Preventing Youth Suicide: Potential "Crossover Effects" of Existing School-Based Programs.

Notable increases in youth mental health problems combined with strains on the already stretched mental health workforce raise concerns that there will be an ensuing increase in youth suicide thoughts, behaviors, and even deaths. Schools are recognized as crucial settings for youth mental health support and suicide prevention activities, yet schools also face staff shortages and ever-increasing responsibilities for student well-being. Evidence is emerging that prevention programs originally designed to improve problem-solving skills and social-emotional functioning in youth have demonstrated downstream, "crossover effects," that is, unanticipated benefits, on youth suicidal behavior. Relatively little research on crossover effects has been conducted within school settings, despite the strong potential for commonly administered programs to have an impact on later suicide risk. We review key suicide risk factors and their proposed mechanisms of action; we also discuss factors that may protect against suicide risk. We then identify upstream prevention programs targeting the same factors and mechanisms; these programs may hold promise for downstream, crossover effects on youth suicide risk. This paper is intended to provide a framework to help researchers, practitioners, and policymakers as they consider how to prevent youth suicide using existing school-based resources. Rigorous investigation of upstream prevention programs is urgently needed to determine ideal approaches schools and communities can deploy to prevent youth suicide.

Medical-encounter mental health diagnoses, non-fatal injury and polypharmacy indicators of risk for accident death in the US Army enlisted soldiers, 2004-2009.

Accidents are a leading cause of deaths in U.S. active duty personnel. Understanding accident deaths during wartime could facilitate future operational planning and inform risk prevention efforts. This study expands prior research, identifying health risk factors associated with U.S. Army accident deaths during the Afghanistan and Iraq war. Military records for 2004-2009 enlisted, active duty, Regular Army soldiers were analyzed using logistic regression modeling to identify mental health, injury, and polypharmacy (multiple narcotic and/or psychotropic medications) predictors of accident deaths for current, previously, and never deployed groups. Deployed soldiers with anxiety diagnoses showed higher risk for accident deaths. Over half had anxiety diagnoses prior to being deployed, suggesting anticipatory anxiety or symptom recurrence may contribute to high risk. For previously deployed soldiers, traumatic brain injury (TBI) indicated higher risk. Two-thirds of these soldiers had first TBI medical-encounter while non-deployed, but mild, combat-related TBIs may have been undetected during deployments. Post-Traumatic Stress Disorder (PTSD) predicted higher risk for never deployed soldiers, as did polypharmacy which may relate to reasons for deployment ineligibility. Health risk predictors for Army accident deaths are identified and potential practice and policy implications discussed. Further research could test for replicability and expand models to include unobserved factors or modifiable mechanisms related to high risk. PTSD predicted high risk among those never deployed, suggesting importance of identification, treatment, and prevention of non-combat traumatic events. Finally, risk predictors overlapped with those identified for suicides, suggesting effective intervention might reduce both types of deaths.

Associations of childhood bullying victimization with lifetime suicidal behaviors among new U.S. Army soldiers.

BACKGROUND: Prior studies have documented associations of childhood bullying victimization with suicidal behaviors. However, many failed to adjust for concomitant risk factors and none investigated this relationship in military personnel. This study aimed to estimate independent associations of childhood bullying victimization with suicidal behaviors among U.S. Army soldiers. METHODS: Soldiers reporting for basic training completed a cross-sectional survey assessing mental disorders, suicidal behaviors, and childhood adversities including two types of bullying victimization: (1) Physical Assault/Theft and (2) Bullying Comments/Behaviors. Associations of childhood bullying experiences with suicidal behaviors were estimated using discrete-time survival analysis of person-year data from 30,436 soldiers. Models adjusted for sociodemographic factors, childhood maltreatment by adults, and mental disorders. RESULTS: After comprehensive adjustment for other risk factors, more frequent Physical Assault/Theft by peers during childhood was associated with increased odds of lifetime suicidal ideation (adjusted odds ratio [AOR] = 1.18, 95% CI: 1.11-1.26, P < .001) and attempt (AOR = 1.30, 95% CI: 1.13-1.50, P < .001). More frequent Bullying Comments/Behaviors were associated with increased risk of ideation (AOR = 1.30, 95% CI: 1.26-1.35, P < .001), plan (AOR = 1.44, 95% CI: 1.35-1.54, P < .001), attempt (AOR = 1.24, 95% CI: 1.15-1.33, P < .001), and onset of plan among ideators (AOR = 1.09, 95% CI: 1.03-1.15, P = .002). Relative to no bullying victimization, exposure to the most persistent bullying was associated with two- to fourfold increase in risk for suicidal behaviors. CONCLUSIONS: Childhood bullying victimization is associated with lifetime suicidal behaviors among new soldiers. Exposure to Bullying Comments/Behaviors during childhood is associated with progression from suicidal ideation to plan. Improved recognition of these relationships may inform risk mitigation interventions for soldiers.

