1. Depression
Dr. Aubrey H. Fine

2. For many years, children and adolescents were thought incapable of experiencing depression. It was considered an adult disease.
1975- National Institute of Mental Health met and discussed depression among children.
1977- Diagnosis and existence of depression in children and adolescents is recognized.

3. Major Depression Disorder (MDD)
Age of first onset of major depression is in adolescence and young adulthood
Adolescent depression is a chronic, recurrent and serious illness.
Children of depressed parents vs. children of non-depressed parents have 2 to 4 fold increased risk of depression.
Symptoms: twice as common in females, substance abuse, suicidal behaviors, social, occupational and educational disability.

4. Diagnosis
5 or more of the following symptoms must be present nearly every day during the same 2-week period to diagnose an adolescent with MDD
Depressed or irritable mood most of the day
Markedly diminished interest or pleasure in almost all activities, most of the day
Significant weight loss or gain, or change in appetite; failure to gain expected weight
Sleep disturbance
Psychomotor agitation or retardation

5. Diagnosis – con’t Fatigue or loss of energy
Feelings of inappropriate guilt or hopelessness
Indecisiveness or diminished ability to concentrate
Recurrent thoughts of death or suicidal ideation, suicide attempt.

6. At least one of the following two symptoms must be present: depressed or irritable mood, or markedly diminished interest or pleasure in almost all activities.
MDD can be rated as mild, moderate, severe.
Diagnosed s chronic when episodes last more than 2 years.

7. An undetected diagnosis in adolescents is dysthymia- depressed or irritable mood that must be present for a year or longer and never be symptom free for more than 2 months.
2 or more symptoms must be present: change in appetite, change in sleep, decrease in energy, low self-esteem, difficulty making decisions or poor concentration, feelings of hopelessness.
Adolescents with dysthymic disorder and who develop a major depressive episode are considered to have a “double depression”

8. Comoribidity
When depression is tied up with any number of other childhood mental illnesses
Anxiety disorders are the most common, with over 60% of depressed adolescents having a history or a concomitant anxiety disorder.
Social phobia (pathological self-consciousness)
Separation anxiety disorder (marked by fears about the well-being of the family)
Generalized anxiety disorder (a fear of the future and constant worries about one’s performance)
Of those who have both anxiety and depression, research indicates that 85% experience anxiety first.

9. One study at the New York University Child Study Center found that among children with anxiety disorder as preadolescents, 30% went on to have depression later on.
Peer relationships is a predictive factor in adolescent depression- not so much anxiety about relating with one’s friends but about whether they have friendships.

10. Conduct disorder or juvenile delinquency is frequently comorbid with depression in young people but the relationship between the two is controversial. Is the teenager depressed because he’s been caught doing something illegal or improper and is now facing consequences? Or is he depressed or demoralized about life, and this in turn leads to outrageous, illegal or oppositional-defiant conduct?
Some young people simply have both disorders at the same time.

11. Posttraumatic stress disorder (PTSD) also has an association with depression.
Occurs when a person witnesses or experiences a traumatic, fatal, or life-threatening event and later relives it, either in his thoughts or dreams.
Can bring extreme distress-intense fear, agitated behavior, flashbacks, and even physical reactions that might include re-experiencing smells.
A person experiencing PTSD might be jumpy, has trouble sleeping, and will take pains to avoid anything associated with the trauma.

12. Substance abuse in late adolescence with MDD is common.
Some people feel that depressed adults “medicate” themselves with drugs and alcohol, and that the same holds true for teenagers
Studies have found an association between adolescent depression and obesity, headaches, and asthma.

13. Risk Factors for Depression in Adolescence
Having a parent who has depression. Rates of depression are 2-4 times higher in children of depressed parents.
Having an anxiety disorder, especially in preadolescence, or a childhood history of depression
Being a female
Having a serious negative life event or an accumulation of damaging experiences (e.g. loss of social support systems, loss of a parent, a childhood history of physical or sexual abuse)
Poverty
Exposure to violence

14. Cognitive Vulnerability
Negative beliefs about themselves, the world and their future
Tend to make global, stable and internal attributions for negative events.
When confronted with stressful life events, these individuals will appraise the stressors and their consequences negatively and hence are more likely to become depressed than are individuals who do not have such cognitive styles.

15. Stress
Environmental conditions that threaten to harm the biological or psychological well-being of the individual
May occur either as an acute event or as chronic adversity, and as a major life event or as minor events with accumulated effects.
Events may be normative (school, transition) or pathological (abuse)
May be independent of, or directly related to an thus dependent on, and individual’s actions.

16. Link between stressful life events and depression in children and adolescents.
Depressive symptoms and disorders are highly associated with minor and major undesirable life events in children.
Negative life events are more prevalent among depressed than non-depressed children.
Stress that occurs as early as at conception likely contributes to an increased vulnerability to depression.

17. Examples of Stressors That are Associated with Depression
Childhood abuse or maltreatment
Sexual assault
Poverty (depression among low-income mothers is twice as high as in the general population)
Events such as disappointments, loss, separation, and interpersonal conflict

18. Interpersonal Relationships
Families with a depressed member are characterized by less support and more conflict.
Family dysfunction increases children’s risk of developing depression.
Depressed individuals are themselves more interpersonally difficult, which results in greater problems in their social network.
Family dysfunction, parent-child conflict, peer difficulties, and interpersonal rejection show that social problems precede depression and depression contributes to interpersonal difficulties.
Link between interpersonal vulnerability and depression is bidirectional

19. Bipolar Disorder

20. Primary feature is a significant change or disturbance in mood.
Mood Disorders
Bipolar disorder belongs to the category of mental-health experiences called mood disorders.
Primary feature is a significant change or disturbance in mood.
Mood disorders fall into four groups:
Depressive disorders
Bipolar disorders
Mood disorder due to a general medical condition
Substance-induced mood disorder

21. Diagnosis
Pediatric mania tends to be chronic and continuous rather than episodic and acute
Childhood-onset mania is a non-episodic, chronic, rapid-cycling, mixed manic state
Early-onset manics are more likely to have comorbid behavior disorders in childhood, and compared to adult-onset cases of mania, to have fewer episodes of remission over a 2 year period

22. “mixed mania” affects 20-30% of adults with mania
High rate of suicide
Poor response to treatment
Early history of neuropsychological deficits highly suggestive of ADHD

23. Criteria to diagnose bipolar disorder:
A distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week
During the period of mood disturbance, 3 or more of the following symptoms have persisted and have been present to a significant degree:

24. Inflated self-esteem or grandiosity
Decreased need for sleep
More talkative than usual or pressure to keep talking
Flight of ideas or subjective experience that thoughts are racing
Distractibility
Increase in goal-directed activity
Excessive involvement in pleasurable activities that have a high potential for painful consequences

25. Comorbidity
Another mental-health experience overlapping or separate from bipolar disorder.
May share similarities with bipolar, making them challenging to pinpoint or diagnose.
It is critical to focus on symptoms, not behaviors

26. The systematic overlap of childhood mania with ADHD is one major source of diagnostic controversy. Rates of ADHD range from 60% to 90% in pediatric patients with mania.
Although ADHD has a much earlier onset than pediatric mania, the symptomatic syndromatic overlap between pediatric mania and ADHD raises a fundamental question- do children presenting with symptoms suggestive of mania and ADHD have ADHD, mania, or both?

