Adolescent help-seeking and the Yellow Ribbon Suicide Prevention Program: an evaluation

Suicide Prevention Takes a Nation: Collaborative Approaches to Universalize Suicide Prevention

Suicide is a complex public health issue impacting many children and adolescents-and their families-each year, and it requires a complex public health solution. Local, state, and national collaboratives that leverage evidence-based strategies, foster community engagement, and prioritize equity are necessary to holistically address this issue. Here, the authors discuss the necessary steps for fostering inclusive community partnerships and outline the rationale for partnering with schools, youth groups, faith organizations, parent-teacher organizations, clinical settings, and professional organizations, as well as collaborating with the juvenile justice and child welfare systems and working together to foster suicide prevention policy.

The Culturally Infused Curricular Framework (CICF) for Suicide Prevention Trainings

Although suicide prevention trainings (SPT) have been a standard approach for suicide prevention for years, researchers have noted a need for more clarity in the definition of core competencies for SPTs, particularly in the areas of diversity and culture. Recent research has identified key theoretically- and empirically-based cultural considerations for suicide prevention, but translation is needed to infuse these standards for culture-related competencies into SPTs. This study performed a systematic literature review with a thematic synthesis analytic approach to establish a set of curricular guidelines for infusion of cultural considerations into SPTs. The study also examined the extent to which existing community trainings already incorporate cultural components. Based on the thematic synthesis of 39 SPT studies from 2010 to 2020 and seminal reviews of the cultural and suicide literature, results identified three overarching categories of cultural curricular competencies (suicide knowledge and awareness, suicide intervention skills, and curriculum delivery) and 14 core cultural curricular subthemes for community trainings (e.g., culturally informed risk factors and warning signs, systemic inequities, etc.). These three categories with 14 core cultural curricular competencies comprise the Culturally Infused Curricular Framework (CICF) for Suicide Prevention Trainings. The majority of trainings (62%) included five or less out of 14 total possible core cultural competencies in their training curricula, pointing to insufficient integration of cultural components in existing community trainings. This study's research-based guideline establishes a culture-inclusive framework to strengthen content and approach of community trainings and suicide prevention across cultural groups.

Perceptions of rural high school teachers - on the frontline of youth suicide

OBJECTIVE

This study aimed to investigate the perceptions and beliefs of rural high school teachers about student suicide completion in their school and their perceived self-efficacy in identification of suicidality in students (suicidal ideation, plans and behaviours).

DESIGN

A cross-sectional survey methodology.

SETTING

Gippsland and the Loddon Mallee regions of Victoria, Australia.

PARTICIPANTS

Rural high school teachers.

OUTCOME MEASURE

A survey that aimed to obtain participants' perceptions and self-reports about students who had died by suicide in their school within the last 5 years, their perceived self-efficacy in identifying suicidal students and barriers to helping students at risk.

RESULTS

Two hundred and seventy-seven rural high school teachers participated and 86% reported that a student from their school had died by suicide within the last 5 years. Sixty-five per cent believed that more than one student had died by suicide and 70% perceived they were currently aware of students experiencing suicidality in their class. Receiving professional development about suicide and obtaining help from mental health clinicians predicted perceived self-efficacy in identification of suicidality in students. Participants perceived the barriers to help students at risk included insufficient numbers of school-based mental health professionals and community mental health services.

CONCLUSIONS

Many rural high school teachers perceive they are at the front line of the youth suicide crisis due to unmet service need in youth mental ill health. Increased access to effective services immediately after teachers become aware of suicidality may assist in reducing youth suicide in rural areas.

Wer profitiert von einem Workshop zur Suizidprävention an Schulen?

