org/10.1002/jcop.21509.

Zalsman, G., Hawton, K., Wasserman, D., Heeringen, K. V., Arensman, E.,
Sarchiapone, M., … Zohar, J. (2016). Suicide prevention strategies revisited: 10-year
systematic review. The Lancet Psychiatry, 3(7), 646–659. https://doi.org/10.1016/
s2215-0366(16)30030-x

S. Poland and S. Ferguson

https://doi.org/10.1002/jclp.20227

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0445

https://doi.org/10.2105/ajph.2007.127928

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0455

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0455

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0460

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0460

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0465

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0465

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0465

https://doi.org/10.1542/peds.2016-0436

https://doi.org/10.1007/s12310-018-9245-8

https://doi.org/10.1007/s12310-018-9245-8

Home

https://www.fairfaxcounty.gov/health/sites/health/files/assets/images/suicide-epi-aid-final-report

https://www.fairfaxcounty.gov/health/sites/health/files/assets/images/suicide-epi-aid-final-report

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0480

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0480

https://doi.org/10.1007/s11414-009-9174-2

http://abcnews.go.com/Technology/apples-siri-now-prevent-suicides/sotry?id=19438495

http://abcnews.go.com/Technology/apples-siri-now-prevent-suicides/sotry?id=19438495

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0495

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0495

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0500

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0500

https://www.samhsa.gov/ebp-resource-center

https://store.samhsa.gov/product/Preventing-Suicide-A-Toolkit-for-High-Schools/SMA12-4669

https://store.samhsa.gov/product/Preventing-Suicide-A-Toolkit-for-High-Schools/SMA12-4669

https://suicidepreventionlifeline.org/

https://suicidepreventionlifeline.org/

Schools

http://www.sprc.org/resources-programs

https://www.sprc.org/sites/default/files/migrate/library/SuicideBullyingIssueBrief

https://www.sprc.org/sites/default/files/migrate/library/SuicideBullyingIssueBrief

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0540

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0540

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0540

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0545

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0545

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0545

https://digitalcommons.linfield.edu/psycfac_pubs/1

https://www.stopbullying.gov/cyberbullying/what-is-it/index.html

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0560

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0560

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0560

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0565

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0565

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0570

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0570

https://www.who.int/news-room/fact-sheets/detail/suicide

https://www.who.int/news-room/fact-sheets/detail/suicide

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0580

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0580

https://doi.org/10.2105/ajph.2009.190025

https://doi.org/10.2105/ajph.2009.190025

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0590

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0590

http://refhub.elsevier.com/S1359-1789(21)00033-1/rf0590

https://doi.org/10.1002/jcop.21509

https://doi.org/10.1016/s2215-0366(16)30030-x

https://doi.org/10.1016/s2215-0366(16)30030-x

Youth suicide in the school context
1 Introduction
2 Youth suicide & seasonal variations
3 Risk factors in the school context
3.1 Social connectedness
3.2 Bullying
3.3 LGBTQ population
3.4 Ethnicity and culture
4 Legal implications of suicide in the school context
4.1 School liability: relevant legal cases
4.2 Legislation
5 Addressing youth suicide in the school context
5.1 Prevention
5.1.1 School suicide prevention programs
5.1.2 Enhancement of protective factors
5.1.3 Screening tools
5.1.4 Gatekeeper trainings
5.1.5 Curriculum based programs
5.1.6 Peer leadership
5.2 Intervention
5.2.1 Identification of at-risk youth
5.2.2 Risk assessment
5.2.3 Safety plan
5.2.4 Referrals
5.2.5 Re-entry
5.3 Postvention
6 Conclusion
7 Future directions and additional recommendations
Declaration of competing interest
References

Journal of Adolescent Health 70 (2022) 83e90

www.jahonline.org

Original article

Preventing Adolescent and Young Adult Suicide: Do States With
Greater Mental Health Treatment Capacity Have Lower Suicid

e

Rates?

Evan V. Goldstein, Ph.D., M.P.P. a, Laura C. Prater, Ph.D., M.P.H., M.H.A. b, and
Thomas M. Wickizer, Ph.D., M.P.H. c,*
a Division of Health System Innovation & Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
b Firearm Injury Prevention & Research Program, Harborview Medical Center, The University of Washington, Seattle, Washington
c Division of Health Services Management & Policy, The Ohio State University College of Public Health, Columbus, Ohio

Article history: Received December 30, 2020; Accepted June 17, 2021
Keywords: Gun violence; Suicide prevention; Adolescent suicide; Firearm suicide; Mental health

A B S T R A C T
IMPLICATIONS AND

Purpose: Youth suicide is increasing at a significant rate and is the second leading cause of death
for adolescents. There is an urgent public health need to address the youth suicide. The objective of
this study is to determine whether adolescents and young adults residing in states with greater
mental health treatment capacity exhibited lower suicide rates than states with less treatment
capacity.
Methods: We conducted a state-level analysis of mental health treatment capacity and suicide
outcomes for adolescents and young adults aged 10e24 spanning 2002e2017 using data from
Centers for Disease Control and Prevention, U.S. Bureau of Labor Statistics, Federal Bureau of
Investigation, and other sources. Multivariable linear fixed-effects regression models tested the
relationships among mental health treatment capacity and the total suicide, firearm suicide, and
nonfirearm suicide rates per 100,000 persons aged 10e24.
Results: We found a statistically significant inverse relationship between nonfirearm suicide and
mental health treatment capacity (p ¼ .015). On average, a 10% increase in a state’s mental health
workforce capacity was associated with a 1.35% relative reduction in the nonfirearm suicide rate
for persons aged 10e24. There was no significant relationship between mental health treatment
capacity and firearm suicide.
Conclusions: Greater mental health treatment appears to have a protective effect of modest
magnitude against nonfirearm suicide among adolescents and young adults. Our findings under-
score the importance of state-level efforts to improve mental health interventions and promote
mental health awareness. However, firearm regulations may provide greater protective effects
against this most lethal method of firearm suicide.

� 2021 Society for Adolescent Health and Medicine. All rights reserved.

Conflicts of interest: The authors have no conflicts of interest to disclose.
* Address correspondence to: Thomas M. Wickizer, Ph.D., M.P.H., Division of

Health Services Management & Policy, 1841 Neil Avenue, Columbus, Ohio 43210.
E-mail address: Wickizer.5@osu.edu (T.M. Wickizer).