Timing the Mode Switch in a Sequential Mixed-Mode Survey: An Experimental Evaluation of the Impact on Final Response Rates, Key Estimates, and Costs.

Mixed-mode surveys need to determine a number of design parameters that may have a strong influence on costs and errors. In a sequential mixed-mode design with web followed by telephone, one of these decisions is when to switch modes. The web mode is relatively inexpensive but produces lower response rates. The telephone mode complements the web mode in that it is relatively expensive but produces higher response rates. Among the potential negative consequences, delaying the switch from web to telephone may lead to lower response rates if the effectiveness of the prenotification contact materials is reduced by longer time lags, or if the additional e-mail reminders to complete the web survey annoy the sampled person. On the positive side, delaying the switch may decrease the costs of the survey. We evaluate these costs and errors by experimentally testing four different timings (1, 2, 3, or 4 weeks) for the mode switch in a web-telephone survey. This experiment was conducted on the fourth wave of a longitudinal study of the mental health of soldiers in the U.S. Army. We find that the different timings of the switch in the range of 1-4 weeks do not produce differences in final response rates or key estimates but longer delays before switching do lead to lower costs.

Reported Wandering Behavior among Children with Autism Spectrum Disorder and/or Intellectual Disability.

OBJECTIVE: To characterize wandering, or elopement, among children with autism spectrum disorder (ASD) and intellectual disability. STUDY DESIGN: Questions on wandering in the previous year were asked of parents of children with ASD with and without intellectual disability and children with intellectual disability without ASD as part of the 2011 Survey of Pathways to Diagnosis and Services. The Pathways study sample was drawn from the much larger National Survey of Children with Special Health Care Needs conducted in 2009-2010. RESULTS: For children with special healthcare needs diagnosed with either ASD, intellectual disability, or both, wandering or becoming lost during the previous year was reported for more than 1 in 4 children. Wandering was highest among children with ASD with intellectual disability (37.7%) followed by children with ASD without intellectual disability (32.7%), and then children with intellectual disability without ASD (23.7%), though the differences between these groups were not statistically significant. CONCLUSIONS: This study affirms that wandering among children with ASD, regardless of intellectual disability status, is relatively common. However, wandering or becoming lost in the past year was also reported for many children with intellectual disability, indicating the need to broaden our understanding of this safety issue to other developmental disabilities.

APPROXIMATING A DSM-5 DIAGNOSIS OF PTSD USING DSM-IV CRITERIA.

BACKGROUND: Diagnostic criteria for DSM-5 posttraumatic stress disorder (PTSD) are in many ways similar to DSM-IV criteria, raising the possibility that it might be possible to closely approximate DSM-5 diagnoses using DSM-IV symptoms. If so, the resulting transformation rules could be used to pool research data based on the two criteria sets. METHODS: The pre-post deployment study (PPDS) of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) administered a blended 30-day DSM-IV and DSM-5 PTSD symptom assessment based on the civilian PTSD Checklist for DSM-IV (PCL-C) and the PTSD Checklist for DSM-5 (PCL-5). This assessment was completed by 9,193 soldiers from three US Army Brigade Combat Teams approximately 3 months after returning from Afghanistan. PCL-C items were used to operationalize conservative and broad approximations of DSM-5 PTSD diagnoses. The operating characteristics of these approximations were examined compared to diagnoses based on actual DSM-5 criteria. RESULTS: The estimated 30-day prevalence of DSM-5 PTSD based on conservative (4.3%) and broad (4.7%) approximations of DSM-5 criteria using DSM-IV symptom assessments were similar to estimates based on actual DSM-5 criteria (4.6%). Both approximations had excellent sensitivity (92.6-95.5%), specificity (99.6-99.9%), total classification accuracy (99.4-99.6%), and area under the receiver operating characteristic curve (0.96-0.98). CONCLUSIONS: DSM-IV symptoms can be used to approximate DSM-5 diagnoses of PTSD among recently deployed soldiers, making it possible to recode symptom-level data from earlier DSM-IV studies to draw inferences about DSM-5 PTSD. However, replication is needed in broader trauma-exposed samples to evaluate the external validity of this finding.