Zusammenfassung. Um die Suizidprävention an Schulen zu verbessern, wurden psychoedukative Workshops für Schüler_innen implementiert und angeboten. N=200 Schüler_innen der 8.–10. Jahrgangsstufe wurden zufällig einer Experimental- oder Kontrollgruppe zugewiesen. Vor und nach dem Training sowie nach drei Monaten wurden sie zu ihrem hilfesuchenden und hilfegebendem Verhalten sowie ihrer depressiven Symptomatik befragt. Die Ergebnisse weisen darauf hin, dass besonders die als stärker suizidgefährdet eingestuften Jugendlichen von dem Training durch eine Abnahme ihrer depressiven Symptomatik profitierten. Schüler_innen der Kontrollgruppe verbesserten sich demgegenüber nicht signifikant in ihrer depressiven Symptomatik. Für das hilfesuchende ebenso wie das hilfegebende Verhalten zeigten sich positive Trends, die jedoch nicht statistisch signifikant wurden. Diese Ergebnisse zeigen – wenn auch mit Limitationen aufgrund von Ausfällen durch die Coronapandemie 2020 und durch ein restriktives Vor-Screening – die Wirksamkeit einer aufwändigen außerschulischen Suizidprävention auf Befinden und Verhalten.

Systematic Review: The State of Research Into Youth Helplines

OBJECTIVE

Helplines are generally a population-level resource for providing free, timely, easy-to-access, and anonymous counseling and/or information. Helplines have been developed and widely implemented for specific use by young people. The current study aimed to systematically review the literature to determine the status of research into the use of helplines among young people.

METHOD

Following the PRISMA checklist, 5 electronic databases were searched using relevant terms for literature published until May 2020. The extracted studies were summarized with the intention of identifying key themes that highlighted common findings, key implications, and important gaps in understanding.

RESULTS

A total of 52 articles fitting study inclusion criteria were identified. Most studies were quantitative papers from the United States and Australia. The types of helpline interactions studied were a mixture of telephone-based and SMS/text-based interactions. Three major themes were identified: awareness of and engagement with helpline services, nature of problems faced by young people, and service-related factors. Subthemes were use and awareness, barriers to help seeking, psychosocial problems, suicidality, telephone- versus text-based interactions, counselor-caller interaction, and provision of services to historically and systemically marginalized groups.

CONCLUSION

It appears that helplines may provide a beneficial service to youths, and that myriad psychosocial concerns provide the basis for calling. The literature is limited by a lack of controlled trials, on one hand, and complex methodological/ethical barriers preventing such trials, on the other hand. However, more research is needed before conclusions regarding effectiveness in youths can be made, particularly for services provided to systemically marginalized groups and using online text-based approaches.

The Role of Technology and the Continuum of Care for Youth Suicidality: Systematic Review

Background

Youth suicide is a global public health issue, and using technology is one strategy to increase participation in preventive interventions. However, there is minimal knowledge on how technology-enhanced interventions for youth correspond to the stages of care, from illness or risk recognition to treatment follow-up.

Objective

This systematic review aims to examine the efficacy of technology-enhanced youth suicide prevention and interventions across the continuum of care.

Methods

Four electronic databases were searched up to spring 2019 for youth suicide preventive interventions that used technology. The review was not restricted by study design and eligible studies could report outcomes on suicidality or related behaviors, such as formal treatment initiation. An adapted version of the Methodological Quality Ratings Scale was used to assess study quality.

Results

A total of 26 studies were identified. The findings support the emerging efficacy of technology-enhanced interventions, including a decline in suicidality and an increase in proactive behaviors. However, evidence suggests that there are gaps in the continuum of care and recent study samples do not represent the diverse identities of vulnerable youth.

Conclusions

The majority of identified studies were conducted in school settings and were universal interventions that aligned with the illness and risk recognition and help-seeking stages of the continuum of care. This field could be strengthened by having future studies target the stages of assessment and treatment initiation, include diverse youth demographics, and examine the varying roles of providers and technological components in emerging interventions.

What are the barriers, facilitators and interventions targeting help-seeking behaviours for common mental health problems in adolescents? A systematic review

BACKGROUND

Increasing rates of mental health problems among adolescents are of concern. Teens who are most in need of mental health attention are reluctant to seek help. A better understanding of the help-seeking in this population is needed to overcome this gap.

