Youth Suicide Prevention

Madelyn S. Gould, PhD, MPH, and

Rachel A. Kramer, ScD

Y o u t h suicide, the third leading cause of
death among teenagers and young adults, ac-
counts for more deaths in the United States
than
combined among 15-
to 24-year-olds according to the National
Center for Health Statistics (2000a).The pub-
lic health significance of the problem of youth
suicide becomes even apparent when the
high of nonlethal suicidal behavior are
taken into account. This paper reviews the ex-
tensive research literature on youth suicide
that has emerged during the past two decades.
While great advances in knowledge have led
to increased understanding of the risk factors
for child and adolescent suicides, the applica-
tion of this knowledge for designing preven-
tion strategies remains inchoate.
PREVALENCE AND RISK FACTORS
Epidemiology of Completed Suicide
Unintentional injuries, suicide, and homicide
are consistently the leading causes of death
among youth aged 10 to 24 in the United
States (NCHS, 2000a). When examined by
age, suicide is uncommon in childhood and
early adolescence. Within the 1 0 - t o
14-year-old group, most completed suicides
occur between the ages of 12 and 14. Suicide
incidence increases markedly in the late teens
and continues to rise until the early twenties.
An examination of suicide by sex indicates
that in the United States, nearly 5 times more
15- to 19-year-old boys than girls committed
suicide in 1998 (NCHS, 2000b).
Suicide vary by race and ethnicity.
Youth suicide has generally been
mon in whites than in African Americans in the
United States. In the past decade, however, the
differences in the suicide rates between young
whites and African Americans have attenuated
somewhat. The highest youth suicide rate in
the United States is among Native American
males; but there is a marked variability in these
suicide rates by geographic area and tribal affil-
iation (Wallace, Calhoun, Powell, O’Neill, &
James, 1996). The availability of suicide rates
for Latino youth is limited (see the paper by
Cannino & Roberts in this supplement). Three
studies (Demetriades et al., 1998; Gould.
Fisher, Parides, Flory, & Shaffer, 1996; Smith;
Mercy, & Warren, 1985) indicate that Latino
youth do not appear to be overrepresented
among completed suicides in the United States.
In the United States, youth suicide rates, un-
corrected for ethnicity, are highest in the West-
ern states and Alaska and lowest in the
Northeastern states (NCHS, 2000). This may
reflect different ethnic mixes or the differential
availability of firearms (Shaffer, 1988).Exami-
nation of suicide by method indicates that fire-
arms are consistently the most common
method of suicide in the United States and
hanging the second most prevalent, regardless
of age (NCHS, 2300b). Ingestions account for
a greater proportion of female suicides than
male suicides among 15- to 19-year-olds.

Madelyn S. Gould is Professor of Clinical Public Health (Epidemiology) in Psychiatry, Division of Child and Adoles-
cent Psychiatry, Columbia University, College of Physicians and SurgeondDivision of Epidemiology, Columbia Uni-
versity School of Public Health and Research Scientist with the New York State Psychiatric Institute. Rachel A. Kramer
is with Community Healthworks, New York City Department of Health.
Address correspondence t o Dr. Madelyn Gould, Division of Child and Adolescent Psychiatry, Columbia Univer-
sity, 1051 Riverside Drive, Unit 72, New York, NY 10032; E-mail: gouldm@child.cpmc.columbia.edu.
Suicide and Life-Threatening Behavior, Vol. 31 (Supplement), Spring 2001
6 02001 The American Association of Suicidology
GOULD AND KRAMER

30 -
28 - * Total 15- to 19-Year-Olds

- * White Males

-
26

24 - * White Females
22 -

-
African-American Males
20
African-American Females
18
Other Males
16

14
* Other Females

12

10

a
6

0 -I I I I I

Figure 1. Adolescent Suicide Rates (15- to 19-Year-Olds). Rate per 100,000

Note: The “other” groups include all nowwhites.
Sources: National Center for Health Statistics (NCHS), Vital Statistics of the United States, Volume ! I , Mortality
(1964-1 978); NCHS, Death Rates for 72 Selected Causes, by 5-Year Age Groups, Race, and Sex: United States,
1979-1 998, Worktable GMWK 291.

