Suicide Prevention in School: Research and Emerging Best Practices

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Suicide Prevention in School Research and
Emerging Best Practices

• Peter A. Wyman, Ph.D.
• University of Rochester School of Medicine and
  Dentistry
• Department of Psychiatry
• Center for Study and Prevention of Suicide

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Suicidal Behavior in Adolescents

• 2-4 of teens acutely suicidal each year
• about 14 Suicidal Ideation
• Few deaths (10/100,000) but many attempts and
  untreated problems
• Most youth with psychiatric disorders not being
  treated Important role for schools,
  identification and response
• Rural areas 2X higher suicide deaths than more
  urban areas, including in NY

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Overview

• No efficacious suicide prevention programs
  unlike prevention of other youth problems. Some
  promising approaches.
• Gatekeeper Training what weve learned in 4
  years research (NIMH) in collaboration w/ county
  school district
• Sources of Strength a Peer Leader model for
  suicide prevention (SAMHSA)
• NY State Sources of Strength Project in rural
  areas. NYOffice of Mental Health support.

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Gatekeeper Training

• Gatekeeper Training at the forefront of youth
  suicide prevention in U.S.
• Garrett Lee Smith Memorial Act 82million for
  States/Tribes(2004-07)
• Gatekeeper training widespread but largely
  untested
• 4-year project testing underlying assumptions of
  gatekeeper approach. Randomized Trial in a large
  school district.

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Support

• R34MH071189-01 (Wyman, Brown)  NIMH
• RCT of Gatekeeper Training for Suicide Prevention
  
• SM57405-01 ( Wyman, Brown) SAMHSA
• Evaluating Success of a Gatekeeper Program in
  Linking Suicidal Students to Treatment
• Supplement to SM57405-01 ( Wyman, Brown) SAMHSA
• Enhancing Youth and Community Engagement in
  Suicide Prevention
• P20MH071897-01 (Caine)  NIMH
• Developing Center On Public Health and Population
  Interventions For The Prevention Of Suicide
• R01-MH40859 (Brown)    NIMH NIDA  CDC
• Methodology for Mental Health/Substance Abuse
  Prevention Early Intervention
• SPAN-GA Developmental Support from the State of
  Georgia
• Cobb County School District, Georgia
• JDS Foundation (Brown, Wyman) Development of an
  Integrated Suicide Prevention Program for Rural
  and Underserved Youth

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Gatekeeper Training an overview

• Teach warning signs/risk factors for suicide
  (QPR Assist)
• Strategies to ask about suicide engaging someone
  suicidal
• Facilitate referral to mental health services
• Case-Identification approach

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Whats the Evidence for Gatekeeper Training?

• Increased attitudes, knowledge in pre-post and
  comparison group designs (e.g., Eggert et al.,
  1997 King Smith, 2000)
• One part of multi-component US Air Force Program
  (Knox, et al 2004)
• No completed randomized trials modest level of
  evidence (IOM)

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Research Questions for Gatekeeper Model

• Training Impact (Who benefits?)
• Increase Detection 3. Reduce Suicidality
• Referral of Suicidal Youth? Through MH Services?

MH Service Utilization
Improved Mental Health
Referred
Suicidal
All Students
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The Setting Cobb County,Georgia

• 3rd largest in Georgia, NW Atlanta - 650,000
  residents
• 110,000 students (2005)
• 30 African American 11 Hispanic
• Wide SES diversity- 30 low income
• 31 growth last decade
• African American 250
• Hispanic 665

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A twelve-year-old boy hangs himself after being
punished at school. A 16-year-old shoots himself
while visiting a friend. Another boy takes his
own life with a borrowed .357 Magnum. The series
of deaths in the booming suburbs of Cobb County,
just north of Atlanta, are part of a ''suicide
cluster,'' an affliction that has inexplicably
visited half a dozen U.S. communities in this
decade.
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School-Based Wait-Listed Randomized Trial