27. With Conduct Disorder (CD)
CD is strongly associated with pediatric mania
Comorbidity between CD and major depression because pediatric depression often presages mania
CD includes violent behavior that may be categorized as mild, moderate, or severe.
Childhood-onset type (before age 10)
Adolescent-onset type (after age 10)

28. CD behaviors can start out slowly and build over an individual’s lifetime, ranging from lying, stealing, and physical fights to drug use, burglary, rape, and mugging.
20-40% of kids with ADHD have CD
One way to distinguish CD from bipolar disorder is to determine if outbursts or episodes of manic symptoms can seen with other indicators of mania. To be diagnosed with CD, your child must be significantly sidetracked by the symptoms and must have an impaired ability to function throughout each day.

29. For a diagnosis of CD, your child needs to show a regular persisting pattern of violating rules and the rights of others
3 of the following must have happened within the past year and one must have occurred in the past 6 months:

30. Physical cruelty to people or animals
Theft from someone in person
Forcing someone to engage in sexual activity
Violent use of a weapon to cause serious harm
Instigating physical fights
Bullying or threatening others
Arson
Destroying others’ property
Breaking into someone’s house, car, or other building
Conning or manipulating others
Shoplifting, credit card identity theft, forging checks
Breaking curfew
Running away from home overnight at least twice
Skipping school before age 13

31. With Anxiety Disorders
Pediatric studies of youth with panic disorder and youth with mania document a bidirectional overlap.
Subjects with panic disorder and agoraphobia had very high rates of mania
More panic and other anxiety disorders in children with mania.
Mania at any age is frequently comorbid with severe anxiety that requires additional clinical and scientific scrutiny.

32. With Substance Use Disorders (SUD)
Bidirectional overlap between mania and SUD in youth as well as adults
Juvenile-onset mania may be a risk factor for SUD

33. Risk Factors
Risk factors have not been clearly identified from community-based studies.
The most consistent risk factor for bipolar disorder is family history.
Offspring of adult bipolar patients has an increased risk, over 3-fold, of bipolar disorder as well as mood disorders, compared to offspring of controls.

34. Gender
Gender is well known to be an important but poorly understood factor influencing the risk of MDD. The prevalence of MDD, while equal between boys and girls prior to puberty, doubles in young women after puberty. This increase in females has been hypothesized to be secondary to hormonal changes occurring during puberty.

35. Treatment of Depression and Bipolar Disorder

36. Psychosocial Treatments for MDD
Behavior therapy
Cognitive therapy
Interpersonal therapy

37. Behavior Therapy
Primary goal is to increase the frequency of pleasant activities in the patient’s life
Found to be significantly better than psychotherapy, relaxation therapy, and medication
An efficacious, but not uniquely effective, acute treatment for MDD

38. Cognitive Therapy
Most widely studied psychotherapy for MDD
Treatment is based on the model that the cognitions of depressed individuals are negatively biased. Negative beliefs about the self, the world, and the future.
Typically sessions over a period of weeks

39. Involves both behavioral and cognitive techniques
Behavioral techniques serve to help patients engage in activities that give them pleasure, while cognitive techniques are used to evaluate the veracity of their beliefs.
An efficacious acute-phase treatment for MDD

40. Interpersonal Therapy
Depression is usually triggered by problems in four interpersonal domains: role transition, grief, interpersonal deficits, and interpersonal disputes.
In IPT, the interpersonal problem that triggered the current depressive episode is addressed and the person is helped to build communication and interaction skills to resolve it.
The acute phase of IPT typically lasts for sessions.

41. Psychopharmacological Treatment for MDD
Monotherapy
Bupropion- blocks noradrenergic and dopamine reuptake.
Side effects: nausea, insomnia, increased anxiety, restlessness, increased incidence of seizures. No weight gain or sexual dysfunction.

42. SSRIs (Prozac, Zoloft, Luvox, Celexa, Lexapro and Paxil)
Make the most of the serotonin the body is producing at this time
The neurotransmitter (serotonin) lingers longer on the neuron receptors, giving it more of a chance to effectively complete the message it needed to send.
Rarely associated with fatalities and given its safety profile provides an easy treatment option for the clinician.
Side effects: headaches, nausea, dry mouth, insomnia, nervousness, sexual dysfunction, diarrhea, tiredness, and agitation

43. FDA issued an advisory to physicians that the use of antidepressant may lead to suicidal thinking or attempts in depressed youths.
FDA requested that a warning be added to the product label of these antidepressants

44. Antidepressant medications were not originally developed with children and adolescents in mind (nor were they tested on this population)
In addition to relieving symptoms of depression, antidepressants may also be prescribed for treating kids who grapple with other issues.
Phobias (often-school related)
Anxiety
Panic attacks
Eating disorders
ADHD
Bedwetting
OCD
Post-traumatic stress disorder

45. Dosages
Need to remember that the brains and bodies of children and teenagers are still growing and developing
Because bodies are often smaller than adults, the concentration of any medication in their systems is much greater
May lead to amplified side effects that are more intense than those found in adults if great care is not exercised

46. Careful Monitoring
Monitoring and follow-up is critical
Each medication has the potential to react differently in each child
May take weeks before you see any noticeable improvement in mood
Maintain careful communications with doctor

47. Pharmacotherapy for Bipolar Disorders
Mood Stabilizers
Lithium
Side effects: tremor, diarrhea, weight gain, increased urinary frequency, and gastrointestinal distress
Divaloproex and Carbamazepine
Lamotrigine
Antidepressants- should only be used with in combination with a mood stabilizer for the treatment of bipolar disorder

48. Prevention of Depression and Bipolar Disorder
The term prevention refers only to interventions that occur before the initial onset of a disorder
Efforts to identify cases and provide care for known disorders is called treatment
Efforts to provide rehabilitation and reduce relapse and reoccurrence of a disorder were called maintenance/interventions.

49. Universal mental health prevention interventions are defined as efforts that are beneficial to a whole population or group.
They are targeted to the general public or a whole population group that has not been designated or identified as being at risk for the disorder being prevented.
The goal at this level of prevention is the reduction of the occurrence of new cases of the disorder.

50. Selective mental health prevention interventions are defined as those efforts that target individuals or a subgroup of the population whose risk for developing the mental health disorder is significantly higher than average.
Indicated prevention interventions are defined as those efforts that target high-risk individuals who are identified as having minimal but detectable signs or symptoms that predict the mental disorder or biological markers indicating predisposition to the disorder.