1054-139X/� 2021 Society for Adolescent Health and Medicine. All rights reserved.
https://doi.org/10.1016/j.jadohealth.2021.06.020

CONTRIBUTION

The increase in youth sui-
cide requires the develop-
ment of more effective
interventions. This study
elucidates differences be-
tween nonfirearm and
firearm suicide to under-
stand different prevention
pathways. Mental health
treatment capacity is
important for nonfirearm
suicide prevention, while
firearm suicide prevention
may be best addressed
through firearm safety and
storage policies.

The U.S. is in the midst of a suicide epidemic taking the lives of
almost 50,000 Americans each year, with rates increasing in
every state from 1999 to 2016 [1]. Although suicide is the 10th
leading cause of death in the U.S. overall, it is the second leading

mailto:Wickizer.5@osu.edu

http://crossmark.crossref.org/dialog/?doi=10.1016/j.jadohealth.2021.06.020&domain=pdf

http://www.jahonline.org

https://doi.org/10.1016/j.jadohealth.2021.06.020

E.V. Goldstein et al. / Journal of Adolescent Health 70 (2022) 83e9084

cause of death among adolescents and young adults aged 10e24
[1,2]. Adolescent and young adult suicides are increasing at a
faster rate among young females compared to young males [3];
the firearm suicide rate among persons aged 14e24 increased by
54% since 2004 [4]. Among young adults aged 15e24, firearms,
suffocation/hanging, and poisoning are the most frequently used
suicide methods, respectively [5,6]. For persons younger than 15,
suffocation is the most frequently used method, followed by
firearms and poisoning [5]. For females aged 15%e24%, 45% of
suicides were attributed to a firearm injury, 28% to suffocation,
and 17% to poisoning [4]. Among males in the same age range,
53% of suicides were attributed to a firearm injury, 34% to suf-
focation, and 8% to poisoning [4]. Beyond individual mortality,
adolescent and young adult suicides have devastating social
consequences. Among high-income countries in 2014, adoles-
cent and young adult suicides accounted for an estimated loss of
406,730 years of potential life, 77% of which was attributable to
the U.S., the country with the most significant adolescent and
young adult suicide problem [7].

Researchers have found individual and household factors
associated with the risk of suicide among adolescents and
young adults. At the household level, family discord and
parental divorce are associated with increased risk of adoles-
cent suicide [3]. Access to firearms in the home is associated
with higher suicide rates [8], while greater social support and
public welfare expenditures appear to have a protective effect
[9]. Suicide rates are higher among male youth compared to
female youth, but suicidal ideation is more common among
female youth [10]. Male adolescents are also more likely than
females to use firearms in lethal suicide attempts [3]. White
adolescents have experienced higher suicide rates than
nonwhite adolescents [10], despite recent rising rates among
black youth [11]. Those who report same-sex sexual orientation
are also at greater risk for suicide [12]. Mental illness, especially
depression, has been associated with increased risk of adoles-
cent suicide [13]. Unfortunately, many suicides occur prior to
uncovering mental illness [14], making the suicide attempt the
first sign of distress.

With firearms accounting for so many U.S. suicide deaths,
many public policy efforts have focused on limiting access to
firearms through state-level regulatory restrictions. In general,
the academic literature demonstrates that stricter firearm laws,
such as policies aimed at regulating the supply of firearms
through background checks and mandatory waiting periods
before firearm issue, are associated with lower firearm fatality
rates [15,16]. Evidence predating the recent spike in adolescent
suicides demonstrated that child access prevention laws
reduced the rate of youth firearm suicide, and offered some
protective effect on firearm suicide for older members within
the household by limiting access to firearms [17]. Meaningful
firearm safety and control policies remain controversial and
difficult to enact even at the state level, despite states’ authority
to do so [18].

Beyond firearm regulation, much public attention has focused
on mental health treatment interventions to reduce youth sui-
cide. However, studies examining the effectiveness of these in-
terventions have been limited by power issues and small sample
sizes [19]. Substance abuse, interpersonal trauma, and mental
illness are known risk factors strongly linked to suicide attempts
among younger persons [13,20], but studies have shown promise
that primary care-based interventions, adequate outpatient care,
and access to ongoing mental healthcare may reduce youth

suicide [21,22]. Prior research also suggests the assessmen-
t/restriction of lethal means (i.e., firearms, medications) and
counseling by clinicians can reduce lethal suicide attempts
among adults and may improve opportunities to detect and treat
mental health conditions [23e26], but knowledge is more
limited for youth.

Mental healthcare shortages are well-documented across the
U.S., and many families find it difficult to access child or
adolescent mental health clinicians. Prior research [27] has
demonstrated an association between access to mental health-
care and reduced risk of suicide among persons of all ages,
including one recent study suggesting that living in a federally
designated mental health professional shortage area was corre-
lated with suicide death [28]. But less is known about the pro-
tective effects of mental health services for suicide among
adolescents and young adults. To our knowledge, there has not
been a comprehensive state-level analysis of mental health
treatment capacity and suicide rates among adolescents and
young adults.

The severity of youth suicide in the U.S., and the fact that
states have significant power to fund and design their mental
healthcare systems and enact firearm safety and control pol-
icies, prompted this state-level analysis examining the rela-
tionship between mental health treatment capacity and suicide.
Using data from 2002 to 2017, we examined whether states
with greater mental health treatment capacity have lower sui-
cide rates among adolescents (aged 10e19) and young adults
(aged 20e24), including both firearm and nonfirearm
suicide rates, compared with states having less treatment
capacity.

Methods

Data and study design

Our analysis merged data from multiple sources. The pri-
mary data sources were the Centers for Disease Control and
Prevention (CDC) Web-based Injury Statistics Query and
Reporting System (WISQARS) [4], an interactive database that
compiles information on fatal and nonfatal injury and violent
death in the U.S., and the Bureau of Labor Statistics (BLS)
Occupational Employment Statistics program, which produces
state-level, longitudinal employment data for nearly 800 occu-
pations. Additional data sources included the American Com-
munity Survey and Current Population Survey from IPUMS,
Kaiser Family Foundation State Health Facts database, Federal
Bureau of Investigation National Instant Criminal Background
Check System, U.S. Census Bureau Historical Poverty Tables, and
the Urban Institute State and Local Finance initiative.

