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Programs for the Prevention
of Suicide Among Adolescents
and Young Adults
The following CDC staff members prepared this report:
Patrick W. O'Carroll, M.D., M.P.H.
Office of the Director
Office of Program Support
Lloyd B. Potter, Ph.D., M.P.H.
James A. Mercy, Ph.D.
National Center for Injury Prevention and Control
Summary
Incidence rates of suicide and attempted suicide among
adolescents and
young adults aged 15-24 years continue to remain at high levels. In
1992, to
aid communities in developing new or augmenting existing suicide
prevention
programs directed toward this age group, CDC's National Center for
Injury
Prevention and Control published Youth Suicide Prevention Programs:
A
Resource Guide. The Resource Guide describes the rationale and
evidence for
the effectiveness of various suicide prevention strategies, and it
identifies
model programs that incorporate these strategies. This summary of
the
Resource Guide describes eight suicide prevention strategies and
provides
general recommendations for the development, implementation, and
evaluation
of suicide prevention programs targeted toward this age group.
INTRODUCTION
The continued high rates of suicide among adolescents (i.e.,
persons aged
15-19 years) and young adults (persons aged 20-24 years)
(Table_1) have
heightened the need for allocation of prevention resources. To
better focus
these resources, CDC's National Center for Injury Prevention and
Control
recently published Youth Suicide Prevention Programs: A Resource
Guide (1).
The guide describes the rationale and evidence for the
effectiveness of
various suicide prevention strategies and identifies model programs
that
incorporate these strategies. It is intended as an aid for
communities
interested in developing or augmenting suicide prevention programs
targeted
toward adolescents and young adults. This report summarizes the
eight
prevention strategies described in the Resource Guide.
METHODOLOGY
Suicide prevention programs were identified by contacting
suicide
prevention experts in the United States and Canada and asking them
to name
and describe suicide prevention programs for adolescents and young
adults
that, based on their experience and assessment, were likely to be
effective
in preventing suicide. After compiling an initial list, program
represen-
tatives were contacted and asked to describe the number of persons
exposed to
the intervention, the number of years the program had been
operating, the
nature and intensity of the intervention, and the availability of
data to
facilitate evaluation. Program representatives were also asked to
identify
other programs that they considered exemplary. Representatives from
these
programs were contacted and asked to describe their programs. The
list of
programs was further supplemented by contacting program
representatives who
participated in the 1990 national meeting of the American
Association of
Suicidology and by soliciting program contacts through Newslink,
the
association's newsletter.
Suicide prevention programs on the list were then categorized
according
to the nature of the prevention strategy using a framework of eight
suicide
prevention strategies:
School gatekeeper training. This type of program is designed to
help
school staff (e.g., teachers, counselors, and coaches) identify
and refer
students at risk for suicide. These programs also teach staff
how to
respond to suicide or other crises in the school.
Community gatekeeper training. These programs train community
members
(e.g., clergy, police, merchants, and recreation staff) and
clinical
health-care providers who see adolescent and young adult
patients (e.g.,
physicians and nurses) to identify and refer persons in this
age group
who are at risk for suicide.
General suicide education. Students learn about suicide, its
warning
signs, and how to seek help for themselves or others. These
programs
often incorporate a variety of activities that develop
self-esteem and
social competency.
Screening programs. A questionnaire or other screening
instrument is used
to identify high-risk adolescents and young adults and provide
further
assessment and treatment. Repeated assessment can be used to
measure
changes in attitudes or behaviors over time, to test the
effectiveness of
a prevention strategy, and to detect potential suicidal
behavior.
Peer support programs. These programs, which can be conducted
in or
outside of school, are designed to foster peer relationships
and
competency in social skills among high-risk adolescents and
young adults.
Crisis centers and hotlines. Trained volunteers and paid staff
provide
telephone counseling and other services for suicidal persons.
Such
programs also may offer a "drop-in" crisis center and referral
to mental
health services.
Restriction of access to lethal means. Activities are designed
to
restrict access to handguns, drugs, and other common means of
suicide.