• System-wide crisis protocol and rapid mental
  health evaluations since 1988
• QPR- Question, Persuade, Refer (Quinett, 1995)
• Trained all staff starting in 2004
• 32 Schools
• 12 High Schools 20 Middle Schools
• ½ received early/ ½ late, randomly assigned

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Strengthening Collaboration w/ School District

• Superintendent of Schools co-PI on NIMH grant
• Bottom down and top up
• Integration w/ current priorities staff-student
  relationships

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QPR
In School

• Indirect or Coded Verbal Clues
• Im tired of life, I just cant go on.
• My family would be better off without me.
• Who cares if Im dead anyway.
• I just want out.
• I wont be around much longer.
• Pretty soon you wont have to worry about me.

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QQUESTIONHOW TO ASK THE SUICIDE QUESTION

• Less Direct Approach
• Have you been unhappy lately? Have you been
  very unhappy lately? Have you been so unhappy
  lately that youve been thinking about ending
  your life?
• Do you ever wish you could go to sleep and never
  wakeup?

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Gatekeeper Surveillance ModelThe Underlining
Theory
Increase Awareness
Increase Knowledge
Traditional Gatekeeper Program
Increase Attitudes Towards Taking on a Gatekeeper
Role
Increase Surveillance
Adults
Youth
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Rationale for Surveillance Model

• Students reveal warning signs of suicide (CDC,
  2004)
• Risk factors predictable (Schaffer, 1996)
• Suicidal youth under-identified and
  under-utilizing treatment (Gould Kramer, 2001)
• Adults with knowledge of services connect more
  youths to treatment (Stiffman, 2002)
• Consistent with other broad public health
  initiatives (e.g. defibrillators in community)

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Surveillance may not be sufficient

• Limited recognition of youth problems even
  among professionals (Burns et al., 1995 Earls,
  1989)
• Many adults non-responsive to suicidal
  communication (Wolk-Wasserman 1986)
• Suicide behavior more impulsive in youth (Brent,
  1999)
• Suicidal students may not seek help - negative
  coping (Gould 2001)

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Impact on School Staff

• 350 of 4000 staff enrolled for longitudinal
  surveys
• 76 staff trained w/ 1 year average follow-up
• Knowledge, Efficacy
• Asking Students about Suicide (QPR goal)
• Communication
• Wyman, Brown et al., Journal Consulting Clinical
  Psychology, 2008.

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Significant Improvements from QPR Training on
Knowledge
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Highly Significant Gains in Appraisals and
Awareness
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Much Smaller Improvements in Self-Reported
Intervention Behaviors
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Training Increased Asking Students about
Suicide for 14 of staff already asking
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Conclusions about Impact on Staff

• QPR increased knowledge, appraisals
• Asking about suicide increases limited to staff
  already asking youth
• Knowledge and attitudes not sufficient to
  increase suicide identification behaviors

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2. Does QPR Increase Referrals for Life
Threatening Behavior (LTB)

• Referral for Immediate Crisis Evaluation due to
  Life Threatening Behavior
• Crisis response protocol in existence since 1988.
• Parents called, child kept safe, including
  referral for evaluation verification child is
  safe before return to school
• Of nearly 400 LTB referrals, all but 1 evaluated

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Analyses of LTB

• Examined each Life Threatening Behavior Referral
  over 2 years obtained date of referral, gender,
  race/ethnicity, grade
• Linked to numbers of pupils in same categories
  and each time interval (48,000 students)

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Dramatic differences in LTB referrals by grade
highest at 8th grade
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Did QPR training increase referrals for LTB?
No overall increase in referrals Middle schools
modest effect staff trained
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Conclusions Study 2

• Small to negligible effects of QPR training on
  LTB referrals
• Middle Schools- modest indication of benefit only
  when training exceeds 60 of staff trained
• Why is QPR not increasing identification and
  referral of suicidal students?