51. The IOM identified three aims or desired outcomes for mental health prevention:
Reduction in the number of new cases of the disorder
Delay in the onset of illness
Reduction in the length of time the early symptoms continue as well as halting the progression of severity so that individuals ultimately do not meet diagnostic criteria.

52. Goals of prevention programs:
To extend the lives of individuals who were at risk but did not develop the disorder by reducing both the risk of suicide completion and the behavioral and biological sequalae of the disorder.
To teach resiliency to the program participants
To develop skills and abilities to spring back from or adapt to adversity
To enhance and enrich the positive aspects of living so individuals who otherwise might have a marginally happy life may have the opportunity to develop greater self-efficacy and live a more successful and adaptive live
Emotional intelligence may also be enhanced by successful preventive programs.

53. Prevention programs for adolescents
Preventative strategies are based primarily on cognitive behavioral and family-educational approaches that seek to reduce risk factors and enhance protective and resiliency factors associated with depression in youth.

54. The IOM suggested that prevention development and evaluation proceed through 5 stages.
First and second stages are identifying risk factors and describing the relative contributions of different factors to the disorder.
The third stage is applying strategies developed in pilot studies and completing efficacy trials to evaluate the overall effectiveness of these approaches.
The fourth stage involves the examination of such strategies in multiple sites in large-scale investigations under non-ideal, real-world conditions.
The final stage consists of implementing such strategies in large-scale public health campaigns.

55. Penn Prevention Program
Seligman and colleagues developed and evaluated a school-based “indicated” prevention program treating year olds in districts in the Philadelphia suburbs.
The youth were defined as at risk for depression.
Participants were assigned to one of three treatment programs:
A cognitive training program
A social problem-solving program
A combined program

56. Results indicated that children who participated in any of the treatment groups reported significantly fewer depressive symptoms immediately following the program and at the 6- month and 2-year follow-ups but not at the 12- month and 3-year follow-ups.
Teacher reports revealed better classroom behavior in treatment participants.

57. Clarke and Colleagues
Among the first to study prevention of MDD among adolescents.
Study included 150 students from 9th-10th grade
Assigned randomly to either a “prevention” or “usual-care” group.
The prevention program entitled “Adolescent Coping with Stress Course” was delivered in groups.
The 5-week intervention was conducted within the adolescents’ school setting and comprised fifteen 45-minute group sessions.

58. The “usual-care” youngsters were free to continue with preexisting treatment or seek new treatment.
This program employed both behavioral and cognitive coping techniques designed to reduce vulnerability to future depressive episodes.
Participants were followed for 1 year and the results were positive.
The major strengths of this program include random assignment of subjects, adequate sample sizes, diagnoses of clinical mood disorders and encouraging outcomes.

59. Beardslee and Associates
Prevention program were designed to be public health interventions and useful to all families in which a parent is depressed.
Programs are to be sued by a range of health practitioners, including internists, pediatricians, school counselors, and nurses, as well as by mental health practitioners such as child psychiatrists, child psychologists, and family therapists.
This approach includes a strong emphasis on treatment because so much depression is undiagnosed and untreated.

60. 3 characteristics that described resilient children of depressed parents.
Support for activities and accomplishment of developmental tasks outside of the home
A deep involvement in human relationships
The capacity for self-reflection and self-understanding, in particular, in relationship to the parent’s disorder.

61. Resilient youth repeatedly said that understanding that their parent was ill, that the disorder had a name, and that they were not to blame for it contributed substantially to their doing well. This, then, became a central part of the preventive intervention.
Families believe that these programs are helpful. Of the first 20 families enrolled, promising effects were observed 6 months after intervention and a further follow-up report showed sustained effects over 3 years.

62. Youth Suicide

63. Fifty years ago suicide among young people aged was a relatively infrequent event and suicides in this age group constituted less than 5% of all suicides in the U.S.
Between the mid-1950s and the late 1970s, the rate of suicide rose markedly among this age group.
This increase was observed most dramatically among young males, whose suicide rates more than tripled between
Among females ages 15-24, the suicide rate more than doubled during this same period.

64. By 1980, suicides by year olds constituted almost 17% of the approximately 30,000 suicides in the U.S.
suicide rates continued to rise
1994- reached a peak rate of 13.6 suicides per 100,000.
Began to decline decreasing to 9.9 per 100,000 by 2002 a drop of over 27%.

65. Suicide before the age of 12 is rare, but increases with every year past puberty.
In 2002, year olds had a suicide rate of 12.3 per 100,000 compared to the rate of 7.4 among year olds.
4,010 suicides in 2002
1,513 between the ages of 15-19
2,497 between the ages of 20-24

66. Suicide is the 3rd leading cause of death among youth; only accidents and homicide claim more young lives.
Among college students specifically, suicide is the 2nd leading cause of death, surpassed only by accidental injury.

67. Increase of youth suicide due to:
Increase in the rate of depression since the 1950s
Increased availability of firearms
Diminishing cohesion of the family observed since WWII has been blamed for a wide range of youth problems behaviors, including both drug abuse and suicide.
Greater freedom in sexual behavior since the 1960s as well as changes in the expectations that young men and women had for themselves and for their relationships

68. Decrease of youth suicide is due to:
Efforts to restrict firearms availability among youth. The proportion of suicides that involve firearms has decreased somewhat in recent years, although firearms are still used in about 60% of all suicide deaths.
Increased use of antidepressant medication in treating young depressed people.
Improved economic conditions in the 1990s have been credited for the recent decline, just as they were blamed for the high national rates during the depression of the 1930s.

69. The most current YRBS data indicate that 8. 5% of U. S
The most current YRBS data indicate that 8.5% of U.S. high school youth surveyed (5.4% of males and 11.5% of females) made one or more suicide attempts in the prior 12-month period; 2.9 percent (2.4% of males and 3.2% of females) required medical attention as a result of suicide attempt
Youth who are not currently attending school have been found to be at higher risk for suicide attempts and suicide deaths than those who are in school.

70. Among young people ages 15-24, males die by suicide almost six times more frequently than females.
In 2002, the suicide rate among young men ages was 16.4% per 100,000 and the rate among young women was 2.9%.
Although young males die by suicide more often than females, females report suicidal ideation and attempts more often than males.

71. In 2002, white youth had a suicidal rate of 10
In 2002, white youth had a suicidal rate of 10.6 per 100,000 compared to rates of 6.5 for African Americans, 6.6 for Hispanic youth, 5.3 for Asian Americans/Pacific Islanders, and 17.9 for American Indians and Alaskan Natives.