Intervention after a suicide. These programs focus on friends
and
relatives of persons who have committed suicide. They are
partially
designed to help prevent or contain suicide clusters and to
help
adolescents and young adults cope effectively with the feelings
of loss
that follow the sudden death or suicide of a peer.
After categorizing suicide prevention efforts according to this
framework, an expert group at CDC reviewed the list to identify
recurrent
themes across the different categories and to suggest directions
for future
research and intervention.
FINDINGS
The following conclusions were derived from information
published in the
Resource Guide:
Strategies in suicide prevention programs for adolescents and
young
adults focus on two general themes. Although the eight
strategies for
suicide prevention programs for adolescents and young adults
differ, they
can be classified into two conceptual categories:
Strategies to identify and refer suicidal adolescents and
young
adults for mental health care. This category includes
active
strategies (e.g., general screening programs and targeted
screening
in the event of a suicide) and passive strategies (e.g.,
training
school and community gatekeepers, providing general
education about
suicide, and establishing crisis centers and hotlines).
Some passive
strategies are designed to lower barriers to self-referral,
and
others seek to increase referrals by persons who recognize
suicidal
tendencies in someone they know.
Strategies to address known or suspected risk factors for
suicide
among adolescents and young adults. These interventions
include
promoting self-esteem and teaching stress management (e.g.,
general
suicide education and peer support programs); developing
support
networks for high-risk adolescents and young adults (peer
support
programs); and providing crisis counseling (crisis centers,
hotlines,
and interventions to minimize contagion in the context of
suicide
clusters). Although restricting access to the means of
committing
suicide may be critically important in reducing risk, none
of the
programs reviewed placed major emphasis on this strategy.
Suicide prevention efforts targeted for young adults are rare.
With a few
important exceptions, most programs have been targeted toward
adolescents
in high school, and these programs generally do not extend to
include
young adults. Although the reasons for this phenomenon are not
clear, the
focus of prevention efforts on adolescents may be because they
are
relatively easy to access in comparison with young adults, who
may be
working or in college. In addition, persons who design and
implement such
efforts may not realize that the suicide rate for young adults
is
substantially higher than the rate for adolescents
(Table_1).
Links between suicide prevention programs and existing
community mental
health resources are frequently inadequate. In many instances,
suicide
prevention programs directed toward adolescents and young
adults have not
established close working ties with traditional community
mental health
resources. Inadequate communication with local mental health
service
agencies obviously reduces the potential effectiveness of
programs that
seek to identify and refer suicidal adolescents and young
adults for
mental health care.
Some potentially successful strategies are applied
infrequently, yet
other strategies are applied commonly. Despite evidence that
restricting
access to lethal means of suicide (e.g., firearms and lethal
dosages of
drugs) can help to prevent suicide among adolescents and young
adults,
this strategy was not a major focus of any of the programs
identified.
Other promising strategies, such as peer support programs for
those who
have attempted suicide or others at high risk, are rarely
incorporated
into current programs.
In contrast, school-based education on suicide is a common
strategy. This
approach is relatively simple to implement, and it is a
cost-effective
way to reach a large proportion of adolescents. However,
evidence to
indicate the effectiveness of school-based suicide education is
sparse.
Educational interventions often consist of a brief, one-time
lecture on
the warning signs of suicide -- a method that is unlikely to
have
substantial or sustained impact and that may not reach
high-risk students
(e.g., those who have considered or attempted suicide).
Further, students
who have attempted suicide previously may react more negatively
to such
curricula than students who have not. The relative balance of
the
positive and the potentially negative effects of these general
educational approaches is unclear.
Many programs with potential for reducing suicide among
adolescents and
young adults are not considered or evaluated as suicide
prevention
programs. Programs designed to improve other psychosocial
problem areas
among adolescents and young adults (e.g., alcohol- and
drug-abuse
treatment programs or programs that provide help and services
to
runaways, pregnant teenagers, and/or high school dropouts)
often address
risk factors for suicide. However, such programs are rarely
considered
suicide prevention programs, and evaluations of such programs
rarely
consider their effect on suicidal behavior. A review of the
suicide
prevention programs discussed in the Resource Guide indicated
that only
a small number maintained working relationships with these
other
programs.