METHODS

Five databases were searched to identify the principal barriers, facilitators and interventions targeting help-seeking for common mental health problems in adolescents aged 10-19 years. The search was performed in June 2018 and updated in April 2019. Two independent screening processes were made using the eligibility criteria. Quality assessment of each study was performed, and findings summarised using a narrative synthesis.

RESULTS

Ninety studies meet the inclusion criteria for this review for barrier and facilitators (n = 54) and interventions (n = 36). Stigma and negative beliefs towards mental health services and professionals were the most cited barriers. Facilitators included previous positive experience with health services and mental health literacy. Most interventions were based on psychoeducation, which focused on general mental health knowledge, suicide and self-harm, stigma and depression. Other types of interventions included the use of multimedia and online tools, peer training and outreach initiatives. Overall, the quality of studies was low to medium and there was no general agreement regarding help-seeking definition and measurements.

CONCLUSION

Most of the interventions took place in an educational setting however, it is important to consider adolescents outside the educational system. Encouraging help-seeking should come with the increased availability of mental health support for all adolescents in need, but this is still a major challenge for Child and Adolescent Mental Health Services. There is also a need to develop shared definitions, theoretical frameworks and higher methodological standards in research regarding help-seeking behaviours in adolescents. This will allow more consistency and generalisability of findings, improving the development of help-seeking interventions and ensuring timely access to mental health treatments.

Change Pathways in Indigenous and Nonindigenous Youth Suicide

Multivariate dynamic relationships among suicide attempts, anxiety and/or depressive symptoms, hope, and help-seeking were examined across time in Native Hawaiian and non-Hawaiian adolescents, using data from a 5-year longitudinal cohort study (N = 7,317). The rate of suicide attempts decreased over time, but this reduction was significantly less among Native Hawaiian youth than their non-Hawaiian peers. There were also significant differences between groups in hope and help-seeking, with Native Hawaiian youth increasing help-seeking and decreasing hope to a greater degree. Youth-centered, cultural approaches to suicide prevention are essential in enhancing well-being in indigenous communities.

Using the PRECEDE-PROCEED model for an online peer-to-peer suicide prevention and awareness for depression (SPAD) intervention among African American college students: experimental study

Background: Suicide rates are high among African American students because they are at a greater risk of depression. A commonly used suicide prevention approach is the gatekeeper training. However, gatekeeper training is neither evidence-based nor has it been identified as culturally-appropriate for African American college students. Therefore, the purpose of this study was to develop and evaluate an online peer-to-peer PRECEDE-PROCEED model based depression awareness and suicide prevention program that was culturally appropriate for African American college students.

Methods: The setting was a predominantly Black institution in southern USA. A pre-experimental repeated measures one group design was used to measure changes in peer educators’ (n = 29) predisposing factors regarding knowledge, skills and attitudes pertaining to depression, reinforcing factors or receiving support from peers, healthcare professionals and teachers to help someone with depression, enabling factors or sureness of finding organizations to help someone with depression, and behavior for helping someone with depression at pretest, posttest and 1-month follow-up. A posttest only one group design was also used to measure effect on predisposing factors and behavior of students (n = 300) trained by peer educators.

Results: There were statistically significant improvements in attitudes related to depression as disease (P = 0.003; η² = 0.39), attitudes about managing depression (P = 0.0001; η² = 0.30), skills(P = 0.0001; η² = 0.41), reinforcing factors (P = 0.018; η² = 0.13), enabling factors (P = 0.0001;η² = 0.31), and behavior (P = 0.016; η² = 0.14). Changes in knowledge about depression and attitudes about helping people with depression were not statistically significant over time for peer educators. The peer-to-peer training was not completely effective in transferring corresponding changes for students trained by peers.

Conclusion: The program was effective for peer educators but peers could not significantly influence other students in all domains. This study provides a starting point toward evidencebased approaches for health promotion interventionists addressing depression awareness and suicide prevention among African American college students.

