Signs of Suicide: A Promising School-Based Suicide Prevention Program in Military Schools

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Signs of Suicide A Promising School-Based
Suicide Prevention Program in Military Schools

• Robert H. Aseltine Jr., PhD

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Scope of the Problem

• Youth Suicide National and International Trends

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Increasing Rates of Youth Suicide

• Nationally, suicide is the 3rd leading cause of
  death among children ages 15-24 (4,405 deaths in
  2006) (CDC, 2004). Only accidents and homicides
  occurred more frequently.
• While suicides accounted for 1.4 of all deaths
  in the U.S. annually, they comprised 12 of all
  deaths among 15-24-year-olds.
• Adolescent suicidal behavior is deemed to be
  underreported because many deaths of this type
  are classified as unintentional or accidental
  (World Medical Association, 2004).
• Centers for Disease Control and Prevention,
  National Center for Injury Prevention and
  Control. Web-based Injury Statistics Query and
  Reporting System (WISQARS) online. (2004)
  cited 2005 Feb 28. Available from URL
  www.cdc.gov/ncipc/wisqars.

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US Suicide Rate Per 100,000 (15-19 year olds)
Source National Center for Health Statistics,
2004
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Youth Suicide in Industrialized Nations Rate
per 100,000
Source Beautrais, 2002
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Suicidal Ideation and Suicide Attempts

• 2009 Youth Risk Behavior Survey found that
• 26.1 felt so sad or hopeless for 2 weeks that
  they stopped doing some usual activity.
• 13.8 seriously considered attempting suicide.
• 10.9 made a suicide plan.
• 6.3 attempted suicide.
• 1.9 of those who made an attempt required
  medical attention
• Find the data for your city/state
• http//www.cdc.gov/HealthyYouth/yrbs/index.htm

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Risk Factors
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Risk Factors for Adolescent Suicide

• MALES FEMALES
• Mood disorder 7.5X 34.3X
• Substance abuse 4.9 36.6
• Conduct disorder 5.6 ---
• Gun in home 4.5 15.0
• Family history of suicide 2.4 ---
• Past attempt 41.4 59.7

Source Brent et al 2002
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Mood Disorders and Suicide

• In 2007, 8.2 of adolescents (1 in 12 an
  estimated 2 million youth aged 12 to 17) reported
  experiencing at least one major depressive
  episode in the past year (SAMHSA, 2009).
• 76-92 youths committing suicide meet criteria
  for mood disorder
• Primarily major depression, bipolar disorder
• Andrews Lewihsohn, 1992 Gould et al, 1998
  Mazza Reynolds, 2001.

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Alcohol Abuse and Suicide
Attempt Suicide/ Past Year Attempt Suicide/Ever
Heavy alcohol use / past year
NO 3.3 10.6
YES 9.0 45.1

Drinking when down / past year
NO 3.2 7.6
YES 18.2 32.5
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Social Context of Youth Suicide

• Adolescence Transition from parents to peers

• Most suicidal youth confide concerns to peers
  (Brent et al., 1988)

• 25 of peer confidants tell an adult (Kalafat
  et al., 1993)

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Preventing Youth Suicide
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Brief History of School-Based Suicide Prevention

• Two types of programs Universal vs. Selective

• Universal programs almost universally
  disappointing

• Temporary changes in knowledge and attitudes

• No impact on behavior

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SOS Signs of Suicide Prevention Programs for
Middle High Schools Diane Santoro,
LICSW Screening for Mental Health, Inc.
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Military Children

• More than two million American children have had
  a parent deploy to Iraq or Afghanistan
• At least 19,000 children have had a parent
  wounded in action
• Over 2,200 children have lost a parent in Iraq or
  Afghanistan
• Children of military families ages 11 to 17 were
  found to have a higher prevalence of emotional
  and behavioral difficulties than children in the
  general population
• Parental deployment places school-age children
  and adolescents at higher risk for a range of
  adverse mood and behavioral changes anger,
  apathy, anxiety, depression, withdrawal, decline
  in school performance, loss of interest in normal
  activities, and social isolation
• National Center for Children in Poverty Trauma
  Faced by Children of Military Families May 2010

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SUICIDE A MULTI-FACTORIAL EVENT
Psychiatric IllnessCo-morbidity
Neurobiology
Personality Disorder/Traits
Impulsiveness
Substance Use/Abuse
Hopelessness
Severe Medical Illness
Suicide
Family History
Access To Weapons
Psychodynamics/ Psychological Vulnerability
Life Stressors
Suicidal Behavior
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What Can Schools Do?