We performed a state-level, time-series cross-sectional
analysis that took advantage of natural variation between
states and over time in our variables of interest. The state-year
was the unit of analysis, which is appropriate because states
have authority over the funding, design, and regulation of their
mental healthcare systems, as well as firearm safety and control
regulation. The final analytic file contained 186 observations
spanning four time periods: t ¼ 2002, 2007, 2012, and 2017.

Dependent variables

Our first dependent variable measured total intentional suicide
among adolescents (aged 10e19) and young adults (aged 20e24).

E.V. Goldstein et al. / Journal of Adolescent Health 70 (2022) 83e90 85

Our second and third dependent variables measured intentional
firearm and nonfirearm suicide, respectively, among adolescents
and young adults. Because the CDC recognizes suicide as a leading
cause of death among persons up to age 24 [1], we extracted crude
rates of annual suicides per 100,000 persons aged 10e24 from the
WISQARS Fatal Injury database for the three dependent variables
[4]. CDC data restrictions prevent the analysis of state-level suicide
rates involving less than 10 decedents. For this reason, for each
dependent variable, we combined the annual suicide rates for
each time period and its preceding year to develop an average rate
for the 2-year period. Following this process, we excluded state-
years from the analysis if the 2-year average suicide rate for any
dependent variable was still constructed from less than 10 de-
cedents. Excluded state-years were Connecticut (2012), Delaware
(2002, 2007), Hawaii (2002, 2007, 2017), Massachusetts (2012),
New Hampshire (2012), Rhode Island (all years), Vermont (2002,
2007), and Washington, DC (all years), representing 8.8% of all
possible state-years.

Independent variables

We had one independent variable: mental health treatment
capacity, measured as the annual mental health workforce size for
each state-year. To construct this measure, we extracted occupa-
tional (OCC) codes gathered from the Occupational Employment
Statistics database [29]. OCC codes 19-3031 (clinical, counseling,
and school psychologists), 21-1011 (substance abuse and

Table 1
Characteristics of the analytic sample: 2002e

2017

2002 2007

Total suicide rate per 100,000
(2-year averages)

8.5 (3.2) 8.6

Firearm suicide rate per
100,000 (2-year averages)

4.8 (2.4) 4.3

Nonfirearm suicide rate per
100,000 (2-year averages)

3.7 (1.3) 4.4

Mental health practitioners per
state, in 1,000s

10.6 (10.5) 12.4

Annual FBI firearm background
checks per state, in 100,000s

1.8 (1.5) 2.4

State population, in 100,000s 61.6 (64.6) 64.5
Race (% of population)
White 80.6% (10.1) 79.3%
Black 10.3% (9.7) 10.4%

Male (% of population) 49.0% (.8) 49.4%
Adult population with high

school diploma (%)
83.9% (4.1) 86.0%

Population reporting divorced
marital status (%)

7.9% (1.2) 8.0%

Per capita public expenditure
on parks, recreation, and
libraries

$175.3 (63.7) $185.2

State unemployment rate 5.2% (1.0) 4.6%
Population living below

poverty (%)
11.8% (3.2) 11.9%

Affordable Care Act Medicaid
expansion
Expansion not yet adopted 46 0% 46
State adopted expansion 0 100% 0
Observations 46 46

Authors’ analysis of data from the Web-based Injury Statistics Query and Reporting S
Population Survey from IPUMS CPS, Federal Bureau of Investigation (FBI) National Insta
initiative, U.S. Census Bureau, and Kaiser Family Foundation, 2002e2017. For each var
included in the analytic. Standard deviations are shown in parentheses for continuou
States could enact the Affordable Care Act Medicaid expansion beginning in 2014.

behavioral disorder counselors), 21-1014 (mental health coun-
selors), 21-1022 (medical and public health social workers), 29-
1066 (psychiatrists), 31-1013 (psychiatric aides), and 21-1023
(mental health and substance abuse social workers) were used to
construct the variable for each state-year in the analytic sample.

Covariates

We included covariates in our statistical models to adjust for
potential confounding factors. We used data from the Bureau of
Labor Statistics, U.S. Census Bureau, and American Community
Survey to adjust for state-level, temporal differences in unem-
ployment rate, poverty rate, and educational attainment, race,
and gender compositions. Our models adjusted for the total
population of each state across time to account for population-to
size-related variation in mental health workforce capacity. We
included data from the Current Population Survey to adjust for
the percentage of people in each state-year who reported
“divorced” for their marital status. To adjust for state-level dif-
ferences in the availability of social support resources, we used
data from the Urban Institute to construct a proxy measure of the
per capita public expenditure on parks, recreation, and libraries.
Because the Affordable Care Act Medicaid expansion may have
been associated with reductions in suicide by improving access
to healthcare [30], we included data from Kaiser Family Foun-
dation to adjust for whether states enacted the Affordable Care
Act Medicaid expansion. Finally, we included dummy variables

2012 2017

(3.8) 10.1 (3.6) 12.5 (5.1)

(2.3) 5.0 (2.6) 6.3 (3.4)

(1.8) 5.1 (1.9) 6.2 (2.3)

(13.1) 12.9 (14.5) 14.8 (15.8)

(2.6) 4.1 (4.5) 5.1 (7.3)

(67.6) 65.3 (72.0) 67.1 (73.9)

(10.4) 77.2% (13.0) 77.4% (10.7)
(9.6) 10.8% (9.9) 10.8% (9.7)
(.8) 49.4% (.8) 49.4% (.8)
(3.7) 87.9% (3.2) 89.5% (2.7)

(1.1) 8.5% (1.3) 8.6% (1.4)

(73.2) $175.4 (61.6) $179.4 (76.4)

(.9) 7.7% (1.6) 4.4% (.9)
(2.9) 14.5% (3.3) 12.1% (2.9)

0% 46 0% 19 39.6%
100% 0 100% 29 60.4%

46 48

ystem (WISQARS) Fatal Injury system, American Community Survey and Current
nt Criminal Background Check System, the Urban Institute State and Local Finance
iable, unadjusted average percentages or counts per year are shown for the states
s variables, and percentages are shown in parentheses for categorical variables.