The Role of Sleep Disturbance in Suicidal and Nonsuicidal Self-Injurious Behavior among Adolescents

The relationship between different sleep disturbances and self-harm thoughts and behaviors was examined among 223 adolescents presenting to a community clinic for mood disorders and suicidal and nonsuicidal self-injurious behaviors. Two-thirds of the adolescents reported nightly, severe sleep complaints. Relative to adolescents without significant sleep complaints, patients with severe sleep complaints at the time of clinic entry endorsed significantly more engagement in nonsuicidal self-injury. Middle insomnia and circadian reversal were both significant predictors of suicide attempts. Terminal insomnia was significantly associated with suicidal ideation. Results support the importance of assessing sleep difficulties among adolescents at risk for suicide.

A Theater Intervention to Promote Communication and Disclosure of Suicidal Ideation

Young adults from Montana have a higher rate of suicide than their national counterparts. There is a clear need for targeted interventions to address this disparity. The authors evaluate a community-based, narrative theater project designed to increase awareness and use of suicide prevention resources among eastern Montana youth. As a first step, seven group interviews with Montana young adults (n = 27) were conducted to identify current perceptions about suicide and suicide prevention. Interviews were conducted before and after subjects were exposed to a community-based theater production about suicide. Emergent thematic categories were organized using the four main constructs of the extended parallel process model. After the performance, participants expressed increased awareness of prevention resources; perceived susceptibility to the threat of suicide and depression; and self-efficacy for accessing help and assisting others. There were mixed results for perceived response efficacy. Implications and recommendations for intervention development are discussed.

Suicide prevention strategies revisited: 10-year systematic review

BACKGROUND

Many countries are developing suicide prevention strategies for which up-to-date, high-quality evidence is required. We present updated evidence for the effectiveness of suicide prevention interventions since 2005.

METHODS

We searched PubMed and the Cochrane Library using multiple terms related to suicide prevention for studies published between Jan 1, 2005, and Dec 31, 2014. We assessed seven interventions: public and physician education, media strategies, screening, restricting access to suicide means, treatments, and internet or hotline support. Data were extracted on primary outcomes of interest, namely suicidal behaviour (suicide, attempt, or ideation), and intermediate or secondary outcomes (treatment-seeking, identification of at-risk individuals, antidepressant prescription or use rates, or referrals). 18 suicide prevention experts from 13 European countries reviewed all articles and rated the strength of evidence using the Oxford criteria. Because the heterogeneity of populations and methodology did not permit formal meta-analysis, we present a narrative analysis.

FINDINGS

We identified 1797 studies, including 23 systematic reviews, 12 meta-analyses, 40 randomised controlled trials (RCTs), 67 cohort trials, and 22 ecological or population-based investigations. Evidence for restricting access to lethal means in prevention of suicide has strengthened since 2005, especially with regard to control of analgesics (overall decrease of 43% since 2005) and hot-spots for suicide by jumping (reduction of 86% since 2005, 79% to 91%). School-based awareness programmes have been shown to reduce suicide attempts (odds ratio [OR] 0·45, 95% CI 0·24-0·85; p=0·014) and suicidal ideation (0·5, 0·27-0·92; p=0·025). The anti-suicidal effects of clozapine and lithium have been substantiated, but might be less specific than previously thought. Effective pharmacological and psychological treatments of depression are important in prevention. Insufficient evidence exists to assess the possible benefits for suicide prevention of screening in primary care, in general public education and media guidelines. Other approaches that need further investigation include gatekeeper training, education of physicians, and internet and helpline support. The paucity of RCTs is a major limitation in the evaluation of preventive interventions.

INTERPRETATION

In the quest for effective suicide prevention initiatives, no single strategy clearly stands above the others. Combinations of evidence-based strategies at the individual level and the population level should be assessed with robust research designs.

FUNDING

The Expert Platform on Mental Health, Focus on Depression, and the European College of Neuropsychopharmacology.