72. Risk Factors Psychopathology Family and Genetic Depression
Drug and alcohol abuse
Aggressive-impulsive behavior
Hopelessness
Pessimism
Conduct Disorder (male)
Panic Disorder (female)
Family and Genetic
Family history of suicidal behavior
Parental psychopathology

73. Environment Biology Firearm availability Diminished family cohesion
Lack of parental support
Parent-child conflict
Negative life events
Child sex abuse
Suicidal contagion
Biology
High 5-HT receptor expression is prefrontal cortex and hippocampus
Serotonergic dysfunction

74. Previous suicidal behavior
Suicide attempts
Sexual Orientation
Same-sex sexual orientation

75. Overwhelming evidence that psychopathology is the most significant risk factor for both suicide deaths and suicide attempts among adolescents.
One recent analysis suggested that eliminating psychopathology could prevent 78-87% of youth suicides.
Conduct disorder is also prevalent in young males with suicidal behavior, often comorbid with substance disorders and anxiety and mood disorders.

76. Panic disorder has been found to be related to suicidal behavior, particularly among girls.
Some studies have reported a relationship between bipolar disorder and both suicide deaths and suicide attempts among youth.
Suicide ideation appears to be less directly related to psychopathology than either suicide attempts or suicide death, perhaps because ideation, while occurring with higher frequency, is less persistent and may be fleeting.

77. Aggressive-impulse behavior has an increased association with suicidal behavior, particularly in the context of a mood disorder
Hopelessness and pessimism are also important factors associated with youth suicidal behavior
Previous suicide attempts is one of the strongest predictors of both subsequent attempts and suicide deaths. This relationship is particularly strong among youth with mood disorders.

78. The risk for future suicidal behavior has been estimated to increase 3-17 times when a previous attempt has occurred.
A number of studies report increased rates of nonlethal suicidal behavior among youth with same-sexual orientation.
Stigmatization, victimization, isolation, and parental rejection have been identified as factors in suicidal behavior among gay, lesbian, and bisexual youth.

79. Universal Approaches to Youth Suicide Prevention

80. Two broad types of universal prevention programs
The ultimate goal of all suicide prevention programs is to reduce death by suicide.
Two broad types of universal prevention programs
Educational programs that aim to increase students’ knowledge and awareness about suicidal behavior, encourage troubled students to seek help, and improve recognition of at-risk students by teachers, counselors, and other “gatekeepers” within the school or community setting.
Screening programs that seek to identify and refer to treatment youth who are at risk for suicidal behavior.

81. A wide range of suicide education and awareness programs have been developed.
Assumptions underlying such programs are that the conditions that contribute to suicide risk in adolescents and young adults often go unrecognized, undiagnosed, and untreated, and that educating students and gatekeepers about the warning signs for suicide and appropriate responses will result in better identification of at-risk youth, and increase in help seeking and referrals for treatment.

82. Program Examples
Such programs are exemplified by those developed by Kalafat and colleagues, which incorporate education about the warning signs of suicide and appropriate help-seeking behaviors into the regular physical education or related curricula.
Such education has been reported by the program developers to result in students’ increased knowledge about suicidal behavior, more positive attitudes about talking to friends they believe to be suicidal, and seeking of helps from adults.

83. In its most fully developed form, the Adolescent Suicide Awareness Program (ASAP) includes education for teachers, school staff, and parents, as well as students.
The Sign of Suicide (SOS) program, developed by Jacobs and colleagues.
Delivers the core message that suicidal behavior is directly related to mental illness, particularly depression, and needs to be responded to as a mental health emergency.
The instructional component, which occurs over 1-2 class periods, may be augmented with screening and parent-awareness activities.

84. Schools in which the program has been implemented have reported substantial increases in students’ help-seeking behavior and high satisfaction with the program among school officials.
Students who had participated in the SOS program reported lower rates of suicide attempts and greater knowledge and more adaptive attitudes about depression and suicide.

85. Dade County, Florida, Public School System provide an example of universal programs applied on a community wide level.
Began in 1989 included related curricula across K-12, although only 10th graders received direct discussion of suicide and suicide prevention.
Also included intervention and postvention activities by school-based crisis teams.
The annual suicide rate decreased from 12.9 deaths per 100,000 youth prior to the program to 4.6 per 100,000 during the 5 years of program operation.

86. Many states are currently implementing universal youth suicide prevention programs that, in addition to student education, frequently include parent and gatekeeper training.
The Suicide Options, Awareness and Relief (SOAR) program, for example, trains school counselors to identify students at risk of suicide and increase the likelihood and effectiveness of their interventions.
This program has been reported to result in improved knowledge and increased comfort and confidence in dealing with at-risk students.

87. Applied Suicide Intervention Skills Training (ASIST) is the most frequently applied gatekeeper training program
Developed by LivingWorks Education for application in a wider community setting.
It is a 2 day workshop for teachers, counselors, youth leaders, and other community care givers that seeks to increase their awareness and understanding of suicide, address the associated stigma and taboos, develop their readiness and ability to use “first-aid” action to prevent suicidal behavior, and network with other gatekeepers to improve communication and continuity of care.

88. Pre- to post-evaluations of participants suggest increased knowledge about suicidal behavior, greater willingness to intervene, and improved competence in dealing with suicidal individuals.
In one training program in Australia, more than ¾ of ASIST workshop participants reported using their knowledge and intervention skills directly during the 4 months following their participation in the program.

89. Training for Trainers (T4T)
5 day course, offered worldwide, trains and certifies gatekeepers to provide the ASIST training in their local communities.
Another approach to gatekeeper training has involved educating general practitioners to more effectively identify suicidal patients.
One workshop in Australia sought to encourage screening of young patients for psychological distress, depression, and suicidal behavior.
Reported to have resulted in increased identification of distressed, depressed, and suicidal adolescents; no changes were reported in physicians’ management of such patients.

90. Suicide awareness and education programs for college students are far less cohesive and identifiable than programs addressed to high school students.

91. One of the few programs that involve more than a single campus is Finding Hope and Health, developed by the National Mental Health Association in 2001.
Facilitates partnership between a local mental health association and a university to develop and implement campus educational programs on suicide and related mental health problems.
These “campus coalitions” work with residence hall advisers, campus counseling centers, relevant academic departments, campus ministries, and other student affairs personnel to design trainings for students and staff, peer counseling programs, and other activities to increase knowledge and awareness of mental health concerns.

92. Another effort that targets colleges and universities is the recently produced film developed by the American Foundation for Suicide Prevention (AFSP), “The Truth About Suicide: Real Stories of Depression in College.”
The film is accompanied by a Facilitator’s Guide that includes recommendations for its use in classrooms, orientation sessions, and dorm meetings and at other student activities, as well as educational materials to assist faculty and other facilitators in guiding student discussions and answering specific questions about suicide.

93. Critique
Most suicide aware ness and suicide education programs involve one or a limited number of relatively brief sessions focused on suicidal behavior, frequently as part of a larger curricular effort aimed at reducing multiple high-risk behaviors.
Although pre- to post-evidence suggests that such programs can increase students’ knowledge and awareness of suicide risk and improve their help-seeking behaviors, little attention has been paid to determining the scientific accuracy of program content.

94. Generalizable conclusions about the efficacy and effectiveness of suicide education programs for both high school and college students are further limited by the lack of control or comparison groups that would make it possible to differentiate program impact from broader co-occurring trends.
In the case of the comprehensive, multilevel educational programs, insufficient attention has been paid to documenting which program components are responsible for the reported outcomes.