Table 2
National suicide and crude death rates by year and age group: 2002e2017

Panel A: ages 10e19

Year Total suicide rate
per 100,000, ages 10e19

Firearm suicide rate
per 100,000, ages 10e19

Nonfirearm suicide rate
per 100,000, ages 10e19

Crude death rate per 100,000,
ages 10e19 (all causes)

2002 4.23 1.98 2.25 42.85
2007 3.87 1.59 2.28 39.00
2012 4.97 2.05 2.92 30.79
2017 7.18 3.09 4.09 33.65

Panel B: ages 20e24

Year Total suicide rate
per 100,000, ages 20e24

Firearm suicide rate
per 100,000, ages 20e24

Nonfirearm suicide rate
per 100,000, ages 20e24

Crude death rate per 100,000,
ages 20e24 (all causes)

2002 12.33 6.65 5.68 95.01
2007 12.62 6.03 6.59 98.13
2012 13.68 6.47 7.21 84.61
2017 17.04 8.38 8.66 95.57

National suicide rates were obtained from the CDC Web-based Injury Statistics Query and Reporting System (WISQARS) Fatal Injury Reports and crude death data were
obtained from the CDC WONDER database. Crude rates per 100,000 shown.
CDC ¼ Centers for Disease Control and Prevention.

E.V. Goldstein et al. / Journal of Adolescent Health 70 (2022) 83e9086

for each time period and each state to adjust for secular time
trends and unmeasured, time-invariant state-level policies and
characteristics.

Firearm availability is associated with suicide [31], but we
were unable to directly control for it. Consistent measures of
firearm availability are not available at the state level for all
states. As recommended elsewhere [32], we included the mea-
sure of annual federal firearm background checks from the
Federal Bureau of Investigation National Instant Criminal Back-
ground Check System as a proxy for gun ownership rates in the

Table 3
Highest and lowest total suicide rates per 100,000, by state and year: 2002e2017

2002

States with highest ratesa Total suicide rate per 100,000

Alaska 19.78
Wyoming 17.84
South Dakota 14.19
Idaho 12.56
Montana 12.33
New Mexico 11.64
Colorado 11.37
Arizona 10.96
Kansas 10.41
New Hampshire 10.39

2017
States with highest ratesa Total suicide rate per 100,000

Alaska 32.81
Montana 23.48
South Dakota 23.12
Wyoming 19.72
North Dakota 18.81
New Mexico 18.63
Colorado 16.99
Oklahoma 16.60
Utah 16.37
Idaho 15.99

Authors’ analysis of data from the CDC Web-based Injury Statistics Query and Reportin
average of crude firearm suicide rates for individuals aged 10e24 for each study time
observations were available in this analysis. For 2002 and 2017, we compared the av
highest and lowest suicide rates using bivariate t-tests and Mann-Whitney U-tests. p

a The states with the highest suicide rates had significantly greater federal firearm

statistical models for total and firearm suicide rates, but not in
the nonfirearm suicide rate model.

Analysis

We tested multivariable linear fixed-effects regression
models to examine the relationships between mental health
treatment capacity and suicide rates. Robust standard errors
were clustered at the state level to correct for problems poten-
tially caused by heteroscedasticity or serial correlation. To

States with lowest rates Total suicide rate per 100,000

New Jersey 3.58
Massachusetts 4.41
California 4.42
New York 4.71
Connecticut 4.84
South Carolina 6.1
Illinois 6.31
Florida 6.54
Maryland 6.69
Virginia 6.71

States with lowest rates Total suicide rate per 100,000

New Jersey 5.54
New York 5.90
Connecticut 6.50
Massachusetts 6.56
California 6.83
Maryland 6.87
Delaware 7.58
Florida 8.17
Illinois 8.23
North Carolina 9.56

g System (WISQARS) Fatal Injury Reports. The total suicide variable is the 2-year
period (and its preceding year), as described in the manuscript. Not all state-year
erage federal firearm background checks per capita between the states with the
< .01 using both tests. background checks per capita than the states with the lowest suicide rates.

Table 4
Estimating the effects of greater mental health treatment capacity on suicides per 100,000 persons aged 10e24

1 2 3

Outcome: total
suicides/100,000 persons

Outcome: firearm
suicides/100,000 persons

Outcome: nonfirearm
suicides/100,000 persons

Mental health practitioners per state, in 1,000s �.073 �.021 �.052*
.106 .521 .015

Annual FBI firearm background checks, in 100,000s .025 .022
.430 .221

State population, in 100,000s �.009 �.007 �.003
.746 .706 .984

Race (%)
White �.032 �.12 .083

.734 .136 .112
Black �.643* �.518þ �.131

.035 .077 .307
Male population (%) 1.192 .324 .866þ

.162 .541 .069
Adult population with high school diploma (%) �.453** �.14 �.299**

.005 .222 <.001 Population reporting divorced marital status (%) �.294 .047 �.335*

.127 .693 .018
Per capita public expenditure on parks, recreation, and libraries .005 .003 .002

.361 .432 .432
Unemployment rate (state) .086 .062 .01

.653 .546 .931
Population living below poverty (%) .074 .026 .043

.544 .786 .376
Affordable Care Act Medicaid expansion
Expansion not yet adopted Reference Reference Reference
State adopted the expansion �.459 �.432 �.066

.448 .342 .849
Year
2002 Reference Reference Reference
2007 .843 �.339 1.138**

.177 .348 <.001 2012 3.450** .583 2.847**

<.001 .268 <.001 2017 7.272** 2.505** 4.666**

<.001 .004 <.001 Constant .322 15.327 �15.783

.933 .543 .503
Observations 186 186 186
Adjusted R2 .69 .52 .69

p values are shown in italics below each coefficient. State fixed-effects (FE) coefficients not shown. Authors’ analysis of data from the Web-based Injury Statistics Query
and Reporting System (WISQARS) Fatal Injury system, American Community Survey from IPUMS USA, Current Population Survey from IPUMS CPS, Federal Bureau of
Investigation (FBI) National Instant Criminal Background Check System, U.S. Census Bureau, Kaiser Family Foundation, and the Urban Institute State and Local Finance
initiative, 2002e2017.
FBI ¼ Federal Bureau of Investigation.
þp < .10; *p < .05; **p < .01.

E.V. Goldstein et al. / Journal of Adolescent Health 70 (2022) 83e90 87

facilitate the interpretation of our findings, we generated
regression-adjusted annual probabilities of suicide for each study
year, while keeping other covariates at their observed values (i.e.,
estimating average marginal effects). We established an a priori
two-sided statistical significance level of .05. Analyses were
conducted using Stata version 15.1 (College Station, TX). Insti-
tutional Review Board approval was not necessary for this state-
level study.

