Adolescent suicide prevention: Gender differences in students' perceptions of the acceptability and intrusiveness of school-based screening programs

Suicidal behavior is a significant problem among adolescents in the United States. Three types of school-based suicide prevention programs have been proposed to address this problem including curriculum programs, staff in-service training, and school-wide screening. The relative acceptability of these three programs among older adolescents was examined. The sample included 662 freshmen (496 females, 161 males) enrolled in a large private university. Respondents rated the degree to which they considered adolescent suicide to be a significant problem, and the acceptability, intrusiveness, and time demands of the three suicide prevention programs. A majority (85.9%) of the sample agreed that adolescent suicide was a significant problem. Significant gender differences were observed in relation to the acceptability ratings of the school-based suicide programs. Female participants rated the curriculum-based program and staff in-service training as more acceptable than male participants. In addition, female participants rated the curriculum-based program as significantly less intrusive and less time demanding than male participants. Implications of these findings for implementation of suicide prevention programs and for future research are discussed.     

Evidence-Based Psychological Assessment

In recent years there has been increasing emphasis on evidence-based practice in psychology (EBPP), and as is true in most health care professions, the primary focus of EBPP has been on treatment. Comparatively little attention has been devoted to applying the principles of EBPP to psychological assessment, despite the fact that assessment plays a central role in myriad domains of empirical and applied psychology (e.g., research, forensics, behavioral health, risk management, diagnosis and classification in mental health settings, documentation of neuropsychological impairment and recovery, personnel selection and placement in organizational contexts). This article outlines the central elements of evidence-based psychological assessment (EBPA), using the American Psychological Association's tripartite definition of EBPP as integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences. After discussing strategies for conceptualizing and operationalizing evidence-based testing and evidence-based assessment, 6 core skills and 3 meta-skills that underlie proficiency in psychological assessment are described. The integration of patient characteristics, culture, and preferences is discussed in terms of the complex interaction of patient and assessor identities and values throughout the assessment process. A preliminary framework for implementing EBPA is offered, and avenues for continued refinement and growth are described.     

Evidence-based practice in psychology

The evidence-based practice movement has become an important feature of health care systems and health care policy. Within this context, the APA 2005 Presidential Task Force on Evidence-Based Practice defines and discusses evidence-based practice in psychology (EBPP). In an integration of science and practice, the Task Force's report describes psychology's fundamental commitment to sophisticated EBPP and takes into account the full range of evidence psychologists and policymakers must consider. Research, clinical expertise, and patient characteristics are all supported as relevant to good outcomes. EBPP promotes effective psychological practice and enhances public health by applying empirically supported principles of psychological assessment, case formulation, therapeutic relationship, and intervention. The report provides a rationale for and expanded discussion of the EBPP policy statement that was developed by the Task Force and adopted as association policy by the APA Council of Representatives in August 2005.     

Have Broad‐Based Community and Professional Education Programs Influenced Mental Health Literacy and Treatment Seeking of those with Major Depression and Suicidal Ideation?

Mental health literacy is the knowledge and beliefs about mental disorders that aid in their recognition, management, or prevention; it is also a determinant of help seeking. As such, it is presumed to be important in community suicide prevention programs. In Australia there have been a number of government, professional, and charitable organizations as well as pharmaceutical company suicide prevention initiatives which have been designed to enhance public and professional knowledge about mental disorders, particularly depression. This naturalistic study conducted between 1998 and 2004 in a random and representative population sample examined the changes in mental health literacy and treatment seeking of those with major depression, both with and without suicidal ideation, and those who were neither depressed nor suicidal. Results indicated that there was marked improvement in mental health literacy for all three groups, although there was less change for those most in need of intervention (i.e., those with major depression and suicidal ideation). Furthermore, there were fewer changes in appropriate treatment seeking in those with major depression and suicidal ideation. These findings are consistent with literature reporting limited problem solving and decision making in those who are suicidal, and indicate that there are limits to broadbased community education programs. More focused suicide prevention initiatives are required, specifically for those who are depressed and suicidal.     