• School systems are not responsible for meeting
  every need of their students. But when the need
  directly affects learning, the school must meet
  the challenge. (Carnegie Task Force on
  Education)
• Schools cannot achieve their mission of educating
  the young when students problems are major
  barriers to learning and development.
• Schools are at times a source of the problem and
  need to take steps to minimize factors that lead
  to student alienation and despair
• Schools also are in a unique position to promote
  healthy development and protective buffers, offer
  risk prevention programs, and help to identify
  and guide students in need of special assistance
• Center for Mental Health in Schools at UCLA
  (http//smhp.psych.ucla.edu)

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Implementing a Universal Prevention Program

• Change environments and systems by applying
  intervention universally with particular
  concern for diversity
• Enhance awareness and increase information among
  students, staff, family, and community
• Enhance identification of those at risk and build
  capacity of school, family, community to help
• Enhance competence related to social and
  emotional problem solving
• Enhance protective buffers

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SHOW DVD CLIP
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SOS Signs of Suicide Program Goals

• Decrease suicide and attempts by increasing
  knowledge and adaptive attitudes about depression
• Encourage individual help-seeking and
  help-seeking on behalf of a friend
• Reduce stigma - link suicide to mental illness
  that, like physical illness, requires treatment
• Engage parents and school staff as partners in
  prevention by educating them to identify signs of
  depression and suicide and by providing
  information about referral resources
• Encourage schools to develop
  community-based partnerships.

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SOS Signs of Suicide Student Goals

• Help youth understand that depression is a
  treatable illness
• Educate youth that suicide is not a normal
  response to stress but rather a preventable
  tragedy that often occurs as a result of
  untreated depression
• Inform youth of the risk associated with alcohol
  use to cope with feelings.
• Increase help-seeking by providing students with
  specific action steps to take if they are
  concerned about themselves or others and by
  identifying resources.
• Encourage students to engage in discussion about
  these issues with their friends and with their
  parents

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SOS Program Components High School Program

• Implementation Guide
• Educational DVD Discussion Guide
• Brief Screen for Adolescent Depression (BSAD) -
  Parent Student Version
• High School Student Newsletter
• Customizable Wallet Cards
• Posters
• Educational Materials for Staff, Students,
  Parents

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SOS Program Components Middle School Program

• Implementation Guide
• Educational DVD Discussion Guide
• Center for Epidemiological Studies Depression
  Scale for Children (CES-DC)
• Student Parent Newsletters
• Customizable Wallet Cards
• Posters
• Educational Materials for Staff, Students,
  Parents

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Implementation Overview
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1. Identify and Train Your Team

• Review program goals and assign
  roles/responsibilities
• Review kit, video, and discussion guide
• Review screening form and scoring
• Designate time and date for program
  implementation
• Review school policies for handling suicide
  disclosure, parental consent, record keeping, etc

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2. Decide On Format

• Provide program school-wide or select target
  student group based on grade level, class
  enrollment, or special need
• Screening Implementation Options
• Eliminate (do not screen)
• Non-anonymous
• Anonymous with number ID
• Anonymous
• Anonymous with Response Card