Student Evaluation of the Yellow Ribbon Suicide Prevention Program in Midwest Schools

OBJECTIVE

Yellow Ribbon is a gatekeeper-type suicide prevention program that is widely used in public schools. However, data on its effectiveness are limited. The purpose of our study was to evaluate self-reported changes in knowledge and comfort level communicating about suicide following Yellow Ribbon training for a large, representative sample of students from a public school system in the midwestern United States.

METHODS

The program was administered to students within the same school district during 2006 through 2009. A pre-post survey using a 4-point Likert scale was administered to rate students' knowledge of risk factors and available resources, comfort level communicating about suicide, estimate of friends at risk for suicide, and behavioral intent toward help-seeking.

RESULTS

Aggregate responses from 3,257 students, aged 11 to 18 years, were collected by the schools; 51% were female, 33% were Hispanic, and 30% were white. Suicide-related knowledge of risk factors, where to go for help, and resources, along with comfort level in asking for help, all significantly improved following program participation (Cramer's V = 0.243 to 0.376, P < .001). Responses were associated with age and gender, indicating that younger males may benefit more than older males.

CONCLUSIONS

Implementation of the Yellow Ribbon school-based suicide prevention program appears to be beneficial for students in the midwestern United States. We observed significant improvement in knowledge, comfort level, and behavioral intent for help-seeking if suicidal thoughts occur. Findings also suggested that Yellow Ribbon training administered during middle school may be especially helpful for males.

A comprehensive review of mental health gatekeeper-trainings for adolescents and young adults

Mental disorders account for a larger burden of disease among adolescents and young adults than any other class of health conditions, and most of these disorders are untreated. Gatekeeper-trainings represent a potentially powerful mechanism for increasing access to treatment. This article is a comprehensive review of 21 gatekeeper-training studies conducted in schools and other youth settings around the world. Despite the widespread use of these programs, little is known about how they actually affect the abilities and actions of trained gatekeepers and the subsequent help-seeking behaviors of adolescents and young adults. Certain outcomes (knowledge, attitudes, and self-efficacy) have been commonly measured whereas others (behaviors, skills, and population-level outcomes) have rarely been assessed. The studies reviewed here also suggest that positive training effects often diminish over time. The article identifies opportunities for advancing gatekeeper-training research and practice.

Gender differences in suicide prevention responses: implications for adolescents based on an illustrative review of the literature

Background: There are well-documented gender differences in adolescent suicidal behavior; death by suicide is more common in males, while nonfatal suicide attempts are more common among females. Over the past three decades, researchers have documented the effectiveness of a myriad of suicide prevention initiatives. However, there has been insufficient attention to which types of suicide prevention interventions are effective in changing attitudes and behaviors for young males and females. In this review of the literature, we consider common examples of primarily universal suicide prevention programs from three implementation settings: school-based, community-based, and healthcare-based. Our purpose is to delineate how the potential gender bias in such strategies may translate into youth suicide prevention efforts. Methods: Research in which gender was found to moderate program success was retrieved through online databases. Results: The results that feature programming effects for both males and females are provocative, suggesting that when gender differences are evident, in almost all cases, females seem to be more likely than males to benefit from existing prevention programming. Conclusions: We conclude by considering recommendations that may benefit males more directly. Implications for adolescent suicide prevention in particular are discussed. Personalization of suicide intervention is presented as a promising solution to reduce suicide rates.

The impact of universal suicide-prevention programs on the help-seeking attitudes and behaviors of youths

BACKGROUND

While the ultimate goal of adolescent suicide-prevention efforts is to decrease the incidence of death by suicide, a critical intermediary goal is directing youths toward effective sources of assistance.

AIM

To comprehensively review the universal prevention literature and examine the effects of universal prevention programs on student's attitudes and behaviors related to help-seeking.

METHOD

We systematically reviewed studies that assessed help-seeking outcomes including prevention efforts utilizing (1) psychoeducational curricula, (2) gatekeeper training, and (3) public service messaging directed at youths. Of the studies reviewed, 17 studies evaluated the help-seeking outcomes. These studies were identified through a range of sources (e.g., searching online databases, examining references of published articles on suicide prevention).

