Suicide prevention and intervention among high school students: A review of literature.
Suicide is a major public health issue that is a leading, yet preventable cause of death among young people from all backgrounds and racial- and ethnic-groups. Suicide among high school students not only affects the individual’s immediate family and friends, but also causes significant disruption to the school learning environment. Schools are therefore unique environments that provide necessary opportunities for intervention of youth suicide. The Office of Safe and Healthy Students (2017) notes that schools play a vital role in reducing factors that amplify the risk of suicide and increasing factors that promote resilience. It is therefore relevant to explore how schools identify and respond to at-risk students and how suicide education is made available to those who serve this population. This paper provides a comprehensive review of existing literature that discusses suicide prevention and intervention among high school students. It specifically considers a range of suicide prevention programs and suicide education for staff.
The truth about suicide
Suicide is not a recent issue. Literature concerning youth suicide prevention dates back well prior to the 21st century and concerns youth worldwide. Recently, The World Health Organisation WHO (2018) reported that suicide is the second leading cause of death among 15-29-year-olds. This claim is supported by a myriad of studies, highlighting numbers and statistics that emphasise the weight of the subject. In 2013, Centres for Disease Control and Prevention CDC sent out a survey to American high schools and reported that 17% of students that took part in the survey claimed to have seriously considered suicide during the 12 months prior to taking the survey. Furthermore, 8% of students attempted suicide during the same period. National research has produced equally shocking statistics (Torcasso ; Hilt, 2017). A 2009 Organisation for Economic Co-operation and Development OECD report compared New Zealand’s youth suicide rates to those of 36 other countries belonging to the OECD. The report claimed that in 2009 New Zealand had the highest rate of youth suicide in the OECD. Similarly, a 2015 OECD report placed New Zealand among the five countries with the highest youth suicide rates. Both reports considered teenagers between the ages of 15 and 19 and the latter concluded that Canada, Estonia, Latvia, Iceland and New Zealand all had 10 or more suicides per 100 000 teens per year. In 2015, the Ministry of Health MOH highlighted their specific concern for youth suicide, remarking that in New Zealand, youth between the ages of 15 and 24 had a suicide rate of 18.0 deaths per 100 000 population, which is significantly higher than the average suicide rate of 11.0 deaths per 100 000.
Schools as platforms for intervention
Ranahan (2013) remarks that the education realm is considered to play a vital role in suicide prevention strategies based on the assumption that education provides a platform for professionals to identify, manage and care for suicidal persons. Research staffs that youth-serving professionals play key roles in preventing youth suicide, by recognizing and responding to at-risk students and establishing links to resources within the wider continuum of mental health care (Ranahan, 2013). A 2007 Canadian study by Cheung and Dewa investigated 619 individuals aged 15 to 24 who had screened positive for depression and suicidality in the past 12 months. They examined the use of mental health services by these individuals and reported that 50% of 15 to 18-year-olds with suicidality had not used any mental health services. They also remarked that among the same age group, 48% of individuals with depression had not accessed such services. Cheung and Dewa’s (2007) emphasis on the high percentages of at-risk youth that do not access mental health services highlights the need for youth-serving professionals, such as teachers, to take up their position alongside formal mental health care providers. The preparation of youth-serving professionals, such as teachers, for encountering and responding to at-risk youth is therefore a growing interest among researchers such as Ranahan (2013).
Ranahan (2013) examines the relevance of school systems in suicide intervention efforts and explores how suicide education is made available to school staff. He notes that any professional who develops therapeutic relationships with young people is in an appropriate position to engage in suicide prevention and intervention practices. Teaching staff in particular are positioned to be involved in such practices by virtue of their proximity to vulnerable youth. However, the emphasis, as noted by Marraccini and Brier (2017) is on relationships. In 2017, Marraccini and Brier conducted a meta-analytic study, investigating the association between school connectedness and suicidal thoughts and behaviours (STB). They describe the term school connectedness as encompassing, among other things, positive school relationships and feeling cared about or respected by adult figures in the school. The investigation involved a sample of youth attending school in grades 6-12 and produced results that indicated a strong association between school connectedness and reduced reports of STB. The link between the quantity and quality of social connections and suicidality has been investigated for over a century. Durkheim (1897) first explored the concept and suggested that a chief cause of suicide could be traced back to the weakening of bonds that normally integrate individuals into a collective. Whitlock, Wyman and Moore (2014) elaborate on this concept, focusing specifically on social ties between adolescents and adults. Their research similarly posits that an inverse relationship exists between connectedness and STB. Whitlock and colleagues (2014) note the particular importance of such ties being formed with family members, who are supportive and engaging. However, the teacher’s role becomes amplified when familial ties are weakened or broken. A range of other studies compliment Whitlock and colleagues’ claims, commenting that both the quality and accessibility of adult relationships in school are critical factors in youth suicide prevention (Seeley, Rohde, ; Jones, 2010). Lieberman, Poland and Kornfeld (2014) conclude that the fostering of teacher-student relationships increases the likelihood of students seeking help when they or their peers experience STB.
