Implementing an Evidence-Based Suicide Prevention Program in Your School Diane Santoro, LICSW Screening for Mental Health, Inc.

Implementing an Evidence-Based Suicide Prevention

Program in Your SchoolDiane Santoro, LICSWScreening for Mental Health, Inc.

What is Screening for Mental Health, Inc.

SMH is a national non-profit organization whose mission is to promote the improvement of mental health by providing the public with education, screening, and treatment resources.

SMH pioneered the concept of large scale mental health screening and education programs in 1991, with its flagship program, National Depression Screening Day® (NDSD).

Screening for Mental Health National Depression Screening Day®

National Eating Disorders Screening Program®

National Alcohol Screening Day®

CollegeResponse®

Military Pathways® (for Military Instillations and VA’s, DoDEA schools, and military impacted schools)

WorkplaceResponse® and HealthcareResponseTM

SOS Signs of Suicide® (Middle School and High School)

Signs of Self-Injury (High School)

Goals of Today’s Webinar

Understand the importance of suicide prevention

Learn about the evidence-based SOS Signs of Suicide Prevention program.

Learn strategies to implement the program in your school/community

Prevalence of Suicide Among Youth 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.

Whereas 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.

Depression & Youth 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).

In children and adolescents, an untreated depressive episode may last between 7 to 9 months, potentially an entire academic year!

More than 90% of people who complete suicide have a diagnosable mental disorder, most commonly a depressive disorder or a substance abuse disorder (NIMH, 2009).

By the Numbers… 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

Risk Factors

The first step in preventing suicide is to identify and understand the risk factors

Risk factors are not necessarily causes

Risk Factors for Suicide

Mental illness is the leading risk factor for suicide in the general population

The strongest risk factors for suicide in youth are depression, substance abuse, and previous attempts (NAMI, 2003)

76-92% youths who die by suicide meet criteria for mood disorder (1992; Gould et al)

Why Do People Want to End Their Lives? Situations that might contribute to a feeling of

hopelessness include: Break-ups/relationship issues Family problems Feeling like you don't belong anywhere Sexual, physical or mental abuse Drug or alcohol addiction Mental illness The death of a loved one School or work problems Unemployment or being unemployed for a long time Any problem that seems hopeless.

SUICIDE: A MULTI-FACTORIAL EVENT

Neurobiology

Severe MedicalIllness

Impulsiveness

Access To Weapons

Hopelessness

Life Stressors

Family History

SuicidalBehavior

Personality Disorder/Traits

Psychiatric IllnessCo-morbidity

Psychodynamics/Psychological Vulnerability

Substance Use/Abuse

Suicide

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)

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)

SOS Signs of Suicidean evidence based youth suicide prevention program

SHOW DVD CLIP

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

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.

• Encourage students to engage in discussion about these issues with their friends and with their parents

• Increase help-seeking by providing students with specific action steps to take if they are concerned about themselves or others and by identifying resources.

SOS Program Components

Implementation Guide

Educational DVD & Discussion Guide

Brief Screen for Adolescent Depression (BSAD) - Parent & Student Version – High School

Center for Epidemiological Studies Depression Scale for Children (CES-DC) – Middle School

High School Student Newsletter / Middle School Student & Parent Newsletters

Customizable Wallet Cards/ ACT stickers / Posters

Educational Materials for Staff, Students, and Parents

Postvention Guide

Implementation Overview

1. Identify and Train Your Team Review program goals and assign roles/responsibilities

Review kit, DVD 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

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

Non-anonymous Anonymous with number ID Anonymous Anonymous with Response Card Eliminate (do not screen) and use Response Card

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):_________________________________

HOMEROOM 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.

3. Demonstrate the Program Suggestions for an all staff training:

Review the signs of depression and suicide

Answer questions; dispel myths

Show the DVD 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

4. Prepare for Follow-Up Use SAMHSA’s 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 to send with parent letter

Have copies of the student follow-up form available

Review school’s emergency procedures and parental notification

Identify in advance who will be handling emergencies

Notify the nearest crisis response center about the program in advance in order to facilitate referrals.

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

Evaluation of the SOS Program

SOS is the only universal school-based suicide prevention program for which a reduction in self-reported suicide attempts has been documented with a randomized experimental design

Based on evidence from the first year of a 2-year study involving over 2,100 students in 5 schools (Aseltine, 2004), the SOS program was added to SAMHSA’s National Registry of Evidence-Based Programs and Practices

Study published in BMC Public Health, 2007 found SOS to be associated with significantly greater knowledge, more adaptive attitudes about depression and suicide, and most importantly, significantly fewer suicide attempts among intervention youths relative to untreated controls (Aseltine, 2007)

Prevention Programs – Reducing Liability

Common Themes in Lawsuits

The institution ignored warning signs of suicide. The institution provided the tools that the student used for

suicide. The institution took insufficient steps to address warning

signs. The institution failed to notify the family about the

student’s condition.

-United Educators, “The Suicidal Student: Issues in Prevention,Treatment, and Institutional Liability” Roundtable Discussion, 2003

Student Mental Health Screening: A Risk Management Perspective

A record of prevention programs is important.

Screening efforts and counseling services help show that the school takes student mental health issues seriously. Many causes of serious student injury and death relate to mental health concerns.