An Evidence-Based Approach to Managing Suicidal Patients in the Patient-Centered Medical Home

Primary care is a critical setting for suicide prevention because it is often the first and only source of mental health care for the U.S. general population. It is also important because suicidal patients report a greater number of somatic complaints and make more frequent medical visits compared to nonsuicidal patients. Models for managing suicide within primary care have recently arisen, yet no models have been proposed for use within the patient-centered medical home (PCMH), a primary care model that integrates behavioral health into its practice. The authors suggest a chronic disease model for the management of suicide risk in the PCMH along with collaborative strategies that may include suicide screening and targeted assessment, warm hand-offs, cognitive-behavioral interventions, routine collaborative medication management, and means restriction counseling. The current paper advises how those within the PCMH can adapt and implement evidence-based practices to manage suicide. Finally, the authors discuss a case example illustrating these evidence-based and collaborative methods.     

A Community’s Response to Suicide Through Public Art: Stakeholder Perspectives from the Finding the Light Within Project

Suicide is a preventable public health problem and a leading cause of death in the United States. Despite recognized need for community-based strategies for suicide prevention, most suicide prevention programs focus on individual-level change. This article presents seven first person accounts of Finding the Light Within, a community mobilization initiative to reduce the stigma associated with suicide through public arts participation that took place in Philadelphia, Pennsylvania from 2011 through 2012. The stigma associated with suicide is a major challenge to suicide prevention, erecting social barriers to effective prevention and treatment and enhancing risk factors for people struggling with suicidal ideation and recovery after losing a loved one to suicide. This project engaged a large and diverse audience and built a new community around suicide prevention through participatory public art, including community design and production of a large public mural about suicide, storytelling and art workshops, and a storytelling website. We present this project as a model for how arts participation can address suicide on multiple fronts—from raising awareness and reducing stigma, to promoting community recovery, to providing healing for people and communities in need.     

How does evidence-based practice in psychology work? – As an ethical demarcation

Evidence-based practice in psychology (EBPP) is ordinarily understood to demarcate between legitimate and illegitimate psychotherapy practice, based upon the epistemic demarcation distinguishing scientific from non-scientific knowledge. EBPP emphasizes the value of effective and efficient interventions identified through randomized controlled trials and cost-benefit analyses. Basing the template for choice of action or strategy on randomized controlled trials and cost-benefit analyses create a deceptive appearance of ethical neutrality. However, there is an implicit ethical demarcation at work in EBPP, which favors a non-articulated specific position in normative ethics. More particularly, evidence-based practice in psychology is structured according to a utilitarian framework, severely limiting the kinds of ethical perspectives available to assess psychotherapy practice. The latter point is illustrated through a new mode of delivering psychotherapy services called “Internet-based guided self-help” (IBGSH). In EBPP the only relevant ethical question is to what extent any intervention, such as IBGSH, is effective and efficient. Some of the limiting effects of the ethical, utilitarian, demarcation are showcased by presenting three alternative ethical perspectives by which psychotherapy practice in general and IBGSH in particular can be analyzed. The analysis concludes that EBPP is not suited to ethically regulate the practice of psychotherapy.     

A systematic meta-review of evaluations of youth violence prevention programs: Common and divergent findings from 25 years of meta-analyses and systematic reviews

Violence among youth is a pervasive public health problem. In order to make progress in reducing the burden of injury and mortality that result from youth violence, it is imperative to identify evidence-based programs and strategies that have a significant impact on violence. There have been many rigorous evaluations of youth violence prevention programs. However, the literature is large, and it is difficult to draw conclusions about what works across evaluations from different disciplines, contexts, and types of programs. The current study reviews the meta-analyses and systematic reviews published prior to 2009 that synthesize evaluations of youth violence prevention programs. This meta-review reports the findings from 37 meta-analyses and 15 systematic reviews; the included reviews were coded on measures of the social ecology, prevention approach, program type, and study design. A majority of the meta-analyses and systematic reviews were found to demonstrate moderate program effects. Meta-analyses yielded marginally smaller effect sizes compared to systematic reviews, and those that included programs targeting family factors showed marginally larger effects than those that did not. In addition, there are a wide range of individual/family, program, and study moderators of program effect sizes. Implications of these findings and suggestions for future research are discussed.     