Along with teacher-student relationships, Ranahan (2013) notes that the ability for teaching staff to identify and respond to at-risk students is vitally important to suicide prevention. The large amount of time teachers spend with their students positions them to notice any changes in behaviour and, with appropriate knowledge, deal with it in the best possible way. The emphasis here is that teaching staff require the appropriate knowledge that will allow them to identify at-risk youth, respond to them in an effective manner and initiate connections with further mental health care providers. However, the absence of suicide content and suicide education in pre-service programs is highlighted as a primary concern by Ranahan (2013). He stresses his concern for the limited attention paid to the education of future professionals in suicide prevention and intervention at undergraduate level. Similarly, Oordt and colleagues exclaimed that the absence of explicit and comprehensive suicide prevention and intervention training in pre-service programs forces professionals to obtain such competencies “downstream” (Oordt, Jobes, Fonseca, ; Schmidt, 2009, p.22). The responsibility consequently shifts to in-service employers to provide educational opportunities for staff. However, in a 1999 study, conducted by King, Price, Telljohann and Wahl, 58% of the 228 health teachers surveyed claimed that suicide prevention and intervention education had not been offered at their school within the past five years. Consequently, only 9% of the participants believed they could recognise a student at risk of attempting suicide. While this is a relatively old study, recent research does not indicate a significant shift in the availability of pre- or in-service suicide prevention training. Hence, in 2009, Oordt and colleagues still stressed the necessity of future integration of suicide content into the training of youth-serving professionals, such as teachers (Oordt et al., 2009) and Ranahan, in 2013 expressed his concern for the level of attention that has been paid to preparing youth-serving professionals for encounters with suicide. He concludes, in his review of existing literature, that suicide as a topic of study remains very limited within pre-service university programs.
Pathways of intervention and prevention
The WHO (2012) discusses aspect of effective frameworks for suicide prevention. It highlights the identification of risk and protective factors as key components of effective strategies. Though risk factors may not be a direct cause of suicide, where they are present, the WHO (2012) stresses that it should be assumed that there is a greater likelihood of suicidal behaviour. Risk factors according to the WHO (2012) can fall under three distinct categories. Firstly, individual risk factors may include previous suicide attempts, mental health disorders, alcohol or drug abuse, sense of isolation and aggressive tendencies etc. Secondly, socio-cultural risk factors may include stigma associated with help-seeking behaviour, cultural or religious beliefs and exposure to suicidal behaviour. Thirdly, situational risk factors include job and financial losses, relational and social losses, stressful life events etc. Cash and Bridge (2010) highlight similar risk factors, claiming that a comprehensive understanding of these may promote early identification of suicidal behaviours and hence increase the chance of effective intervention. Kutcher and Szumilas (2008) pinpoint psychiatric disorders as the most significant risk factor, claiming that over 90% of suicide victims have at least one mental disorder. The most common of these diagnoses include affective, conduct and substance disorders (Kutcher, ; Szumilas, 2008). While the identification and management of specific risk factors may prove effective in the way it allows for quicker identification of suicidality, Kalafat (2003) proposes that the promotion of protective factors can moderate the occurrence of problem behaviours even among groups exhibiting a range of risk factors. Such protective factors may include contact with caring adults, a sense of connection to school, family and community as well as personal characteristics such as good problem-solving skills (Kalafat, 2003). Based on these protective and risk factors, intervention and prevention strategies are suggested at population, sub-population and individual levels. A number of examples at each level is discussed below.