United Educators actively encourages schools to provide a safe environment for students and reduce the institution’s liability. They believe that the SOS Suicide Prevention program can serve as an important risk management tool for schools.

Constance Neary, Vice President for Risk Management, United Educators Insurance

Student Mental Health ScreeningIt is important to convey to students and parents that

the mental health screenings being conducted in your school are for educational purposes

Screenings are informational, not diagnostic - Diagnoses, treatment recommendations and opinions should not be given

The goal of the screening is to identify students with symptoms consistent with depression and/or suicidality and to advise a complete professional evaluation

Best Practices Prompt disclosure of a suicide threat to a parent is both legal

and prudent

Document steps taken by the school, including parental follow-up and clinical care status

Joint decision making and good documentation help justify decisions should they later be challenged

Confidential materials should be stored under lock and key

Always consult with the school legal department for questions regarding policies

Common Objections & Talking Points Suicide is not a problem in our school

No school is immune to adolescent suicide

Schools are not appropriate for suicide prevention programs Student problems with academics, peers, and

others are more apt to be evident in school. The majority of parents are unaware of their child’s suicidality.

The program may introduce the idea to students There has been no harm seen in screening teens

for suicide risk (Gould, M., et al, 2005)

I don’t agree with labeling youth The screenings are not diagnostic

Common Objections & Talking PointsI don’t have enough staff/time

The program can be implemented in one class period using existing resources and partnerships with community providers.

There are no referral resources in my area Identifying the need for resources can help

justify the need for funding. We cannot conduct mental health screenings

Screenings can be done confidentially or not at all

We already have a suicide prevention program SOS is the only evidence-based that addresses

suicide risk and depression, while reducing attempts.

It can also compliment other programs (QPR)

Screening for Mental Health, Inc.One Washington Street, Suite 304 Wellesley Hills, MA 02481

Phone: 781.239.0071 Fax: 781.431.7447www.MentalHealthScreening.org

Aseltine, R., et al. (2007). Evaluating the SOS suicide prevention program: A replication and extension. BMC Public Health 7(161).

Aseltine Jr., R.H. & DeMartino, R. (2004). An Outcome Evaluation of the SOS Suicide Prevention Program. American Journal of Public Health, 94 (03), 446-451.

Centers for Disease Control and Prevention. 2009 Youth Risk Behavior Survey. Available at: www.cdc.gov/yrbss.

Gould, M., et al. (2003). Youth suicide risk and preventive interventions: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 42 (4), 386-405. 

Resources

Resources National Institute of Mental Health. (2009) Suicide in the U.S.,

statistics and prevention. Retrieved June 15, 2009, from http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtml

National Alliance of Mental Illness (NAMI). (2003). Depression in Children and Adolescents. Retrieved on June 16, 2009 from http://www.nami.org/Template.cfm?Section=By_Illness&template=/ContentManagement/ContentDisplay. cfm&ContentID=17623

UCLA Center for Mental Health in Schools. School community partnerships: a guide. Retrieved from http://smhp.psych.ucla.edu/pdfdocs/guides/schoolcomm.pdf

ResourcesCenter for Disease Control and Prevention. (2008). Web based injury

statistics query and reporting system (WISQARS). Retrieved June 11, 2009, from http://www.cdc.gov/injury/wisqars/index.html

Doan, J., Roggenbaum, S., & Lazear, K. (2003). Youth suicide prevention school-based guide. Tampa, FL: Department f Child and Family Studies, Division of State and Local Support, Louis de la Parte Florida Mental Health Institute, University of South Florida.

Guild, M., Marrocco, F., Kleinman, M, Graham, J., Mostkoff, K, Cote,J. & Davies, M. (2005). Evaluation iatrogenic risk of youth suicide screening programs: a randomized controlled trial. Journal of the American Medical Association, 293 (13).

Kalafat, J., Ryerson, D., and Underwood, M. Lifelines ASAP - LifelinesAdolescent Suicide Awareness and Response Program. Piscataway, NJ: Rutgers University.

Resources 

Grossman, D., et al. (2005). Gun storage practices and the risk of youth suicide and unintentional firearm injuries. Journal of the American Medical Association, 293 (6), 707-714.

Kerr, M. Suicide Prevention in Schools: Best practices and questionable practices [PDF document]. Retrieved from STAR-Center Online Website: http://www.starcenter.pitt.edu/suicidepreventionresources/56/default.aspx

Litts, D. (August 2, 2004). USAF Suicide Prevention Program: Lessons for Public Health Prevention in Non-military Communities. Retrieved June 2, 2009 from http://www.sprc.org/traininginstitute/disc_series/disc_1.asp

Resources National Adolescent Health Information Center. (2006). Fact sheet

on suicide-Adolescents and young adults. San Francisco, CA: Author, University of California, San Francisco.

Office of Applied Studies. (2006). Results from the 2005 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 06-4194, NSDUH Series H-30). Rockville, MD: Substance Abuse and Mental Health Services Administration.

Shenassa, E., Rogers, M., Spalding, K. (2004). Safer storage of firearms at home and risk of suicide: a study of protective factors in a nationally representative sample. Journal of Epidemiology and Community Health, 58, 841-848.

World Health Organization. (2000). Preventing suicide: A resource for teachers and other school staff. Geneva, Switzerland: Mental and Behavioral Disorders, Department of Mental Health.