Results

On average, the total suicide rate among individuals aged 10e
24 in the states included in this analysis increased 47.1% from
2002 to 2017 (Table 1). The average firearm and nonfirearm
suicide rates grew by 31.3% and 67.6%, respectively, over the same
time period. Mental health treatment capacity, as measured by
our mental health workforce variable, grew by 28.6% on a per

capita basis. Table 2 shows that the total suicide rate from 2002
to 2017 grew more among adolescents aged 10e19 (69.8% in-
crease) than young adults aged 20e24 (38.2% increase). From
2002 to 2017, the firearm and nonfirearm suicide rates increased
by 56.1% and 81.8%, respectively, among 10- to 19-year olds and
by 26.2% and 52.5%, respectively, among 20- to 24-year olds. In
2002, 9.9% of all deaths among individuals aged 10e19 were
suicides. By 2017, approximately 21.3% of all deaths among per-
sons aged 10e19 and 17.8% of all deaths among persons aged 20e
24 were suicides.

Table 3 demonstrates the between-state variation in total
suicide rates over the study period, listing states with the highest
and lowest total suicide rates at the beginning and end of our
study. Among the states included in our analysis, Alaska,
Wyoming, Montana, and South Dakota experienced the highest
adolescent and young adult suicide rates, on average, from 2002
to 2017, and the rates increased in all four states from 2002 to

0.0000%

0.0020%

0.0040%

0.0060%

0.0080%

0.0100%

0.0120%

0.0140%

0.0160%

2002 2007 2012 2017

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id

e

Any suicide Firearm suicide Non-firearm suicide

Figure 1. Adjusted probability of suicide, by method of suicide: 2002e2017. This figure shows the regression-adjusted probability of any suicide, firearm suicide, and
nonfirearm suicide for the years 2002, 2007, 2012, and 2017. These probabilities were calculated for the entire estimation sample for each year, keeping all other
covariates at their observed values (i.e., using average marginal effects).

E.V. Goldstein et al. / Journal of Adolescent Health 70 (2022) 83e9088

2017. In contrast, New Jersey, New York, Massachusetts, Califor-
nia, and Connecticut were consistently ranked among the states
experiencing the lowest suicide rates from 2002 to 2017,
although the suicide rates also increased in these states from
2002 to 2017. Bivariate analyses comparing the states with the
lowest and highest suicide rates in 2017 also showed that the 10
states with the highest suicide rates likely had significantly
greater firearm availability, as measured by the annual federal
firearm background checks per capita. In 2017, the states with the
highest suicide rates had an average of .096 federal firearm
background checks per capita, compared to an average of .047
federal firearm background checks per capita in the states with
the lowest suicide rates (p < .001).

Table 4 shows the results of our multivariable analysis. We
found an inverse relationship between the state-level mental
health workforce capacity and the total suicide rate (b ¼ �.073,
p ¼ .106). Although the finding was not statistically significant
at the .05 significance level, the result implies that, on average,
a 10% relative increase in the mental health workforce capacity
in a state would be independently associated with a
.923% relative reduction in the total suicide rate for persons
aged 10e24 (p ¼ .106). We found a statistically significant,
inverse relationship between the mental health workforce
capacity and the nonfirearm suicide rate (b¼ �.052, p ¼ .015).
This result implies that, on average, a 10% relative increase in
the mental health workforce capacity in a state would be
independently associated with a 1.35% relative reduction in the
nonfirearm suicide rate for persons aged 10e24 (p ¼ .015).
There was no statistically significant relationship between
state-level mental health workforce capacity and the firearm
suicide rate.

Figure 1 shows the adjusted probability of suicide in a given
year for persons aged 10e24 over the study period, as
observed in our estimation sample. The adjusted probability of
a person aged 10e24 dying by any method of suicide in a year
increased from .0071% in 2002% to .0143% in 2017da 101.4%
relative increase. Although the adjusted probability of firearm
suicide increased only modestly over time, the adjusted
probability of a persons aged 10e24 dying by nonfirearm

suicide in a year increased considerably from .0027% in 2002 to
.0074% in 2017.

There was a negative relationship between the percentage of
a state’s population reporting divorced marital status and the
nonfirearm suicide rate (Table 4; p ¼ .018). The percentage of a
state’s adult population with a high school diploma was also
inversely related with the total (p ¼ .005) and nonfirearm suicide
rates (p < .001).

Discussion

Our findings suggest that greater mental health treatment
capacity at the state level has a statistically significant protective
effect of modest magnitude against nonfirearm suicide among
adolescents and young adults aged 10e24, though no protective
effect against firearm suicide. Our findings have relevance for
policy considerations and for the development of interventions
aimed at reducing youth suicide incidence.

Substance abuse, interpersonal trauma, and mental illness are
strongly linked to suicide attempts among younger persons
[13,20,33,34]. The high case-fatality rate of firearm suicide [35]
may dampen the ability of mental health practitioners to diag-
nosis a mental illness or successfully intervene when necessary,
yet only 7% of those who make a nonfatal suicide attempt go on
to die from a future attempt [36]. For younger persons who will
attemptdor have attempteddsuicide using less lethal means,
risk factors for suicide may be more sensitive to greater mental
illness detection efforts, and improving access to mental health
treatment when needed may help prevent nonfirearm suicide
attempts.

Previous studies have shown promise that adequate outpa-
tient care, primary care-based interventions such as improved
screening for suicide risk factors and access to cognitive behav-
ioral therapy, and access to mental healthcare after presenting in
an emergency department following a suicide attempt may
reduce youth suicide [21,22,34,37,38]. Lethal means assessment/
restriction has also shown promise among youth with programs
such as SafetyCheck [39]. As index suicide attempts (IA) have
been shown to be more lethal for youth and young adults across

E.V. Goldstein et al. / Journal of Adolescent Health 70 (2022) 83e90 89

all methods [3,40], prevention efforts should start prior to an IA
and consider an approach that addresses both identifying serious
suicidal ideation and restricting access to lethal means.