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BASED ON THE VIDEO AND/OR SCREENING,
I FEEL THAT ? I need to talk to
someone ? I do not need to talk to someone
ABOUT MYSELF OR A FRIEND.
NAME(PRINT)_________________________________ HOM
EROOM SECTION_________________________
TEACHER_____________________________________
IF YOU WISH TO SPEAK WITH SOMEONE, YOU WILL BE
CONTACTED WITHIN 24 HOURS. IF YOU WISH TO SPEAK
WITH SOMEONE SOONER, PLEASE APPROACH STAFF
IMMEDIATELY.
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3. Demonstrate the Program

• Staff Training Suggestions
• Review the signs of depression and suicide
• Answer questions dispel myths
• Show the video and facilitate a discussion
• Review the Screening Form
• Review the school protocol for handling students
  who disclose suicidal intent
• Review school and community mental health
  resources

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4. Prepare for Follow-Up

• Use SAMHSAs Find Treatment Locator to identify
  additional referral resources
• Contact local mental health facilities and verify
  their referral procedures, wait lists, insurance
  details, etc.
• Create a Referral Resource List
• Track student follow-up
• Identify in advance who will be handling
  emergencies
• Notify the nearest crisis response center about
  the program in advance in order to facilitate
  referrals.

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On the Day of the Program

• Introduce program
• Show video
• Facilitate discussion
• Students complete screening forms and Response
  Card
• Set expectation about when follow-up can be
  expected provide referral information
• Follow up with students requesting help
• Respond to requests for help track students
  seeking help using the Student Follow-Up form

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Summary What SOS Does

• EDUCATION about depression/suicide
• Defines as illness ? reduces stigma

• SCREENING for depression

• MOBILIZES peers

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Does SOS Work?

• In 3 previous randomized controlled studies

• Increase in knowledge about suicide and attitudes
  toward suicide
• Decrease in suicide attempts
• No effect on help-seeking
• On SAMHSAs National Registry of Evidence-based
  Programs and Practices

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Current Study

• DOD schools
• Middle school students
• Program implemented and evaluated by school
  staff, not research staff

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Outcome Evaluation of SOS Program among students
in military schools

• Suicidal thoughts and behavior
• Attitudes and knowledge
• Help seeking

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Outcome Evaluation

• Involved students in 10 middle schools and 10
  high schools

• Randomized experiment
• ½ of schools SOS
• ½ of schools Wait list control

• Outcomes assessed at baseline 3 mos.
• anonymous questionnaires during class

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Measures

• Attitudes/Knowledge
• Attitudes 10 item scale
• Knowledge 7 item scale

• Help-seeking past 3 months
• Treatment Y/N
• Talked to parent/guardian, sibling, teacher or
  guidance counselor, other adult, hotline Y/N
• Talked to adult about friend Y/N

• Suicidal behavior past 3 months
• Ideation Y/N
• Plan Y/N
• Attempts Y/N

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Middle School Participants

• Gender
• Male 47
• Female 53
• Racial/ethnic self-identification
• White, non Hispanic 41
• Black, non-Hispanic 12
• Hispanic 20
• Multiethnic 9
• Other 18

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Middle School Participants (Continued)

• ESL/ELL
• No 81
• Yes 19
• Parental deployment
• No 74
• Yes 26

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Effects of SOS Program on Knowledge and Attitudes
About Depression/Suicide
Treatment and controls differ at the .05 level on
knowledge only.
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Standardized Effects of SOS on Knowledge and
Attitudes
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Odds Ratios for Effect of SOS on Attempts in past
3 months
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Effects of SOS Program Change in Suicidal
Ideation and Suicide Attempts
Treatment and controls do not differ at the .05
level for suicide attempts.
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Help seeking

• As in previous studies, no effects on
  help-seeking were found

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Summary

• Increase in knowledge about suicide and attitudes
  toward suicide in DOD middle school students
• Sample size too small to estimate effect of SOS
  on suicide attempts
• Program successfully implemented by school staff

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Summary

• Next steps
• Implement in high-impact schools
• Increase sample size
• Long term benefits?
• Help-seeking?

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Acknowledgements

• Grateful for financial support from U.S.
  Department of Defense

• For more info on program http//www.mentalhealth
  screening.org