death certificates; unfortunately, there is no

The increase in youth suicide rates over the
analogous surveillance system for non-lethal
past three decades is limited to males (Figure
suicidal behavior. Only the State of Oregon
1).A notable recent secular trend is a decline
in suicide rates among adolescent and young has mandated the reporting of all attempted
adult males since 1994. The reasons for thissuicides among persons younger than 18 who
apparent decline are unknown. Speculations are treated at a hospital or a hospital emer-
gency department (Andrus et al., 1991). Nev-
include more effective antidepressant medica-
tions for youth and a decrease in substance ertheless, there has been a surge of general
abuse (Shaffer & Craft, 1999). population studies of suicide attempters and
ideators in the past decade (e.g., Andrews &
Lewinsohn, 1992; Centers for Disease Con-
SECULAR CHANGES IN trol [CDC], 1991, 1998; Fergusson &
SUICIDE RATES Lynskey, 1995; Garrison, McKeown, Valois,
& Vincent, 1993; Gould et al., 1998; Joffe,
Epidemiology of Nonlethal Offerd, & Boyle, 1988; Kandel, Raveis, &
Suicidal Behavior Davies, 1991; Kashani, Goddard, & Rerd,
1989; Roberts & Chen, 1995; Swanson,
Information on the prevalence of completed Linsberg, Quintero-Salinas, Pumarieza, &
suicides is derived from the compilation of Holzer, 1992; Velez & Cohen, 1988; Windle,
8 YOUTH SUICIDE PREVENTION
Miller-Tutzauera, & Domenico, 1992).These
studies consistently estimate that within a pe-
riod of l year, approximately 20% of high
school students express serious suicidal
ideation and 8% make a suicide attempt, of
which nearly 3% require medical attention.
A gender paradox in suicide exists in the
United States in that completed suicide is more
common among males, yet suicidal ideation
and attempts are more common among fe-
males (CDC, 1998; Garrison et al., 1993;
Gould et al., 1998; Lewinsohn, Rohde, &
Seeley, 1996).
There is evidence from a few epidemiologic
studies that Latino youth living in the United
States have higher rates of suicidal ideation
and attempts than other youth (CDC, 1998;
Roberts, Chen, & Roberts, 1997; Roberts &
Chen, 1995); although, as noted earlier, Lati-
nos do not appear to be over-represented
among completed suicides.
Risk Factors of Completed
and Attempted Suicide
The risk factors summarized below have pri-
marily emerged from research employing the
psychological autopsy method for completed
suicide (Brent et al., 1988; Brent, Perper,
Moritz, Allan, et al., 1993; Gould et al., 1996;
Marttunen, Aro, Henriksson, & Lungvist,
1991; Rich, Young, & Fowler, 1986;
Runeson, 1989; Shaffer et al., 1996; Shafii,
Carrigan, Whittinghill, & Derrick, 1985) and
from general population epidemiologic sur-
veys of non-lethal suicidal behavior (e.g., An-
drews & Lewinsohn, 1992; CDC, 1991,
1998; Fergusson & Lynskey, 1995; Garrison
et al., 1993; Gould et al., 1998; Joffe et al.,
1988; Kandel et al., 1991; Kashani et al.,
1989; Roberts & Chen, 1995; Swanson et al.,
1992; Velez & Cohen, 1988; Windle et al.,
1992).
Psychopathology. Psychological autopsy
studies of youth who completed suicide con-
sistently find that the vast majority had signifi-
cant psychiatric problems, including previous
suicidal behavior, depressive disorders, and
substance abuse (Brent et al., 1988; Brent,
Perper, Moritz, Allan, et al., 1993; Gould et
al., 1996; Marttunen et al., 1991; Rich et al.,
1986; Runeson, 1989; Shaffer et al., 1996;
Shafii et al., 1985). Depressive disorders con-
sistently constitute the most prevalent disor-
ders: 64% in the Finnish National study
(Marttunen et al., 1991), 61% in the New
York study (Shaffer et al., 1996), and 49% in
the Pittsburgh study (Brent, Perper, Moritz,
Allan, et al., 1993). In these studies, female
victims are more likely than males to have had
an affective disorder. Substance abuse has
been found to be a significant risk, with the ex-
ception of the Israeli study of male military
conscripts (Apter et al., 1993), and is more
prevalent in older adolescent male suicide vic-
tims (Marttunen et al., 1991; Shaffer et al.,
1996). A high prevalence of comorbidity be-
tween affective and substance abuse disorders
has been found consistently. Discrepant re-
sults have been reported for bipolar disorder,
with the Pittsburgh study reporting relatively
high rates (Brent et al., 1988, Brent, Perper,
Moritz, Allan, et al., 1993), while other stud-
ies reported n o o r few bipolar cases
(Marttunen et al., 1991; Runeson, 1989;
Shaffer et al., 1996). Schizophrenia accounts
for very few of all youth suicides (Brent,
Perper, Moritz, Allan et al., 1993; Shaffer et
al., 1996), despite the generally high risk of
suicide among people with schizophrenia. The
marked increase in depression and substance
abuse from early to late adolescence, parallel-
ing the age differential in suicide rates, sug-
gests that the increase in completed suicide
with age may result from the increase in the
rates of these psychiatric disorders.
Between one-quarter to one-third of youth
suicide victims have made a prior suicide at-
tempt (Brent, 1995; Brent, Perper, Moritz,
Allan, 1993; Shaffer et al., 1996). Prior sui-
cidal behavior confers a particularly high risk
for boys (i.e., thirtyfold increase); for girls, the
risk is also elevated (i.e., approximately three-
fold), but is not as potent a risk factor as major
depression (Shaffer et al., 1996). (See Brent,
1995, for a review of the psychiatric risk fac-
tors for youth suicide.)
The psychiatric problems of suicide at-
tempters are quite similar to that of adoles-
cents w h o complete suicide, a n d the
COULD AND KRAMER 9