RESULTS

The results of this review suggest that suicide-prevention programming has a limited impact on help-seeking behavior. Although there was some evidence that suicide-prevention programs had a positive impact on students' help-seeking attitudes and behaviors, there was also evidence of no effects or iatrogenic effects. Sex and risk status were moderators of program effects on students help-seeking.

CONCLUSIONS

Caution is warranted when considering which suicidal prevention interventions best optimize the intended goals. The impact on adolescents' help-seeking behavior is a key concern for educators and mental-health professionals.

Reasons to Love Life

Background: A suicide awareness campaign was initiated in the Austrian federal state of Styria to increase help-seeking behavior in the population. Billboards were shown throughout Styria depicting joyful everyday-life situations with a focus on social and family connectedness, and promoting the Telephone Emergency Service, a crisis hotline. Aims: The present study investigated the impact of this campaign on the utilization of the crisis hotline and on suicide rates. Method: Phone calls and suicide rates in the study region 3 months before the campaign were compared with rates 3 months after the campaign. The changes were contrasted with the characteristics of phone calls and the suicide rate in a comparable control region. Results: There were significantly more phone calls in the study region after the awareness campaign compared to the control region, which was similar to seasonal trends in nonintervention years, and there was no increase of suicide-related phone calls. The proportion of suicide-related phone calls referring to family problems decreased after the initiation of the campaign. Suicide rates did not change. Conclusion: The campaign may have had some minor immediate impact on the utilization of the Telephone Emergency Service, but it did not seem to motivate suicidal individuals, especially those with family problems, to call.

A systematic review of school-based suicide prevention programs

OBJECTIVE

Suicide is one of the leading causes of death among youth today. Schools are a cost-effective way to reach youth, yet there is no conclusive evidence regarding the most effective prevention strategy. We conducted a systematic review of the empirical literature on school-based suicide prevention programs.

METHOD

Studies were identified through MEDLINE and Scopus searches, using keywords such as "suicide, education, prevention and program evaluation." Additional studies were identified with a manual search of relevant reference lists. Individual studies were rated for level of evidence, and the programs were given a grade of recommendation. Five reviewers rated all studies independently and disagreements were resolved through discussion.

RESULTS

Sixteen programs were identified. Few programs have been evaluated for their effectiveness in reducing suicide attempts. Most studies evaluated the programs' abilities to improve students' and school staffs' knowledge and attitudes toward suicide. Signs of Suicide and the Good Behavior Game were the only programs found to reduce suicide attempts. Several other programs were found to reduce suicidal ideation, improve general life skills, and change gatekeeper behaviors.

CONCLUSIONS

There are few evidence-based, school-based suicide prevention programs, a combination of which may be effective. It would be useful to evaluate the effectiveness of general mental health promotion programs on the outcome of suicide. The grades assigned in this review are reflective of the available literature, demonstrating a lack of randomized controlled trials. Further evaluation of programs examining suicidal behavior outcomes in randomized controlled trials is warranted.

Adolescent suicide prevention in a school setting: use of a gatekeeper program

Suicide is a major public health problem. Nationally, suicide is the third leading cause of death for adolescents. The purpose of this quality improvement project was to initiate and evaluate a gatekeeper suicide-prevention program within a local school system targeting faculty and staff without a medical or psychology background who interact regularly with middle- and high-school students. Following the implementation of this program, evaluation of increased knowledge related to adolescent suicide prevention was completed. All participants completed a pretest and posttest, and results indicate that the staff members' knowledge about identification of risk factors, behavioral responses to suicidal students, and knowledge of community resources were increased. This project highlights the need for planned and sustainable education and training for faculty and school staff who regularly interact with adolescents. Additionally, the importance of continued monitoring, training, and advocating for suicide prevention programming is noted.