Our findings may therefore support state-level efforts to
improve mental health treatment capacity and promote mental
health awareness. For example, states can enhance school-based
mental health services capacity, which has been shown to help
reduce depressive episodes and suicide risk among adolescents
[41]. Schools often access funds for school-based mental health
and substance abuse services through state sources, including
Medicaid benefits (e.g., Early and Periodic Screening, Diagnostic
and Treatment) and Medicaid waiver programs; through the
state-level allocation of funds from the Every Student Succeeds
Act (2015); and through state applications to the federal School-
Based Mental Health Services Grant Program.

States can also raise awareness about youth mental health
issues by promoting mental health literacy programs like
Mental Health First Aid (MHFA), which provides training on
common mental health conditions and how to refer youth for
care. Since 2015, 20 states have prioritized MHFA by enacting
policies to fund training, require certification for public sector
employees, and establish state-wide mental health training
requirements. California and Pennsylvania led the U.S. in
funding MHFA trainings in 2014, and Texas allocated $5 million
to train youth educators in MHFA [42]. Prior evaluations have
shown that the MHFA program may help reduce unmet need
for behavioral healthcare in rural areas [43]. The Youth MHFA
program has also helped participants (e.g., neighbors and
teachers) become more aware of mental health resources,
accepting of young persons with mental health conditions, and
willing to help in times of need [44]. States can also fund
mental health awareness campaigns using social media, such
as California’s Each Mind Matters Campaign, which have
improved positive beliefs about the possibility of recovery
from mental illness [45].

Our findings do not suggest that greater mental health
treatment capacity will systematically reduce firearm suicide
among adolescents and young adults. The risk of firearm suicide
may be less about diagnosing a mental illness and more about
the potential impulsivity of those who attempt suicide with
firearms [46,47] and the lethality of firearm suicide [48], which
together often prevent intervention from health professionals.
Prior research suggests that the adoption of stricter firearm
safety and control policies will likely yield greater protective
effects against firearm suicide [27]. Measures often discussed by
policymakers include mandatory waiting periods before firearm
issue and child access prevention laws, which are shown to
reduce youth firearm suicide [49,50]. However, policy interven-
tion to improve firearm control is often overwhelmed by pre-
vailing political forces, even though large majorities of
Americansdincluding both firearm owners and nonfirearm
ownersdsupport a range of regulatory measures to strengthen
firearm safety laws [51]. As described in Table 3, states with the
highest suicide rates had significantly greater federal firearm
background checks per capita, a proxy for gun ownership. Yet
evidence-based policies shown to reduce firearm suicide appear
to be absent in states with the highest suicide rates [17].

Our findings also suggest that higher rates of high school
completion were significantly associated with lower suicide
rates, consistent with other studies [52]. These findings may
support the idea that investments in education are important for
preventing suicide among adolescents and young adults. At the

individual level, suicide risk tends to increase with poor school
performance and dropout [53,54], though the link between
educational attainment and suicide is less certain. However,
when considering education as a measure of aggregate human
capital in the context of other related socioeconomic factors,
education may have a protective effect [55]. Improving funding
for K-12 public education in states with high suicide rates,
encouraging other investments in human capital development,
and providing opportunities for family counseling as part of
schooling [56] should be explored as population-level suicide
prevention strategies.

Limitations

This study has several limitations. First, we used a non-
randomized, retrospective study design, which imposes limits on
causal inference. Second, because we conducted a state-level
analysis, readers should refrain from making inferences about
individual behavior. Third, without more granular data (e.g., in-
dividual or county level), we could not perform a multivariable
analysis within each state longitudinally. Fourth, as described
earlier, CDC data restrictions prevented us from constructing our
dependent variables for all state-years. For this reason, the
generalizability of our results is potentially limited to the states
included in our analytic sample. Fifth, for the same reasons of
insufficient data and data restrictions, we could not conduct
subgroup analyses by sex or age (e.g., only persons <18 years). It would be important to explore how sex may have moderated our findings in future studies using different data. Sixth, due to Bu- reau of Labor Statistics data limitations, we could not identify and include other types of providersdsuch as mental health nurse practitioners or adolescent behavioral health physiciansdin our measure of mental health treatment capacity. Nonmental health practitioners may provide mental health screening or other services to adolescents and young adults. This limitation also prevented us from identifying and constructing a measure of only school-based mental healthcare providers. Finally, we could not directly control for firearm availability, an important pre- dictor of youth suicide. Consistent with other studies we included a proxy measure of the annual number of federal firearm background checks performed in each state [32]. How- ever, federal background checks do not capture private firearm purchases, hence this variable is an incomplete proxy measure for firearm availability.

Conclusions

Increasing the mental health workforce and the availability
of mental health services at the state level appears to be
important for nonfirearm suicide prevention. In contrast,
mental health treatment capacity appears to have little effect on
the more lethal method of firearm suicide. Mental health dis-
orders may go undiagnosed among youth who die by all
methods of suicide. However, given that suicide can be an
impulsive act [46] and suicide attempts using a firearm are
nearly always fatal, preventing firearm suicide directly may be
best addressed through the enactment of evidence-based
firearm safety and storage regulations by state-level policy-
makers. Population-level investments in human capital devel-
opment may also promote future well-being and protect young
persons from suicide.

E.V. Goldstein et al. / Journal of Adolescent Health 70 (2022) 83e9090

Funding Sources

Dr. Prater receives research funding support from the State of
Washington.

References

[1] Centers for Disease Control and Prevention. Suicide & self-inflicted injury.
2017. Available at: https://www.cdc.gov/nchs/fastats/suicide.htm.
Accessed December 1, 2019.

[2] Heron M. Deaths: Leading causes for 2016. Natl Vital Stat Rep 2018;67:1e
77.

[3] Ruch DA, Sheftall AH, Schlagbaum P, et al. Trends in suicide among youth
aged 10 to 19 years in the United States, 1975 to 2016. JAMA Netw Open
2019;2:e193886.

[4] Centers for Disease Control and Prevention. Web-based injury statistics
query and reporting system (WISQARS) [Internet]. Available at: https://
www.cdc.gov/injury/wisqars/index.html. Accessed December 15, 2020.

[5] Choi NG, DiNitto DM, Marti CN. Youth firearm suicide: Precipitating/risk
factors and gun access. Child Youth Serv Rev 2017;83:9e16.

[6] Centers for Disease Control and Preventation. 10 leading causes of death by
age group, United States e 2017. 2017. Available at: https://www.cdc.gov/
nchs/fastats/leading-causes-of-death.htm. Accessed December 1, 2019.