Lifetime prevalence of DSM-IV mental disorders among new soldiers in the U.S. Army: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

BACKGROUND: The prevalence of 30-day mental disorders with retrospectively reported early onsets is significantly higher in the U.S. Army than among socio-demographically matched civilians. This difference could reflect high prevalence of preenlistment disorders and/or high persistence of these disorders in the context of the stresses associated with military service. These alternatives can to some extent be distinguished by estimating lifetime disorder prevalence among new Army recruits. METHODS: The New Soldier Study (NSS) in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) used fully structured measures to estimate lifetime prevalence of 10 DSM-IV disorders in new soldiers reporting for Basic Combat Training in 2011-2012 (n = 38,507). Prevalence was compared to estimates from a matched civilian sample. Multivariate regression models examined socio-demographic correlates of disorder prevalence and persistence among new soldiers. RESULTS: Lifetime prevalence of having at least one internalizing, externalizing, or either type of disorder did not differ significantly between new soldiers and civilians, although three specific disorders (generalized anxiety, posttraumatic stress, and conduct disorders) and multimorbidity were significantly more common among new soldiers than civilians. Although several socio-demographic characteristics were significantly associated with disorder prevalence and persistence, these associations were uniformly weak. CONCLUSIONS: New soldiers differ somewhat, but not consistently, from civilians in lifetime preenlistment mental disorders. This suggests that prior findings of higher prevalence of current disorders with preenlistment onsets among soldiers than civilians are likely due primarily to a more persistent course of early-onset disorders in the context of the special stresses experienced by Army personnel.

Prevalence and correlates of suicidal behavior among new soldiers in the U.S. Army: results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

BACKGROUND: The prevalence of suicide among U.S. Army soldiers has risen dramatically in recent years. Prior studies suggest that most soldiers with suicidal behaviors (i.e., ideation, plans, and attempts) had first onsets prior to enlistment. However, those data are based on retrospective self-reports of soldiers later in their Army careers. Unbiased examination of this issue requires investigation of suicidality among new soldiers. METHOD: The New Soldier Study (NSS) of the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) used fully structured self-administered measures to estimate preenlistment histories of suicide ideation, plans, and attempts among new soldiers reporting for Basic Combat Training in 2011-2012. Survival models examined sociodemographic correlates of each suicidal outcome. RESULTS: Lifetime prevalence estimates of preenlistment suicide ideation, plans, and attempts were 14.1, 2.3, and 1.9%, respectively. Most reported onsets of suicide plans and attempts (73.3-81.5%) occurred within the first year after onset of ideation. Odds of these lifetime suicidal behaviors among new soldiers were positively, but weakly associated with being female, unmarried, religion other than Protestant or Catholic, and a race/ethnicity other than non-Hispanic White, non-Hispanic Black, or Hispanic. CONCLUSIONS: Lifetime prevalence estimates of suicidal behaviors among new soldiers are consistent with retrospective reports of preenlistment prevalence obtained from soldiers later in their Army careers. Given that prior suicidal behaviors are among the strongest predictors of later suicides, consideration should be given to developing methods of obtaining valid reports of preenlistment suicidality from new soldiers to facilitate targeting of preventive interventions.

Prevalence of serious psychological distress and mental health treatment in a national sample of pregnant and postpartum women.