95. An additional limitation of currently available data on the impact of universal education programs is their short-term focus.
It is not clear if ongoing interventions might serve as “booster shots” to enhance and reinforce a program’s impact.
Follow-up evaluations of these programs have been rare, and thus little is currently known about their impact on reducing suicidal behavior among the targeted group.

96. Longitudinal controlled studies that look at youth several years after participating in educational programs are needed to address the question of long-term behavioral change.
This will require addressing the fact that neither high schools nor colleges currently have a reliable system for reporting suicidal behaviors among students, thus hampering collection of reliable data to determine an educational program’s impact.
Also, students graduate and leave the school environment, making follow-up difficult.

97. Long-term controlled studies of gatekeeper training programs are likewise needed to determine the frequency or the effectiveness of participants’ direct interventions during the years following the training.
Because little is known about particular approaches that make referral efforts safe and effective, further evaluation is needed of the impact of such programs on referral processes, adequate treatment, and, in turn, the reduction of suicide risk factors and suicidal behavior among youth

98. Some concerns have been voiced by high school personnel and parents that overt discussion of suicide in the school curriculum may increase suicidal thoughts and behavior, and adequate attention has generally not been given by evaluators to documenting adverse effects.
One study found statistically significant increases in hopelessness and maladaptive coping resources among some male students after exposure to a suicide awareness curriculum.

99. Studies by Shaffer and colleagues and Vieland and colleagues found that students who had previously made a suicide attempt were less likely to recommend suicide awareness programs in the schools, and were more likely to feel that talking about suicide in the classroom would increase suicidal behavior among some students.
It is essential that school personnel be made aware of referral sources in the community and for the school to have in place a plan of action for identified students that includes a debriefing component for peers and faculty who are involved in making referrals.

100. In the case of college-based programs, concerns about effects on the institution’s legal liability, reputation, and student enrollment sometimes encourages campus officials to avoid or minimize the problem of student suicide, which appears to have limited the development of educational programs directed to this population.

101. Providing suicide education to college students poses unique issues.
College students are not generally required to take any courses in which education about depression and suicide may be appropriately incorporated.
Other than a few limited number of mandatory orientation sessions, few opportunities exist to reach large numbers of college students with information about mental health issues and services.
Involvement of parents in educational programs on such issues is also extremely limited in most college settings.

102. Most suicide prevention programs directed to young adults are designed specifically for college students, who represent less that half of all persons aged in the United States.
Although few research studies have examined suicide risk among young adults not in college, this population may have particular risk factors, including more involvement with substance use, as well as less access to mental health resources.

103. Screening Programs
Universal screening programs as a youth suicide prevention strategy are designed to identify young people at risk for suicidal behavior and refer them to treatment.
Some programs focus specifically on identifying symptoms of psychopathology known to be related to adolescent and young adult suicidal behavior, while others assess specifically for signs of suicidality.

104. The primary assumption underlying screening programs is that because anxiety, depression, substance abuse, and suicidal preoccupation among youth often go unnoticed and untreated, a systematic, universally applied effort is needed to improve identification of at-risk individuals.
Screening programs also rest of the assumptions that identification of youth with psychiatric disorders will substantially increase the number receiving treatment, the treatment will be sufficiently effective, and effective treatment will decrease suicides.

105. Reynolds described one of the first high school-based screening programs for youth at risk for suicide.
The program involved a two stage method, in which a general population of students was first screened using the Suicide Ideation Questionnaire.
Students with scores above a defended cutoff value were subsequently evaluated clinically with the Suicide Behavior Interview, and those identified as being at risk were referred treatment.

106. The program devoted particular attention to determining an appropriate cutoff score for identifying at-risk youth, comparing two different scores with regard to sensitivity (the ability to identity correctly those who have the problem, with few false negatives) and specificity (the ability to identify correctly those who do not have the problem, with few false positives).
Reynolds found that increasing the cutoff score led to missing a disproportionate number of at- risk youth.
The impact of suicidal behavior and the adherence to treatment recommendations were not reported.

107. The most widely used high school screening program, the Columbia TeenScreen Program (CTSP), employs a multistage procedure.
In one variant of the CTSP, students complete a brief, self-report questionnaire.
Those who screen positive on this measure are given a computerized instrument, the Voice DISC 2.3, which has been found to accurately identify a comprehensive range of psychiatric disorders in children and adolescents. This stage of the screening is regarded as particularly important for avoiding over-identification of students at risk.

108. In the final stage, youth who have been identified through Voice DISC 2.3 as meeting specific diagnostic criteria for a psychiatric disorder are evaluated by a clinician, who determines whether the student needs to be referred for treatment or further evaluation.
The program also includes a case manager who contacts the parents of students who are referred and establishes links with a clinic to facilitate treatment adherence.

109. Evaluation results indicate that most of the adolescents identified as being at high risk for suicide through the program were not previously recognized as such, and very few had received prior treatment.
About half of the students referred for treatment attended at least one treatment visit.
The program’s requirements of a clinician and a case manager may be a resource burden for many schools.

110. The screening strategy is based on a public health prevention model that emphasizes the identification of at-risk students on the basis of observable behaviors.
The first level of screening involves a review of high school attendance registers to identify students having high absenteeism. Teachers and guidance counselors are asked to recommend students they deem to be at risk.
Identified youth are then assessed by means of the Suicide Risk Screen (SRS).
Those with elevated risk for suicidal behaviors are given an appropriate intervention within the school setting or are referred for further evaluation and treatment.

111. Screening initiatives for college students include the Comprehensive College Initiative (CCI) developed by Jacobs to identify students at risk for depression and facilitate them to get treatment.
The program has been offered at a large number of colleges in conjunction with National Depression Screening Day.
In addition to the in-person screenings offered at this event, the program includes an online year-round screening component.

112. In campuses where it has been implemented, the CCI has been described by its developers as effective in identifying at-risk students and motivating them to seek treatment.
Almost 20% of students taking the screening measure scored “very likely” to be suffering from depression and 5% reported persistent suicidal ideation.
Both student participants and college officials were reported to have positive reactions to the in-person and online program components.

113. Another recent program is the College Screening Project developed by the American Foundation for Suicide Prevention.
This project uses the campus network to target students and encourage them to complete a Depression Screening Questionnaire, which has been established to be an effective tool for identifying depression among community samples.
The screening includes depression, items dealing with current suicidal ideation, past suicide attempts, anxiety and other affects, drugs, alcohol, and eating disorders.

114. Assisted by a computer program, a clinically trained counselor evaluates the responses and assigns the student into one of three tiers on the basis of their suicide risk.
The counselor then writes a personalized reply that the student accesses on the Web site. Students with significant problems as determined by a well-defined set of criteria are urged to come in for a face-to-face evaluation.
The Web site also contains a “Dialogue” feature that allows students to communicate with the counselor online to discuss concerns they may have prior to an evaluation.