[7] Doran CM, Kinchin I. Economic and epidemiological impact of youth sui-
cide in countries with the highest human development index. PLoS One
2020;15:e0232940.

[8] Knopov A, Sherman RJ, Raifman JR, et al. Household gun ownership and youth
suicide rates at the state level, 2005e2015. Am J Prev Med 2019;56:335e42.

[9] Minoiu C, Andrés AR. The effect of public spending on suicide: Evidence
from U.S. state data. J Socio Econ 2008;37:237e61.

[10] Cash SJ, Bridge JA. Epidemiology of youth suicide and suicidal behavior.
Curr Opin Pediatr 2009;21:613e9.

[11] Lindsey MA, Sheftall AH, Xiao Y, Joe S. Trends of suicidal behaviors among
high school students in the United States: 1991-2017. Pediatrics 2019;144:
e20191187.

[12] Russell ST, Fish JN. Mental health in lesbian, gay, bisexual, and transgender
(LGBT) youth. Annu Rev Clin Psychol 2016;12:465e87.

[13] Nanayakkara S, Misch D, Chang L, Henry D. Depression and exposure to
suicide predict suicide attempt. Depress Anxiety 2013;30:991e6.

[14] Stone DM, Simon TR, Fowler KA, et al. Trends in state suicide rates 1999-
2016. Morb Mortal Wkly Rep 2018;67:617e24.

[15] Fleegler EW, Lee LK, Monuteaux MC, et al. Firearm legislation and firearm-
related fatalities in the United States. JAMA Intern Med 2013;173:732e40.

[16] Santaella-Tenorio J, Cerdá M, Villaveces A, Galea S. What do we know
about the association between firearm legislation and firearm-related in-
juries? Epidemiol Rev 2016;38:140e57.

[17] Smart R, Morral A, Smucker S, et al. The science of gun policy. 2nd ed. Santa
Monica: RAND Corporation; 2020.

[18] Goldstein EV, Prater LC, Bose-Brill S, Wickizer TM. The firearm suicide
crisis: Physicians can make a difference. Ann Fam Med 2020;18:265e8.

[19] Robinson J, Bailey E, Witt K, et al. What works in youth suicide prevention? A
systematic review and meta-analysis. EClinicalMedicine 2018;4-5:52e91.

[20] Joshi K, Billick SB. Biopsychosocial causes of suicide and suicide prevention
outcome studies in juvenile detention facilities: A review. Psychiatr Q
2017;88:141e53.

[21] Asarnow JR, Baraff LJ, Berk M, et al. An emergency department intervention
for linking pediatric suicidal patients to follow-up mental health treat-
ment. Psychiatr Serv 2011;62:1303e9.

[22] Campo JV. Youth suicide prevention: Does access to care matter? Curr Opin
Pediatr 2009;21:628e34.

[23] Boggs JM, Beck A, Ritzwoller DP, et al. A quasi-experimental analysis of
lethal means assessment and risk for subsequent suicide attempts and
deaths. J Gen Intern Med 2020;35:1709e14.

[24] Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: A sys-
tematic review. J Am Med Assoc 2005;294:2064e74.

[25] Yip PSF, Caine E, Yousuf S, et al. Means restriction for suicide prevention.
Lancet 2012;379:2393e9.

[26] Daigle MS. Suicide prevention through means restriction: Assessing the
risk of substitution. A critical review and synthesis. Accid Anal Prev 2005;
37:625e32.

[27] Goldstein EV, Prater LC, Wickizer TM. Behavioral health care and firearm
suicide: Do states with greater treatment capacity have lower suicide
rates? Health Aff (Millwood) 2019;38:1711e8.

[28] Johnson KF, Brookover DL. Counselors’ role in decreasing suicide in mental
health professional shortage areas in the United States. J Ment Health
Couns 2020;42:170e86.

[29] Bureau of Labor Statistics. Occupational Employment Statistics [Internet].
Available at: https://www.bls.gov/oes/. Accessed December 15, 2020.

[30] Borgschulte M, Vogler J. Did the ACA Medicaid expansion save lives?
J Health Econ 2020;72:102333.

[31] Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and
risk for suicide and homicide victimization among household members: A
systematic review and meta-analysis. Ann Intern Med 2014;160:
101e10.

[32] Lang M. Firearm background checks and suicide. Econ J 2013;123:1085e
99.

[33] Nock MK, Green JG, Hwang I, et al. Prevalence, correlates, and treatment of
lifetime suicidal behavior among adolescents. JAMA Psychiatry 2013;70:
300.

[34] Cavanagh JTO, Carson AJ, Sharpe M, Lawrie SM. Psychological autopsy
studies of suicide: A systematic review. Psychol Med 2003;33:395e405.

[35] Spicer RS, Miller TR. Suicide acts in 8 states: Incidence and case fatality
rates by demographics and method. Am J Public Health 2000;90:1885e
91.

[36] Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm.
Br J Psychiatry 2002;181:193e9.

[37] Bridge JA, Horowitz LM, Fontanella CA, et al. Prioritizing research to reduce
youth suicide and suicidal behavior. Am J Prev Med 2014;47(3 Suppl 2):
S229e34.

[38] Fontanella CA, Warner LA, Steelesmith DL, et al. Association of timely
outpatient mental health services for youths after psychiatric hospi-
talization with risk of death by suicide. JAMA Netw Open 2020;3:
e2012887.

[39] Wolk CB, Jager-Hyman S, Marcus SC, et al. Developing implementation
strategies for firearm safety promotion in paediatric primary care for
suicide prevention in two large US health systems: A study protocol
for a mixed-methods implementation study. BMJ Open 2017;7:
e014407.

[40] McKean AJS, Pabbati CP, Geske JR, Bostwick JM. Rethinking lethality in
youth suicide attempts: First suicide attempt outcomes in youth ages 10 to
24. J Am Acad Child Adolesc Psychiatry 2018;57:786e91.

[41] Paschall MJ, Bersamin M. School-based health centers, depression, and
suicide risk among adolescents. Am J Prev Med 2018;54:44e50.

[42] National Council for Behavioral Health. Mental health first aid policy
handbook. 2019. Available at: https://www.thenationalcouncil.org/wp-
content/uploads/2019/03/031219_NCBH_MHFAPolicyHandbook_v6 ?
daf¼375ateTbd56. Accessed December 15, 2020.