gender-specific diagnostic profiles of suicide depending on the psychiatric disorder of the

attempters parallel those of suicide victims suicide victim (Brent, Perper, Moritz,
(e.g., Andrews & Lewinsohn, 1992; Beautrais, Baugher, 1993; Gould et al., 1996; Marttunen
Joyce, & Mulder, 1996; Gould et al., 1998); et al., 1994; Rich et al., 1988; Runeson et al.,
however, despite the overlap between suicidal 1990).Interpersonal losses are consistently re-
attempts and ideation (Andrews & Lewinsohn, ported to be more common among suicide vic-
1992; Reinherz et al., 1995)and the significant tims with substance abuse disorders (Brent,
prediction of future attempts from ideation Perper, Moritz, Baugher et al., 1993; Gould et
(Lewinsohn, Rohder, Seeley, 1994; Reinherz et al., 1996; Marttunen et al., 1994; Rich et al.,
al., 1995),the diagnostic profiles of attempters 1988). Legal or disciplinary crises were more
and ideators are distinct (Gould et al., 1998). common in victims with disruptive disorders
Substance abuseldependence is more strongly (Brent, Perper, Mortiz, Baugher et al., 1993;
associated with suicide attempts than with sui- Gould et al., 1996) or substance abuse disor-
cidal ideation (Garrison et al., 1993; Gould et ders (Brent, Perper, Mortiz, Baugher,
al., 1998; Kandel, 1988). Schweers, & Ross, 1993). Despite these asso-
ciations, specific stressors, such as legal and
disciplinary problems, are still associated with
Cognitive Factors. Based on the association an increased risk of suicide, even after adjust-
Of hope1essness and suicidality in
(e*g*,ing for psychopatho~ogy( Brent, perper,
Dyer & Kreitman, 1984),a similar relationship
Mortiz, Baugher, et al., 1993; Gould et al.,
has been postulated for and
1996). Similar stressful life events have been
cents. Hopelessness has been shown to be asso-
reported to be risk factors for suicide attempts
ciated with completed suicide in youth (Shaffer among adolescents (Lewinsohn et al., 1996).
et al., 1996);but it is unclear whether hopeless-
ness per se or depression accounted for ;he as-
sociation. Within clinical (Rotheram-Borus, & Family Factors. Family History - A family
Trautman, 1988) and nonclinical (Cole, 1988; history of suicidal behavior greatly increases
Lewinsohn et al., 1994; Reifman & Windle, the risk of completed suicide, as reported in
1995) samples of youth, hopelessness has not several studies (Brent et al., 1988; Brent,
consistently proven to be an independent pre- Perper, Mortiz, Liotus, Schweers, et al., 1994;
dictor of suicidality, once depression is taken Gould et al., 1996; Shaffer, 1974; Shaffi et al.,
into account. Other dysfunctional cognitive 1985). The reasons for this familial aggrega-
styles have been reported to differentiate sui- tion are not yet known. It may reflect a genetic
cidal from nonsuicidal youth (Asarnow, factor (Schulsinger, 1980), rather than a gen-
Carlson, & Guthrie, 1987; Rotheram-Borus, eral index of family chaos and psychopatholo-
Trautman, Dopkins, & Shrout, 1990).Poor in- gy, since a family history of suicidal behavior
terpersonal problem-solving ability has been has been shown to increase suicide risk even
found to be associated with suicidality within when studies have controlled for poor par-
clinical samples of adolescents (Asarnow et al., ent-child relationships and parental psycho-
1987; Rotheram-Borus et al., 1990). pathology (Brent, 1996; Gould et al., 1996).
Studies also have found high rates of paren-
Stressful Life Events. The psychological au- tal psychopathology, particularly depression
topsy research generally supports the associa- and substance abuse, to be associated with