115. During the face-to-face meeting, treatment options, including medication and psychotherapy, are discussed and referrals are made to appropriate services on and off campus.
In an effort to evaluate treatment effects, the project collects data on an ongoing basis from treatment providers on student adherence, treatment progress, and disposition.

116. Initial reports indicate that about 80% of the students who respond to the screening questionnaire indicate some mental health problems, with almost half of all respondents falling into the highest-risk tier.
Fewer than 15% of identified students comply with recommendations for evaluation, which suggests that recommendations need to be refined to make them more acceptable, or that innovative strategies need to be developed to encourage greater number of at-risk students to seek help.

117. One other Web-based screening program for college students the ULifeLine program, has recently been developed by the Jed Foundation.
This program provides computer-generated results to students who complete the screening instrument. Although identified students are provided with recommendations regarding treatment possibilities, no follow-up is offered.
It is not clear whether without a personal connection, such Web-based screenings will succeed in motivating students in need to seek treatment.

118. Critique
In their basic assumptions, screening programs as implemented within both high school and college settings closely conform to scientifically validated premises regarding the causes of suicide – i.e., that suicide risk is not randomly distributed, but rather is conferred by certain factors that are both identifiable and, to a considerable extent, alterable.
At the same time, such programs face a number of challenges.

119. Screening measures with acceptable test characteristics (e. g
Screening measures with acceptable test characteristics (e.g., a sensitivity of 80% and a specificity of 70%, figures similar to screens for depression) will necessarily miss some in the population who will go on to make suicide attempts, while identifying many more as at risk when they are not.
Given that costs are involved each tome a segment of the target is screened, most school-based screening programs assess students only once a year, and in some cases, only once during a several-year period.

120. The timing of the screening may increase the likelihood of identifying students in need of referral (e.g., close to exams, at the beginning of high school or college, or during the senior year) or at other times may reduce this likelihood.
Low adherence with treatment recommendations among those identified through the screening instrument to be at risk due to a range of problems that are beyond the scope of the screening effort (lack of parental support, perceived quality of available treatment, and attitudes of treatment providers) additional strategies appear to be needed to encourage students at risk to access and make effective use of needed treatment services.
In this regard, better integration of suicide education, gatekeeper training programs, and screening programs may be helpful.

121. All school-based suicide screening programs need to be mindful of the availability and quality of mental health services for students who are identified as at risk.
It is estimated that only 38% of colleges provide mental health services and most of those that do limit the number of sessions or offer only group therapy that may not be appropriate for students at risk for suicide.
Although many colleges require students to have health insurance, most students are not adequately covered for acute or long-term mental health services.

122. Even when implemented under ideal conditions, there is no clear evidence that screening for suicide in general populations improves rate reduction outcomes.
No data have been reported on the effectiveness of high school or college-based screening programs in reducing suicide risk factors.
Within high schools, there is evidence that administrators prefer suicide education and awareness programs over screening programs.

123. Many colleges and universities have expressed reluctance about implementing depression and suicide screening programs.
This appears to reflect concerns about the liability schools may assume in the event that students identified as at risk for suicide not follow through with treatment recommendations and actually engage in suicidal behavior.
Identification of at risk students may also put universities into a difficult legal and ethical position with respect to parents. Parents of students over the age of 18 cannot be contacted without written permission from the student. Although confidentiality can be waived in situations in which threat to life is concerned, universities are reluctant to become embroiled in such matters.

124. One complication with Web-based programs is the recent Health Insurance Portability and Accountability Act (HIPAA) which limits the use of electronic technology to transmit identifiable health information, because of the potential threats to patient confidentiality.
This has been interpreted as requiring that a student’s actual identity not be revealed online, making it impossible for the counselor to intervene to help a student believed to be suicidal unless he or she presents in person for evaluation.

125. Preventive Interventions and Treatments

126. School-Based programs for suicidal students
The most comprehensive school-based programs are those developed and tested by Eggert, Thompson, and their colleagues as part of the Reconnecting Youth (RY) Prevention Research Program.
The interventions are directed at students who are deemed to be at risk of dropping out of high school, based primarily on school attendance data and observations of teachers, counselors, and other gate keepers.
Such students have been reported to have multiple co-occurring problems that, in addition to school performance difficulties, include depression, suicidality, drug involvement, and aggressive and violent behaviors.

127. The interventions are based on a theoretical model that rests essentially on improving students’ personal resources, leading to an enhanced sense of personal control and self-esteem, improved decision making, increased use of social support resources, and reduced suicidal behavior.
The early research involved systematic evaluation of a semester-long, school based, small group intervention called the Personal Growth Class (PGC).

128. The intervention included life skills training using strategies of group process, teacher and peer support, goal setting, and weekly monitoring of mood management, school performance, and drug involvement.
Evaluation studies involved 100 high school students who screened positive for suicidal behavior.
The students were randomly assigned to one of three conditions
Assessment protocol plus one semester of PGC
Assessment protocol plus two semesters of PGC
Assessment protocol only

129. Participants were assessed at baseline and at 5-10 months post-intervention.
Participants in all three groups showed significant declines in suicidal behavior.
Unlike the students who received the assessment protocol only, PGC participants showed significant improvement in self-perceived ability to manage problem circumstances.
Also reported was a significant positive impact of both teacher and peer support in decreasing suicide risk behaviors and depression.

130. Also reported was a significant positive impact of both teacher and peer support in decreasing suicide risk behaviors and depression.
Thompson, Eggert, and colleagues subsequently tested two additional school-based prevention programs based on the PGC: a brief one-on-one intervention known as Counselors Care (C-Care) and a small group skills-building intervention program, Coping and Support Training (CAST)
Both interventions were found to reduce suicide risk behaviors and depression.
CAST was most effective in enhancing and sustaining protective factors such as problem-solving coping.

131. Currently the CARE intervention expanded to include a parent intervention component
Being studied to determine the added benefit of this component to further reduce depression, anger, and suicide risk behaviors.
Preliminary results suggest that C-CARE, coupled with the parent intervention, is associated with more rapid rates of decline in suicidal ideation, direct suicide threats, depression, hopelessness, and anxiety when compared to usual care.

132. Critique
The target groups addressed by the studies of Eggert and Thompson may limit the generalizability of the findings to other populations of suicidal youth.
The focus of these programs has been on students at risk of dropping out of school. There is some evidence that high school dropouts may come from more deviant and neglecting families and thus may not be representative of suicidal adolescents overall.

133. Emergency Department Interventions For Young Suicide Attempts
A considerable number of youth who make suicide attempts obtain some form of medical intervention, typically beginning in a hospital emergency department (ED)
Numerous studies, however, have documented that young suicide attempters’ adherence to outpatient treatment recommendations made in the ED is poor, with over 15% never attending any recommended outpatient sessions, and fewer than half attending more that a few sessions.