Is evidence-based practice diverse enough? Philosophy of science considerations

In its policy rationale for evidence-based practice in psychology (EBPP), the APA Presidential Task Force on Evidence-Based Practice claims to have constituted itself with "scientists and practitioners from a wide range of perspectives and traditions, reflecting the diverse perspectives within the field" (p. 273). We applaud this attention to diversity but contend that an entire perspective of the debate was omitted in the Task Force's newly approved policy and its underlying report. The failure to consider a philosophy of science perspective led the Task Force to make a number of epistemological assumptions that are not based on evidence or rationale and that thus violate the very spirit of evidence-based decision making. In this comment, we reveal a few of these assumptions and discuss their detrimental consequences.     

Suicide Prevention from a Public Health Perspective

The public health approach to health problems provides a strong framework and rationale for developing and implementing suicide prevention programs. This approach consists of health-event surveillance to describe the problem, epidemiologic analysis to identify risk factors, the design and evaluation of interventions, and the implementation of prevention programs. The application of each of these components to suicide prevention is reviewed. Suggestions for improving surveillance include encouraging the use of appropriate coding, reviewing suicide statistics at the local level, collecting more etiologically useful information, and placing greater emphasis on analysis of morbidity data. For epidemiologic analysis, greater use could be made of observational studies, and uniform definitions and measures should be developed and adopted. Efforts to develop interventions must include evaluating both the process and the outcome. Finally, community suicide prevention programs should include more than one strategy and, where appropriate, should be strongly linked with the community's mental health resources. With adequate planning, coordination, and resources, and the public health approach can help reduce the emotional and economic costs imposed on society by suicide and suicidal behavior.     

Suicide in America--moving up the public health agenda

Despite improvements in the health of Americans over the last 30 years, the problem of suicide, and its disturbing rise in the last three decades, remains a major American health riddle. Recognizing suicide as a public health concern is essential to discovering strategies to prevent suicide. Such strategies and prevention efforts must be multifaceted, incorporating a number of public health principles and approaches. These approaches include the refinement of epidemiological methods in the study of suicide; development of health education, information, and intervention programs dealing with suicide; and increased community awareness of and participation in all suicide prevention efforts.     

The Garrett Lee Smith Memorial Suicide Prevention Program

In response to calls for greater efforts to reduce youth suicide, the Garrett Lee Smith (GLS) Memorial Act has provided funding for 68 state, territory, and tribal community grants, and 74 college campus grants for suicide prevention efforts. Suicide prevention activities supported by GLS grantees have included education, training programs (including gatekeeper training), screening activities, infrastructure for improved linkages to services, crisis hotlines, and community partnerships. Through participation in both local‐ and cross‐site evaluations, GLS grantees are generating data regarding the local context, proximal outcomes, and implementation of programs, as well as opportunities for improvement of suicide prevention efforts.     

Moving the field of prevention from science to service: Integrating evidence-based preventive interventions into community practice through adapted and adaptive models

The article addresses the adaptation of evidence-based prevention and positive youth development programs for community use. Two complementary approaches for adapting programs are described. In the “adapted” approach, programs are modified to accommodate the culture, climate, and operations of the organization delivering the program. In the “adaptive” approach, programs are modified to accommodate the characteristics, needs and preferences of the individual or family receiving the program. Two examples are provided that illustrate how both adapted and adaptive intervention strategies have been incorporated by community practitioners into the implementation of the Early Risers conduct problems prevention program.     

Suicide and suicidology in the Soviet Union

This study was conducted in order to obtain information on suicide in the Soviet Union, an important subject for which we have no scientific literature. Studies of attempted suicide in Soviet psychiatric journals were analyzed. This information was supplemented by interviews with Soviet psychiatrists now living abroad. The results of this inquiry show that suicide is a subject that clearly has become of increasing concern in the Soviet Union. Furthermore, in spite of the absence of essential statistical data on mortality, there is evidence indicating that the rate of Soviet suicide may be rising in certain parts of the country. Finally, growing concern about suicide has led to expanded prevention programs and to a new emphasis on social and psychological etiological explanations. In particular, the role of the Soviet family in crisis has been emphasized as a major influence in understanding the causes of suicidal attempts.     