[43] Talbot JA, Ziller EC, Szlosek DA. Mental health first aid in rural com-
munities: Appropriateness and outcomes. J Rural Health 2017;33:82e
91.

[44] Noltemeyer A, Huang H, Meehan C, et al. Youth mental health first aid:
Initial outcomes of a statewide rollout in Ohio. J Appl Sch Psychol 2020;36:
1e19.

[45] Collins RL, Wong EC, Breslau J, et al. Social marketing of mental health
treatment: California’s mental illness stigma reduction campaign. Am J
Public Health 2019;109:S228e35.

[46] Simon TR, Swann AC, Powell KE, et al. Characteristics of impulsive suicide
attempts and attempters. Suicide Life Threat Behav 2002;32:49e59.

[47] Peterson LG, Peterson M, O’Shanick GJ, Swann A. Self-inflicted gunshot
wounds: Lethality of method versus intent. Am J Psychiatry 1985;142:
228e31.

[48] Conner A, Azrael D, Miller M. Suicide case-fatality rates in the United
States, 2007 to 2014 a nationwide population-based study. Ann Intern Med
2019;171:885e95.

[49] Webster DW, Vernick JS, Zeoli AM, Manganello JA. Association between
youth-focused firearm laws and youth suicides. J Am Med Assoc 2004;292:
594e601.

[50] Gius M. The impact of minimum age and child access prevention laws on
firearm-related youth suicides and unintentional deaths. Soc Sci J 2015;52:
168e75.

[51] Barry CL, Stone EM, Crifasi CK, et al. Trends in public opinion on us gun
laws: Majorities of gun owners and nonegun owners support a range of
measures. Health Aff (Millwood) 2019;38:1727e34.

[52] Fontanella CA, Saman DM, Campo JV, et al. Mapping suicide mortality in
Ohio: A spatial epidemiological analysis of suicide clusters and area level
correlates. Prev Med 2018;106:177e84.

[53] Kosidou K, Dalman C, Fredlund P, et al. School performance and the risk of
suicide attempts in young adults: A longitudinal population-based study.
Psychol Med 2014;44:1235e43.

[54] Daniel SS, Walsh AK, Goldston DB, et al. Suicidality, school dropout, and
reading problems among adolescents. J Learn Disabil 2006;39:507e14.

[55] Kroll-Desrosiers AR, Crawford SL, Moore Simas TA, et al. Improving preg-
nancy outcomes through maternity care coordination: A systematic re-
view. Womens Health Issues 2016;26:87e99.

[56] Stormshak EA, Connell AM, Véronneau MH, et al. An ecological approach
to promoting early adolescent mental health and social adaptation:
Family-centered intervention in public middle schools. Child Dev 2011;82:
209e25.

https://www.cdc.gov/nchs/fastats/suicide.htm

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref2

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref2

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref3

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref3

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref3

https://www.cdc.gov/injury/wisqars/index.html

https://www.cdc.gov/injury/wisqars/index.html

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref5

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref5

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref5

https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref7

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref7

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref7

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref8

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref8

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref8

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref8

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref9

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref9

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref9

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref10

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref10

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref10

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref11

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref11

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref11

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref12

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref12

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref12

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref13

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref13

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref13

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http://refhub.elsevier.com/S1054-139X(21)00333-5/sref14

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref14

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref15

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref15

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref15

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref16

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref16

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref16

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref16

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref17

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref17

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref18

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref18

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref18

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref19

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref19

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref19

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref19

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http://refhub.elsevier.com/S1054-139X(21)00333-5/sref20

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref20

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref20

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref21

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref21

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref21

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref21

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref22

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref22

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref22

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref23

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref23

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref23

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref23

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref24

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref24

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref24

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http://refhub.elsevier.com/S1054-139X(21)00333-5/sref25

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http://refhub.elsevier.com/S1054-139X(21)00333-5/sref26

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref26

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref26

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref26

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http://refhub.elsevier.com/S1054-139X(21)00333-5/sref28

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref28

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref28

https://www.bls.gov/oes/

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref30

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref30

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref31

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref31

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref31

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref31

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref31

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref32

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref32

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref33

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref33

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref33

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref34

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref34

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref34

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref35

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref35

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref35

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref36

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref36

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref36

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref37

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref37

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref37

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref37

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref38

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref38

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref38

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref38

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref39

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref39

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref39

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref39

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref39

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref40

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref40

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref40

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref40

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref41

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref41

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref41

https://www.thenationalcouncil.org/wp-content/uploads/2019/03/031219_NCBH_MHFAPolicyHandbook_v6 ?daf=375ateTbd56

https://www.thenationalcouncil.org/wp-content/uploads/2019/03/031219_NCBH_MHFAPolicyHandbook_v6 ?daf=375ateTbd56

https://www.thenationalcouncil.org/wp-content/uploads/2019/03/031219_NCBH_MHFAPolicyHandbook_v6 ?daf=375ateTbd56

https://www.thenationalcouncil.org/wp-content/uploads/2019/03/031219_NCBH_MHFAPolicyHandbook_v6 ?daf=375ateTbd56

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref43

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref43

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref43

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref44

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref44

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref44

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref44

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref45

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref45

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref45

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref45

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http://refhub.elsevier.com/S1054-139X(21)00333-5/sref46

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref46

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref47

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref47

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref47

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref47

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref48

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref48

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref48

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref48

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref49

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref49

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref49

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref49

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref50

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref50

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref50

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref50

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http://refhub.elsevier.com/S1054-139X(21)00333-5/sref52

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref52

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref52

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref53

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref53

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref53

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref53

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref54

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref54

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref54

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref55

http://refhub.elsevier.com/S1054-139X(21)00333-5/sref55

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• Preventing Adolescent and Young Adult Suicide: Do States With Greater Mental Health Treatment Capacity Have Lower Suicide R …

Methods
Data and study design
Dependent variables
Independent variables
Covariates
Analysis
Results
Discussion
Limitations
Conclusions
Funding Sources
References