The effectiveness of suicide prevention programs has not been
demon-
strated. The lack of evaluation research is the single greatest
obstacle
to improving current efforts to prevent suicide among
adolescents and
young adults. Without evidence to support the potential of a
program for
reducing suicidal behavior, recommending one approach over
another for
any given population is difficult.
RECOMMENDATIONS
Because current scientific information about the efficacy of
suicide
prevention strategies is insufficient, the Resource Guide does not
recommend
one strategy over another. However, the following general
recommendations
should be considered:
Ensure that suicide prevention programs are linked as closely
as possible
with professional mental health resources in the community.
Strategies
designed to increase referrals of at-risk adolescents and young
adults
can be successful only to the extent that trained counselors
are
available and mechanisms for linking at-risk persons with
resources are
operational.
Avoid reliance on one prevention strategy. Most of the programs
reviewed
already incorporate several of the eight strategies described.
However,
as noted, certain strategies tend to predominate despite
insufficient
evidence of their effectiveness. Given the limited knowledge
regarding
the effectiveness of any one program, a multi-faceted approach
to suicide
prevention is recommended.
Incorporate promising, but underused, strategies into current
programs
where possible. Restricting access to lethal means of
committing suicide
may be the most promising underused strategy. Parents should be
taught to
recognize the warning signs for suicide and encouraged to
restrict their
teenagers' access to lethal means. Peer support groups for
adolescents
and young adults who have exhibited suicidal behaviors or who
have
contemplated and/or attempted suicide also appear promising but
should be
implemented carefully. Establishment of working relationships
with other
prevention programs, such as alcohol- and drug-abuse treatment
programs,
may enhance suicide prevention efforts. Furthermore, when
school-based
education is used, program planners should consider broad
curricula that
address suicide prevention in conjunction with other adolescent
health
issues before considering curricula that address only suicide.
Expand suicide prevention efforts for young adults. The suicide
rate for
persons in this age group is substantially higher than that for
adoles-
cents, yet programs targeted toward them are sparse. More
prevention
efforts should be targeted toward young adults at high risk for
suicide.
Incorporate evaluation efforts into suicide prevention
programs.
Planning, process, and outcome evaluation are important
components of any
public health effort. Efforts to conduct outcome evaluation are
imper-
ative given the lack of knowledge regarding the effectiveness
of suicide
prevention programs. Outcome evaluation should include measures
such as
incidence of suicidal behavior or measures closely associated
with such
incidence (e.g., measures of suicidal ideation, clinical
depression, and
alcohol abuse). Program directors should be aware that suicide
prevention
efforts, like most health interventions, may have unforeseen
negative
consequences. Evaluation measures should be designed to detect
such
consequences.
For a copy of the full report, Youth Suicide Prevention
Programs: A
Resource Guide, write to Lloyd Potter, Ph.D., M.P.H., at the
Centers for
Disease Control and Prevention, National Center for Injury
Prevention and
Control, 4770 Buford Highway, Mailstop K-60, Atlanta, GA
30341-3724. Single
copies are available free of charge.
Reference
CDC. Youth suicide prevention programs: a resource guide.
Atlanta: US
Department of Health and Human Services, Public Health Service,
CDC,
1992.
Table_1
Note:
To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
TABLE 1. Suicide rates * for persons 15-24 years of age, by age group and sex -- United
States, 1950, 1960, 1970, 1980, and 1990
=========================================================================================
Year
----------------------------------------
Age group (yrs)/Sex 1950 1960 1970 1980 1990
-----------------------------------------------------------------------
15-19
Male 3.5 5.6 8.8 13.8 18.1
Female 1.8 1.6 2.9 3.0 3.7
Total 2.7 3.6 5.9 8.5 11.1
20-24
Male 9.3 11.5 19.2 26.8 25.7
Female 3.3 2.9 5.6 5.5 4.1
Total 6.2 7.1 12.2 16.1 15.1
15-24
Male 6.5 8.2 13.5 20.2 22.0
Female 2.6 2.2 4.2 4.3 3.9
Total 4.5 5.2 8.8 12.3 13.2
-----------------------------------------------------------------------
* Per 100,000 persons.
Source: National Center for Health Statistics, CDC.
=========================================================================================
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