Have Mental Health Education Programs Influenced the Mental Health Literacy of Those with Major Depression and Suicidal Ideation? A Comparison between 1998 and 2008 in South Australia

Mental health literacy is the knowledge and beliefs about mental disorders that aid their recognition, management, or prevention and is considered to be an important determinant of help‐seeking. This has relevance in suicide prevention, as depression, the clinical condition most frequently associated with suicidality, has been the target of community and professional education programs designed to enhance mental health literacy. In this study, whether such programs have influenced help‐seeking attitudes and behavior in those who are depressed and suicidal was considered. The results indicate that despite intensive community education programs over the last two decades, there has been little change in those who are depressed and suicidal in terms of their attitudes toward treatment seeking and, more importantly, their treatment‐seeking behavior. These results draw into question the value of current community education programs for those most vulnerable to suicidal behavior.     

Suicide surveillance in the U.S. Military--reporting and classification biases in rate calculations

The military has a well-defined population with suicide prevention programs that have been recognized as possible models for civilian suicide prevention efforts. Monitoring prevention programs requires accurate reporting. In civilian settings, several studies have confirmed problems in the reporting and classification of suicides. This analysis evaluated whether suicides were underreported or misclassified under accident or undetermined manner of death in the military system. We reviewed all 1998 and 1999 military deaths using official death reports and compared these data with additional sources, most importantly the DoD Medical Mortality Registry. We assessed for evidence of expressed suicidal intent and past psychiatric history among deaths classified as undetermined and accidents due to gunshot, overdose, drowning, falls, or asphyxia. Using sources other than official records, we found 17% more suicides than were reported, and an additional 4% of deaths that were suspicious for suicide. This study suggests that reporting and classification errors may account for 21% additional suicides in the military. These findings are comparable to rates seen in civilian studies and add to the literature regarding the problems inherent in using administrative death classification data for medical surveillance purposes.     

The Struggle to Prevent and Evaluate: Application of Population Attributable Risk and Preventive Fraction to Suicide Prevention Researach

Population attributable risk (PAR) estimates have been used in suicide research to evaluate the impact of psychosocial and socioeconomic risk factors, including affective disorders, traumatic life events, and unemployment. A parallel concept of preventive fraction (PF), allowing for estimation of the impact of protective factors and effectiveness of preventive interventions, is practically unknown in suicidology. The study authors discuss the application of both concepts to suicide research and prevention, and review literature on the subject. Despite several methodological and conceptual limitations, both PAR and PF are valuable instruments to inform development and evaluation of suicide prevention programs.     

Suicide Prevention in an Educational Context: Broad and Narrow Foci

This paper reviews the needs and conceptual bases of school-based youth suicide prevention programs, summarizes their current status, and recommends objectives, processes, and evaluation strategies for focused educational programs in this area. In addition, a broad systemic approach is called for that reorganizes the school context to increase students' contributions to and involvement with the educational process. Such approaches appear to have been effective with a variety of youth deviant behaviors such as dropout and delinquency, and seem to be particularly appropriate to suicidal behavior that is characterized by alienation and withdrawal from social supports. A combination of these broad and narrow foci may be necessary to address suicidal behavior in the educational context.     

Functional communication training: From efficacy to effectiveness

Functional communication training (FCT; Carr & Durand, 1985) is a common function‐based treatment in which an alternative form of communication is taught to reduce problem behavior. FCT has been shown to result in substantial reductions of a variety of topographically and functionally different types of problem behavior in children and adults (efficacy). The extent to which these reductions maintain in relevant contexts and result in meaningful changes in the lives of those impacted (effectiveness) is the focus of this paper. This review evaluates the degree to which FCT has been established as an evidence‐based practice in psychology (EBPP) according to the definition set out by the American Psychological Association's 2005 Presidential Task Force on Evidence‐Based Practice. Our review finds overwhelming evidence in support of FCT as an efficacious treatment but highlights significant limitations in support of its effectiveness. In order to also be recognized as an EBPP, future research on FCT will need to focus more closely on issues related to home, school, and community application, feasibility, consumer satisfaction, and more general and global changes for the individual.