This study examines the prevalence and correlates of past month serious psychological distress (SPD) and past year mental health treatment (MHT) across pregnancy and the postpartum. Data are from the 2008 to 2012 National Surveys on Drug Use and Health. Prevalence estimates of SPD as well as MHT among women with SPD were generated for each trimester and across the postpartum period. Correlates of SPD and MHT were examined among pregnant and postpartum women. The prevalence of past month SPD was 6.4 % in first trimester women and 3.9 % in third trimester women. In postpartum women, SPD prevalence ranged from 4.6 % (0-2 months) to 6.9 % (3-5 months). Correlates of SPD among pregnant and postpartum women included being younger; non-Hispanic black; unmarried; making under $20,000 annually; having past month cigarette use; or having a past year alcohol or illicit drug use disorder. Only 38.5 % of pregnant and 49.5 % of postpartum women with past month SPD reported past year MHT. Those who received MHT were more likely to be white; widowed, divorced, or separated; have insurance; and have a history of depression or anxiety than their counterparts with no MHT. Pregnant women with SPD were less likely to report past year MHT than postpartum women, even after adjusting for potential confounders. Over half of pregnant and postpartum women with past month SPD are not receiving MHT. Increased contact with health care professionals during this time may be an opportunity for screening, identification, and referral to MHT.

Research, practice, and data informed investigations of child and youth suicide: A science to service and service to science approach.

BACKGROUND: Suicide rates for children and adolescents have been increasing over the past 2 decades. In April 2023, the National Institute of Mental Health (NIMH) convened a two-day workshop to address child and youth suicide. PURPOSE: The workshop focus was to discuss the state of the science and stimulate a collaborative response between researchers, death investigators, and data collection teams to build a science to service and service to science approach toward understanding - and ultimately preventing - this growing problem of child and youth suicide. HIGHLIGHTS: Topics that meeting participants highlighted as worthy of further consideration for research and practice were: increasing awareness among death investigators, medical examiners, and coroners that child suicide deaths under age 10 years do occur and should be investigated and documented accordingly; emphasizing the value of science based protocols for child and youth death investigations to enhance consistency of approaches; and articulating needs for postvention services to suicide loss survivors. OUTCOMES: The importance of collecting an accurate and complete cause and manner of death (i.e., unintentional, suicide, homicide, undetermined) among all child decedents, and demographic information such as race, ethnicity, and sexual/gender minority status was underscored as critical for enhanced surveillance. For prevention efforts, approaches to assessing and understanding suicidal thoughts and behaviors among diverse groups of children, and the variability in proximal and distal risk factors are needed to inform opportunities for preventive interventions for diverse communities. The need for consistent measures and processes to improve death investigations, fatality review committees, and coordination between data collection systems and agencies was also raised. PRACTICAL APPLICATIONS: Collaborations among researchers, death investigators, and data collection teams can help to fully describe the child and youth suicide crisis and provide actionable information for new research, and prevention and response efforts.

The Key Role of Schools in Youth Suicide Prevention.

The coronavirus disease 2019 (COVID-19) pandemic has presented unprecedented challenges for youth and families dealing with remote school and work, lack of childcare, and social isolation over the course of 2 years. In response, the US Surgeon General recently published an advisory warning of a mental health crisis among youth,1 noting that youth with intellectual and developmental disabilities, racial/ethnic and sexual/gender minority youth, and youth in low-income, rural, and immigrant households were at higher risk of mental health challenges in the pandemic. The advisory arrived on the heels of an emergency declaration about child and adolescent mental health put forth by the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children's Hospital Association in October 2021. Both emphasize that the COVID-19 pandemic exacerbated already growing youth mental health concerns and highlight the key role schools must play in preventing youth suicide. In this commentary, we make the case for why we need schools to be in the business of youth suicide prevention.

Mental Health Service Use Among Lesbian, Gay, and Bisexual Adults Who Report Having Attempted Suicide.