134. Poor adherence has been attributed to ED factors, such as long waits, repetitive evaluations, and poor communication by ED staff, and also to cultural factors including the perception that mental health treatment is shameful.
Rotheram-Borus and colleagues designed and intervention that targeted both the ED staff and families of Latino adolescent females who attempted suicide and followed participants over 18 months.

135. Using video tapes and therapists, this program involved ED staff and families with a focus on encouraging participation in outpatient treatment.
In comparison with patients who received family therapy alone, participants who received both family therapy and the emergency room intervention were found to adhere more frequently to the recommendation to attend a first treatment session.

136. Hospitalization for suicidal behavior, though often securing the safety of the suicidal individual, is quite costly and not always beneficial.
In an effort to decrease hospitalization rates and suicidality and improve functioning, Greenfield, Larson, Hechtman, Rousseau, and Platt implemented the Rapid Response (RR) ED intervention for suicidal adolescents who were not considered to require immediate medical or psychiatric hospitalization.

137. The intervention included family therapy, medication, and community intervention.
Hospitalization rates were decreased and outpatient therapy was initiated more rapidly as a result of the RR intervention when compared with standard care.
Adolescents receiving the intervention were less likely to be rehospitalized during the 6 months after their visit to the ED.

138. Critique
The results of programs implemented to date suggest that some improvement in outpatient treatment adherence by young suicide attempters, as well as reduced hospitalizations, can be achieved by concerted efforts in the ED.
Such efforts require education of ED staff on suicide risks and treatment needs of young suicide attempters.
Barriers to outpatient treatment appear to remain significant and difficult to surmount, even for the most cohesive and well functioning families.
ED interventions provide some continuity of contact with the youth beyond the initial ED visit, which will require additional staffing.

139. Psychotherapeutic Treatments for Suicidal Youth
Most interventions have employed variations of cognitive behavioral therapy.
The underlying assumptions is that the primary focus of treatment should be the suicidal behavior itself, rather than the underlying psychopathology.

140. Program Examples
An intense 2 week program that participants attended for 9 hr/day, included an experiential affective group, psychoeducational classes with homework, and a problem-solving and social competence group.
A variety of strategies such as behavioral rehearsal, role-playing, and modeling were used to improve basic social skills and effective coping.

141. Participants were randomly assigned to either the experimental intervention or a treatment-as-usual condition involving long term outpatient treatment.
In a 2-year follow up, it was found that participants in both groups showed significant reductions in suicidal ideation and behavior and experienced stress, and improvements in self-appraised problem-solving ability.

142. The intensive time-limited intervention was found to be more effective than long-term treatment in retaining the highest-risk participants.
Analyses showed that patients with psychiatric symptomatology experienced the most improvement in response to this intervention.
The rate of suicide attempts at follow-up was not reported for either experimental or control group and conclusions were limited by high attrition rates in both the experimental and control group.

143. Harrington and colleagues in Great Britain developed a home-based family intervention for adolescents with a history of deliberate self-poisoning.
This intervention used a cognitive behavioral approach to address family dysfunction assumed to be related to the suicide attempt, and to improve adherence to treatment by bringing it into the home.
The intervention consisted of five highly structured sessions focusing of goal setting, reviewing the self-poisoning episode, communication, problem solving, and discussing issues related to the family.

144. The program included a treatment manual and videotape for training.
This brief intervention was found to be effective primarily among those adolescents who were not seriously depressed and had less severe suicidal ideation, who made up about one third of the 85 participants.
Adherence and parental satisfaction with treatment were better for participants in this treatment relative to treatment as usual.
The intervention was found to be no more costly than routine care alone.

145. Wood and colleagues have developed an additional psychotherapeutic variant, using developmental group therapy as a alternative to usual care for adolescents who have repeatedly attempted to harm themselves.
The group-therapy format was hypothesized to be useful in providing an arena for working on social problem-solving and relationship skills that are often considered core to suicidal behavior.
Using a developmental approach to address issues unique to adolescents, the intervention combines problem-solving and cognitive behavioral interventions, and psychodynamic approaches.

146. An acute phase focusing on core themes (family and peer relationships, school problems, anger management, depression, self-harm, and hopelessness) is followed by a longer phase that concentrates on group process.
In interviews conducted 7 months after treatment began, participants in the developmental group therapy reported engaging in less self-harm that did adolescents who received routine care, although depression did not appear to improve.
Participants in the developmental group therapy, particularly youth who had made multiple suicidal attempts, also showed reductions in conduct problems.

147. Pharmacological Treatments for Suicidal Youth
Although the effectiveness of antidepressants in treating children and adolescents has not been definitively established, use of SSRIs in treating depressed and suicidal youth has nonetheless become widespread.
A recent U.S. analysis by Olfson, Shaffer, and colleagues reported an inverse relationship between regional change in use of antidepressants among youth aged and suicide mortality.
The relationship was found to be significant specifically among males, among youth aged 15-19, and in geographic regions with lower family median incomes.

148. An intervention by Cornelius and colleagues used fluoxetine (Prozac) to treat adolescents with comorbid major depression and an alcohol use disorder, including some who demonstrated suicidal ideation at baseline.
The intervention was based on findings that reducing depression and problem drinking in adults resulted in a reduction of suicidal behavior
Also found flouxetine to be effective in treating suicidal adults with an alcohol disorder.

149. In their studies involving youth, all patients receiving fluoxetine improved with respect to depressive symptoms, and over half improved in symptoms of alcohol dependence.
Among participants with suicidal ideation at baseline, ideation decreased and these decreases remained 1 year after treatment.

150. A definitive study supported by the National Institute of Mental Health, known as the Treatment of Adolescents with Depression Study (TADS), has provided the strongest evidence to date of the effectiveness of fluoxetine in treating adolescent depression and suicidality.
This study randomly assigned 439 youths ages 12 to 17 diagnosed with moderate to severe depression to one of four treatment conditions for a period of 36 weeks: fluoxetine therapy alone, cognitive-behavioral therapy (CBT) alone, fluoxetine and CBT, and a placebo drug treatment.

151. Based on the results obtained during the first 12 weeks of the study, the highest rate of clinical improvement (71%) was found among those receiving the combination treatment, followed by 61% of those who received fluoxetine alone, 43% of those who received CBT alone, and 35% of those who received the placebo drug treatment.

152. Critique
Since 2003, concerns have been raised about the safety of the newer antidepressant medications for use by children and adolescents, based initially on unpublished data from drug company studies linking use of SSRIs by children and adolescents to suicidal ideation and self-harm behaviors.
These reports led the British drug regulatory agency to recommend against the sue of all SSRIs except fluoxetine in treating depression among youth under age 18.

153. In 2004, the U.S. Food and Drug Administration undertook a review of 23 clinical trials involving the use of 9 different antidepressant medications by over 4,000 children and adolescents.
The results of this analysis found that the medications increased the risk of suicidal thinking and behavior in children and adolescents with major depressive disorder or other psychiatric disorders.