Help-seeking for suicidal thoughts and self-harm in young people: a systematic review

There is a growing body of evidence to suggest that only a minority of young people experiencing suicidal thoughts or self-harm present to any health services. This is of concern given that young people with suicidal thoughts or self-harm often require treatment for mental illness as well as to reduce their risk of completed suicide. We reviewed previously published international community epidemiological studies examining help-seeking for suicidal thoughts or self-harm in young people up to the age of 26. The studies confirm that the majority of these young people do not seek professional help, and this includes seeking medical help after an overdose. The majority of young people studied do, however, seek help from social networks that most commonly are peers. Factors influencing and barriers to help-seeking are discussed and highlight a need for further research into the role that peers and family play in the help-seeking process for young people with suicidal thoughts or self-harm.

Associations between suicidal high school students' help-seeking and their attitudes and perceptions of social environment

Suicide is a leading cause of death among adolescents, many of whom fail to disclose suicide concerns to adults who might help. This study examined patterns and predictors of help-seeking behavior among adolescents who seriously considered suicide in the past year. 2,737 students (50.9 % female, 46.9 % male; racial distribution 79.5 % Caucasian, 11.9 % Hispanic/Latino, and 3.6 % Black/African-American) from 12 high schools in rural/underserviced communities were surveyed to assess serious suicide ideation (SI) in the past year, disclosure of SI to adults and peers, attempts to get help, attitudes about help-seeking, perceptions of school engagement, and coping support. Help-seeking was defined as both disclosing SI to an adult and perceiving oneself as seeking help. The relationship between adolescents' help-seeking disclosure and (1) help-seeking attitudes and (2) perceptions of social resources was examined among suicidal help-seeking youth, suicidal non-help-seeking youth, and non-suicidal youth. Of the 381 (14 %) students reporting SI, only 23 % told an adult, 29 % sought adult help, and 15 % did both. Suicidal help-seekers were similar to non-suicidal peers on all measures of help-seeking attitudes and social environment perceptions. Positive attitudes about help-seeking from adults at school, perceptions that adults would respond to suicide concerns, willingness to overcome peer secrecy requests, and greater coping support and engagement with the school were associated with students' increased disclosure of SI and help-seeking. This study supports prevention strategies that change student norms, attitudes and social environments to promote help-seeking among adolescents with SI. Promising intervention targets include increasing students' perceptions of the availability and capability of adults to help them, and strengthening students' understanding of how existing resources can help them cope.

Three scales assessing high school students' attitudes and perceived norms about seeking adult help for distress and suicide concerns

Validated measures that can be administered to school populations are needed to advance knowledge of help-seeking processes and to evaluate suicide prevention programs that target help-seeking. With 6,370 students from 22 high schools, we assessed the psychometric properties of three brief measures: Help-Seeking Acceptability at School, Adult Help for Suicidal Youth, and Reject Codes of Silence. Internal consistency coefficients ranged from .64 to .84. In support of construct validity, lower scores on each scale were associated with more maladaptive coping norms; for each one unit increase on each scale, students were one third to one half as likely to report suicidal ideation, suicide attempts, and elevated depression.

Social aspects of suicidal behavior and prevention in early life: a review

PURPOSE

The present review summarizes the updated literature on the social aspects of suicidal behavior and prevention in adolescents.

RECENT FINDINGS

The predictive role of psychiatric disorders and past history are well recognized in adolescent suicide, but the role of social and cultural factors is less clear. Studies have focused on the importance of ethnicity, gender, family characteristics, and socioeconomic status. More recently, attention has been addressed to broader social risk factors, such as bullying in adolescents, suicide contagion, sexual orientation, and the popular media. Further empirical evidence is needed to advance our understanding of suicidal youth, develop better assessment tools, and formulate effective prevention and treatment programs.

SUMMARY

Suicidal behavior remains an important clinical problem and major cause of death in youth. Social factors may be at least as important as genetics. Advancing our understanding of underlying cultural and sociological issues in youth suicide will help clinicians achieve more efficient prediction, prevention and treatment.