OBJECTIVE: This study estimated mental health service use among lesbian, gay, and bisexual (LGB) adults in the United States who reported having made a suicide attempt. METHODS: Data came from the pooled 2015-2019 National Surveys on Drug Use and Health. Of the 191,954 adult respondents, 1,946 reported a past-year suicide attempt. Survey-weighted descriptive and regression analyses were conducted to compare mental health service use among LGB and heterosexual adults. RESULTS: Three percent of LGB adults (N=598) reported having attempted suicide in the past year, compared with 0.5% of heterosexual adults (N=1,348). Mental health treatment use was significantly higher among LGB adults than among heterosexual adults (64% versus 56%) before analyses were adjusted for sociodemographic characteristics. CONCLUSIONS: Because suicide attempts and mental health use are elevated among LGB adults, clinicians must provide evidence-based approaches for identifying and managing suicide risk to LGB adults in an affirming manner.

Suicidality Among Sexual Minority Adults: Gender, Age, and Race/Ethnicity Differences.

INTRODUCTION: Lesbian, gay, and bisexual individuals have elevated suicide risk, but there is little information available about how this risk may vary by gender, age, and race/ethnicity. METHODS: This study examined past-year suicide thoughts, plans, and attempts among adult respondents to the 2015-2019 National Surveys on Drug Use and Health (pooled N=191,954). Logistic regression was used to examine the differences between lesbian, gay, and bisexual and heterosexual adults for each outcome, once by gender and age category and once by gender and race/ethnicity category, while controlling for core sociodemographic characteristics. Race/ethnicity and age differences were also estimated within sexual identity groups. RESULTS: Suicide thoughts, plans, and attempts were more common among lesbian, gay, and bisexual adults in almost every age and race/ethnicity category relative to that among corresponding heterosexual adults. In some age and race/ethnicity categories, bisexual women were more likely to report suicidal thoughts than lesbian/gay women. Each outcome decreased significantly across age groups among women of all sexual identity groups and heterosexual men; yet, this age effect was less pronounced among gay and bisexual men. Black women had significantly lower rates of suicidal thoughts and plans than White women in all sexual identity groups. CONCLUSIONS: In light of consistently elevated rates of suicide thoughts and behaviors, lesbian, gay, and bisexual adults may expressly benefit from enhanced prevention, identification, and treatment of suicide risk. Additional research is needed to assess the associations between sexual identity and suicide mortality as well as to understand the heterogeneity in suicide risk among lesbian, gay, and bisexual youth, particularly by race/ethnicity.

Clinical Pathway for Suicide Risk Screening in Adult Primary Care Settings: Special Recommendations.

Suicide is a serious public health concern. On average, 80% of suicide decedents had contact with primary care within 1 year of their suicide. This and other research underscore the importance of screening for suicide risk within primary care settings, and implementation of suicide risk screening is already underway in many practices. However, while primary care practices may be familiar with screening for other mental health concerns (e.g., depression), many feel uncomfortable or unprepared for suicide risk screening. To meet the increasing demand for evidence-based suicide-risk-screening guidance, we provide a clinical pathway for adult primary care practices (to include family medicine, internal medicine, women's health). The pathway was developed by experts with research, clinical expertise, and experience in suicide risk screening and primary care. We also provide detailed guidance to aid primary care practices in their decisions about how to implement the clinical pathway.

Perinatal Depression: Challenges and Opportunities.

Perinatal depression (PND) is a major depressive episode during pregnancy or within 4 weeks after childbirth up to a year. Risk factors for PND include stressful life events, history of depression, poor social support, unplanned and unwanted pregnancies, poor relationship quality, current or previous abuse, and low socioeconomic status. This mental disorder has been shown to have negative effects on mothers' quality of life and their intimate relationships, birth outcomes, and breastfeeding likelihood, as well as long-term effects on children's cognitive and emotional development. To date, no nationally representative study has examined whether there are socioeconomic and/or racial/ethnic differences in PND. This study discusses the prevalence and risk factors for PND, as well as its health consequences for mothers and children, the reasons for its underreporting and undertreatment, the evidence for different screening instruments and different treatment options, and the existing supportive policies to address this disorder in the United States. We conclude with outlining next steps in addressing the gaps in the literature on PND.

Public health surveillance for mental health.