154. Posthospitalization Programs for Suicidal Youth
The only full-developed program of this sort is the Youth-Nominated Support Team (YST) intervention, developed by King and colleagues.
This program was an outgrowth of the developers’ finding that family dysfunction and parental psychopathology significantly impact treatment adherence by suicidal youth after hospitalization.
Concentrating on the high-risk period for suicidality immediately following psychiatric hospitalization, the program specifically targets poor treatment adherence and negative perceptions of family support and helpfulness.

155. Before leaving the hospital, program participants nominate specific adults from their home, school, or community to support them when they are released.
They YST conducts a psychoeducation session with these adults, then engages them in weekly consultations designed to improve their understanding of the suicidal youngster and how he or she can be effectively supported.
A social network is encouraged among the adults, who typically come from diverse settings.

156. The program is designed to supplement usual treatments.
Response to YST by participating youth and the nominated adults has been positive with 80% of those nominated actually participating in the program.
Positive effects have been reported for adolescent females, including reduced suicidal ideation and mood impairment.
Similar benefits were not evidenced among male participants, although some described YST as having beneficial effects.

157. Critique
Since this intervention has only recently been implemented, it is too early to know whether the positive effects found among the suicidal girls will be translated into reductions of suicide attempts and rehospitalizations.
It will also be important to identify the reasons underlying the lack of clear effects among male participants and to incorporate the necessary programmatic changes.

158. Research Agenda for Youth Suicide Prevention

159. What We Don’t Know About Youth Suicide
Although the problem of youth suicide is disproportionately due to its prevalence in young males, explanations for this phenomenon are currently lacking.
The impact of race and ethnicity on suicide vulnerability among youth and what particular risk or protective factors are conferred by membership in particular racial or ethnic groups is not well understood.

160. What external environments increase or decrease youth vulnerability and susceptibility to suicide. How can these be improved?
Relatively little is known about the specific clinical pathways to youth suicide. In particular, much more needs to be known about the contribution of bipolar disorder, panic attacks, and posttraumatic stress disorder to suicide deaths among youth.
The impact of race and ethnicity on diagnostic profiles and clinical pathways to suicide needs greater scrutiny.

161. Much more needs to be known about the role of neurobiological abnormalities that contribute to youth suicidal behavior, and the degree to which these may be inherited.
The extent to which parental and familial psychopathology influences suicide ideation, attempts, and completions among youth, over and above genetic influences, needs to be examined. Specifically, what is the effect of exposure to parental suicide attempts and completion, and suicide risk among youth? Does childhood physical and sexual abuse confer suicide risk independent of other effects of family psychopathology.

162. Much more needs to be understood about the role of personal and social skills in protecting youth from suicidal behavior. Do strong problem-solving skills, decision-making abilities, and support from family and schools actually protect young people from developing suicidal impulses, or is the absence of such skills a manifestation of psychopathology that is more directly related to suicidal thoughts or behavior?
What is the role of culture, identity, and religious beliefs in reducing suicide risk?

163. What We Don’t Know About Suicide Prevention Programs
Most suicide education programs have not identified the active ingredients responsible for the outcomes they produce.
Most suicide education programs target outcomes whose relationship to youth suicide has not been precisely identified. Many, for example, have reported increased knowledge of mental illness and suicide among students, although the impact of this outcome on suicidal behavior is not known.

164. Although increasing the number of referrals to treatment is a key goal of screening programs, there is not clear evidence of a direct linkage between increased referrals and decreased suicidal behavior among youth.
Screening programs have generally not identified effective mechanisms for encouraging larger numbers of youth identified as at risk for suicide into treatment.
Little data are currently available about the cost-effectiveness of school-based screening programs.

165. Although popular in recent years, the effects of postvention programs, both positive and adverse, on youth exposed to a suicide death have not been clearly documented.
Despite limited evidence that educational programs directed at parents, particularly fathers, can decrease youth access to firearms, the impact of means restriction programs on decreasing suicide attempts and suicide deaths among youth ahs not been documented.

166. What We Don’t Know About Treatment of Suicidality and Underlying Disorders Among Youth
The active ingredients of comprehensive high school-based programs for treating students at risk of dropping out, including some who are depressed and suicidal, have not been clearly identified.
It has not been demonstrated that students at risk of dropping out of school are representative of suicidal youth generally, and therefore that programs that address this population have wide applicability.

167. The replication of such programs, which require considerable personnel and financial resources, has not been established.
The impact of emergency department programs for youth suicide attempters and their families on decreasing suicide deaths has not been established.
Although some promising outcomes have been reported, long-term of cognitive behavior therapy with suicidal youth are not yet known.

168. Although there is increasing evidence of the safety and efficacy of Prozac in treating depressed and suicidal youth, the safety and efficacy of the many other antidepressants currently being used have not been established.
Much more needs to be known about the combinations of psychotherapeutic and pharmacological treatment that produce the most positive short- and long-term outcomes for depressed, suicidal youth.
Long-term effects of post-hospitalization programs for suicidal youth have not been documented.

169. Research Needs
In order to effectively address the knowledge needs that have been identified, youth suicide research must expand beyond its present relatively narrow focus to incorporate standards of research design and program evaluation that are routinely used in other prevention fields.

170. Evaluation strategies that have been employed have relied largely on pre-post designs that do not adequately link outcomes to program components. Program controlled studies are needed to determine the effectiveness, safety, and active ingredients of universal and targeted suicide prevention programs including school-based education, screening, and skills development programs; and school and community interventions for at-risk populations, including firearms restriction programs and gatekeeper training programs.

171. A development that is expected to encourage and support the use of scientifically valid evaluation designs by suicide prevention programs is the recent decision of the Substance Abuse and Mental Health Administration (SAMHSA) to expand its National Registry of Effective Programs and Practices (NREPP) fro its original focus on substance abuse prevention programs to include mental health promotion and treatment programs including those associated with suicide prevention.

172. Funding for Evaluation Studies
Few youth suicide prevention programs have had the necessary personnel or financial resources to conduct independent program evaluations.
If the field is to move forward, mechanisms need to be established that mandate and support comprehensive, well-designed outcome studies as a regular part of prevention programming.

173. Much more attention needs to be given to evaluating the outcome of treatment programs for suicidal youth.
Since universal and selective suicide prevention programs focus heavily on encouraging help seeking and on identifying vulnerable youth and referring them to treatment, their impact on reducing youth suicide depends ultimately on the effectiveness of the treatments that are available to such young people. Thus, the single highest priority must be given to determining the relative efficacy and effectiveness of all currently employed treatments and indicated interventions for suicidal youth.

174. Treatment evaluations need to give particular attention to building appropriate safeguards into treatment trials involving high-risk youth populations.
Maintaining troubled youth in treatment trials over an adequate period of time to observe both short- and long-term outcomes is a particular challenge. Time-limited treatments, while easier to evaluate, leave unresolved questions about long-term effectiveness.