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2,059 students surveyed in same schools Suicidal
students less likely to endorse seeking help
from adults

• Suicidal students 1/3rd as likely to seek help
  from adults
• If overwhelmed by life

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Study III In same District, followed students
referred for life-threatening Crisis

• Does referral for mental health services reduce
  suicide risk

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Proportion Suicidal at Crisis Assessment using
standardized questions
¹ Are you currently having thoughts or urges to
harm or kill yourself? ² Have you seriously
thought about killing yourself during the last 4
weeks?
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Referrals by Assessor 1/3rd in acute crisis
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Use of Services and Change in Mental Health Status

• 24.49 months (Average of 2 years) after Referral
  and Evaluation
• 89 Youths/Parents, avg 16.7 years (M)
• Individual interview and assessment

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Any Service Use/Non-Use

• Inpatient - 33.7 Outpatient - 79.1
• Services at School - 24.7
• Psychotropic Medication 52
• Rates of treatment connection highly
  comparable to referral rates
• BUT
• 49.3 of Parents Unsure Whether Child Received
  Professional Help Needed
• 46 Youths Did Not Get All Help Needed

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Proportion of Youth w/ MH Problems after LTB
Referral

• 52.6 Positive Screen for one or more Psychiatric
  Diagnosis
• 34.1 gt 1 Diagnosis 17 Probable
• 13.4 Suicide Attempt last year

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Conclusions Study 3

• Protocol highly successful in completing
  evaluations and linkage w/ services
• After referral weaker in use of services
• Two Year Follow-up High proportion of youths
  elevated problems 13 suicide attempt in past
  year

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Overall Conclusions About Gatekeeper Training

• Small/negligible effects in increasing detection
  of LTB through QPR.
• Modest benefit to Middle Schools after most staff
  trained
• Surveillance Model not supported
• Suicidal students reluctance to communicate with
  adults a formidable barrier

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Overall Conclusions

• Prepared staff (counselors, nurses) may ask
  more students about suicide after QPR but few
  others are communicating with students about
  distress
• Many suicidal students dont receive needed
  mental health services

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Building a Communication Model

• Students attitudes and behaviors -- How reduce
  codes of silence?
• Agents of change in high schools?
• natural resources in communities that help
  teens in crisis?
• Soley relying on formal MH services may not be
  effective

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Sources of Strength in Suicide Prevention
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Sources of Strength

• Teen Peer Leaders need training, information
  on Codes of Silence, clear message to partner
  and involve adults
• Teens already intervening with friends, usually
  without adult knowledge
• Teens can enhance norms about seeking help and
  coping Sources of Strength
• Connect peers in crisis with Trusted Adults

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Sources of Strength
Family Support
Access to Mental Health
Positive Friends
Access to Medical
Caring Adults
Spirituality
Positive Activities
Generosity/Leadership
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Creating Youth Adult Partners

• Codes of Silence in most teen suicides the peer
  group knows about warning signs, but dont tell
  adults
• Peers often handle suicide by themselves, often
  very poorly
• The highest risk teens dont approach adults for
  help
• When teens approach adults for help they approach
  someone they already know and trust

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Training Peer Leaders

• Select a group of diverse teens and adult
  advisors and provide four hour training
• Teens then follow with five action steps
• Peers contact their named adults
• Peers contact 5-10 friends
• Peers to peer classroom messages
• Peers provide Hope, Help, and Strength Messages
• Peers celebrate, receive recognition, message to
  parents

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Sources of Strength

• Over 5,000 teens trained in North Dakota and
  western states (Mark LoMurray, developer)
• North Dakota had 47 reduction in teen suicides
• Sources of Strength modest evaluation to date

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Sources of Strength in NY

• Combine positive benefits of staff gatekeeper
  training with Teen Peer Leader training
• NY-OMH supporting expansion of integrated model
  into rural counties in NY
• Linking with schools through county suicide
  prevention coalition and AFSP chapters