Prevention strategies at a population level
The WHO (2012) identified the restriction of popular means of suicide as one of three primary, evidence-based population level prevention strategies. It proposes the restriction of access to methods of self-harm or suicide and suggests government implemented policies that limit access specifically to firearms, pesticides and other noxious substances (WHO, 2012). Hawton (2007) notes that the absence or restriction of a favoured means of suicide or self-harm does not necessarily result in its substitution with another method. He claims that suicidal impulses are often brief and that the availability of a certain method//means may therefore significantly influence the occurrence and outcome of suicidal acts (Hawton, 2007). Gunnell and colleagues (2007) specifically consider the use of pesticides as a primary means of suicide, estimating that one-third of world suicides are committed through its ingestion. They suggest a range of actions to restrict access to pesticides, including the education of the public on proper handling, use and storage of pesticides, enforced regulations of sales of pesticides, and reducing the toxicity of pesticides. Similarly, Yip and colleagues conducted a trial, examining the effect of restricting access to charcoal as a method of suicide in Hong Kong (Yip et al, 2010). During the trial period, all charcoal packs were removed from the open shelves of major retail outlets in a certain region. Comparatively, in the control region, charcoal packs were displayed as usual. The trail was conducted for 12 months, at the end of which a statistically significant reduction in suicide rates was notes in the intervention region relative to the control region. Sarchiapone, Mandelli, Losue, Andrisano and Roy (2011) highlight that restrictions, such as the ones suggested above, may be particularly effective in situations where the particular method is popular, highly lethal and widely available. However, they along with Hawton (2007) emphasise that this strategy does not address underlying causes of suicide and must be considered in conjunction with other suicide prevention initiatives.
Prevention strategies for vulnerable sub-populations at risk.
The WHO secondly suggest a range of suicide prevention and intervention strategies that may be implemented among at-risk sub-populations. One of the strategies is the widely researched concept on gatekeepers, which are involve professionals positioned to recognise risk factors of suicide due to being in frequent contact with community members. Gatekeepers are responsible for the identification and referral of suicidal individuals to health care professionals. However, in order for these gatekeepers to be effective, their training must be a continuous, sustained effort. Isaac and colleagues (2009) note that gatekeeper training is successful at imparting knowledge building skills moulding the attitudes of trainees. However, Ranahan’s (2013) concern for the limited attention paid to the education of future professionals in suicide prevention and intervention at undergraduate level again stresses the inadequacy of gatekeeper training. Greater effort must be paid to the training of non-health-care professionals, such as teachers, nurses, doctors, and lawyers etc. who come in contact with at-rick youth on a regular basis. Erbacher and Singer (2017) furthermore propose a Suicide Risk Monitoring Tool (SMT) that fills what they describe as a gap in suicide risk assessment. Monitoring, according to Erbacher and Singer (2017) is an essential task for youth-serving professionals to engage in, as it allows quick detection of changes in the behaviours of individuals identified as being at-risk of suicide. Mere identification is insufficient. Changes must be tracked in order to ensure the safety of at-risk groups.
Prevention strategies at the individual level
Finally, prevention strategies at the individual level are essential and made possible in schools by the proximity of professionals to suicidal individuals. The WHO (2012) emphasises the identification and treatment of mental disorders as a primary approach to suicide prevention at an individual level. The shortage of mental health care professionals leaves a multitude of at-risk individuals unrecognized, untreated and therefore vulnerable to suicide. The WHO (2012) therefore emphasises that the management of individuals must involve a range of strategies, including the removal of methods of suicide, referral to psychosocial support and the maintenance of regular contact and follow up interactions. During these interactions, it is vital that protective factors are explored and promoted in conjunction with the management of risk factors (WHO, 2012).
Research continues to stress youth suicide as a major public health issue, which demands of schools to assume a more significant role in its prevention. Schools are considered logical and natural sites of suicide intervention, having great potential to identify and moderate students at risk of attempting suicide (Miller, & Eckert, 2009). However, greater integration of suicide content into pre- and in-service education of youth-serving professionals within schools is required to increase their ability to employ effective prevention and intervention strategies. The myriad of prevention and intervention programs employed by schools all aim to increase protective factors and decrease risk factors. These programs should target the general population (whole school), smaller at-risk populations as well as specific individuals and must involve multifaceted strategies that position school staff as effective intervenors.