Public health systems have relied on public health surveillance to plan health programs, and extensive surveillance systems exist for health behaviors and chronic disease. Mental health has used a separate data collection system that emphasizes measurement of disease prevalence and health care use. In recent years, efforts to integrate these systems have included adding chronic disease measures to the Collaborative Psychiatric Epidemiology Surveys and depression measures to the Behavioral Risk Factor Surveillance System; other data collection systems have been similarly enhanced. Ongoing challenges to integration include variations in interview protocols, use of different measures of behavior and disease, different interval reference periods, inclusion of substance abuse disorders, dichotomous vs continuous variables, and approaches to data collection. Future directions can address linking surveillance efforts more closely to the needs of state programs, increasing child health measurements in surveys, and improving knowledge dissemination from survey analyses.

Advancing Research in Child Suicide: A Call to Action.

OBJECTIVE: To highlight the problem of child suicide, summarize what is known and not known about the problem in the empirical literature, and provide recommendations with ethical considerations for future research and practice. METHOD: The development of this paper was informed by a meeting of national experts on the topic hosted by the National Institute of Mental Health, as well as by a review of the empirical literature. RESULTS: We know something about demographic characteristics that are related to higher child suicide rates, but beyond that we know relatively little about risk factors, prevention, and intervention for suicide risk in children <12 years. It is important for child suicide researchers and practitioners to pay particular attention to ethical issues that may be likely to arise in doing this type of work. CONCLUSION: Much more research is needed on child suicide in the areas of measurement, prevention, and intervention in order to advance the field and provide practitioners with the tools that they critically need.

Increases in Demand for Crisis and Other Suicide Prevention Services After a Celebrity Suicide.

OBJECTIVE: This study examined data on acute (i.e., within 30 days) increases in suicides, help and information seeking, and service capacity after a celebrity suicide. METHODS: Daily suicide data, call volume to the National Suicide Prevention Lifeline (NSPL), and visits to two suicide prevention Web sites before and after entertainer Robin Williams' death on August 11, 2014, were examined. RESULTS: Before August 11 in 2012, 2013, and 2014, daily suicide deaths averaged between 113 and 117; in 2014, the count increased to 142, an increase not observed in 2012 and 2013. The number of calls to the NSPL rose by up to 300%, but answered calls decreased from an average of 71% to 57%. Visits to both Web sites also increased dramatically. CONCLUSIONS: Dramatic increases in all three measured outcomes in the days after a celebrity suicide were noted, suggesting the need for contingency plans to meet immediate increased demand.

National Trends in the Prevalence of Suicidal Ideation and Behavior Among Young Adults and Receipt of Mental Health Care Among Suicidal Young Adults.

OBJECTIVE: This study examined national trends in the prevalence of suicidal ideation and behavior among young adults and receipt of mental health care among suicidal young adults. METHOD: We examined restricted data from 145,800 persons aged 18 to 25 years who participated in the 2009 to 2015 National Surveys on Drug Use and Health. Descriptive analyses and bivariable and multivariable logistic regressions were applied. RESULTS: Among US young adults during 2009 to 2015, the 12-month prevalence of suicidal ideation increased from 6.1% to 8.3%, the 12-month prevalence of suicide plan increased from 2.0% to 2.7%, and 12-month prevalence of suicide attempt increased from 1.1% to 1.6%. After adjusting for personal factors and changes in residing county's population characteristics, we found upward trends in suicidal ideation among non-Hispanic whites and Hispanics, an upward trend in suicide plan among young adults overall, and an upward trend in suicide attempt among those without major depressive episodes (MDE). Among young adults with MDE, the prevalence of suicide attempt remained high and unchanged. During 2009 to 2015, trends in receipt of mental health care remained unchanged among most suicidal young adults and declined slightly among uninsured suicidal young adults. The annual average prevalence of receipt of mental health care was 36.2% among suicidal young adults. CONCLUSION: During 2009 to 2015, suicidal ideation, suicide plan, and suicide attempt increased among young adults overall, but receipt of mental health care among suicidal young adults did not increase. Our results suggest that effective efforts are needed for suicide prevention and promotion of mental health care among young adults.