tion of life stressors, such as interpersonal completed suicide in adolescence (Brent et al.,
losses (e.g., breaking up with a girlfriend or 1 9 8 8 ; Brent, Perper, Mortiz, Liotus,
boyfriend) and legal or disciplinary problems, Schweers, et al., 1994; Gould et al., 1996), as
with suicide (Brent, Perper, Moritz, Baugher, well as with suicidal ideation and attempts
1993; Gould et al., 1996; Marttunen et al., (e.g., Fergusson & Lynskey, 1995; Joffe et al.,
1993; Rich, Young, Fowler, Wagner, & 1988; Kashani et al., 1989). To date, it is un-
Black, 1988; Runeson, 1990).The prevalence clear precisely how familial psychopathology
of specific stressors have been reported to vary increases the risk for suicide.
10
Family Factors. Parental Divorce - Two
large-scale studies with general population
controls (Brent, Perper, Moritz, Allan, et al.,
1 9 9 3 ; Brent, Perper, Moritz, Liotus,
Schweers, et al., 1994; Gould et al., 1996)
have found that suicide victims are more likely
to come from nonintact families of origin; al-
though the overall impact of separatioddi-
vorce on suicide risk is small. In the New York
study (Gould et al., 1996), the association be-
tween separation/divorce and suicide was
somewhat explained by parental psychopa-
thology. This is consistent with the reported
association of divorce and parental depression
(Weissman, Fendrich, W a r n e r , &
Wickwamarante, 1992). Brent, Perper,
Liotus, Schweers, Balach et al. (1994) re-
ported that a nonintact family of origin was
not associated with increased suicide risk after
controlling for family history of psychopa-
thology. Overall, the impact of divorce on sui-
cide risk is quite small in the psychological
autopsy studies.
Family Factors. Parent-Child Relationships -
The New York and Pittsburgh studies, which
are the two largest controlled studies that have
been conducted to date, both report problem-
atic parent-child relationships. The New York
study (Gould et al., 1996) reported that sui-
cide victims had significantly less frequent and
less satisfying communication with their
mothers and fathers. There was no evidence of
more negative interactions between victims
and their parents, nor a greater history of se-
vere physical punishment. The Pittsburgh
study (Brent, Perper, Moritz, Schweers,
Balach et al., 1994) reported that suicide vic-
tims were more likely to be exposed to par-
ent-child discord and physical abuse. The
reason for the discrepancies regarding par-
ent-child conflict and physical abuse in the
New York and Pittsburgh studies is unclear
since the studies used a similar methodology
with demographically matched community
controls and comparable informants. Family
aggression has been noted to be prevalent in
suicidal children identified in the general com-
munity (Beautrais et al., 1996), as well as in
suicidal children seen in clinical settings (see
YOUTH SUICIDE PREVENTION
Spirito, Brown, Overholser, & Fritz, 1989 for
a review).
Contagion. There is considerable evidence
that suicide stories in the mass media, including
newspaper articles (e.g., Barraclough, Shep-
herd, & Jennings, 1977; Blumenthal &
Bergner, 1973; Etzersdorfer, Sonneck, &
Nagel-Kuess, 1992; Ganzeboom & de Haan,
1982; Ishii, 1991; Jonas, 1992; Motto, 1970;
Phillips, 1974, 1979, 1980; Stack, 1989,
1990a, 1991,1996; Wasserman, 1984),televi-
sion news reports (Bollen & Phillips, 1982;
Phillips & Carstensen, 1986; Stack, 1990b,
1993) and fictional dramatizations (Gould &
Shaffer, 1986; Gould, Shaffer, & Kleinman,
1988; Hafner & Schmidkte, 1989; Hawton et
al., 1999; Holding, 1974, 1975; Schmidtke &
Hafner, 1988),are followed by a significant in-
crease in the number of suicides (see Gould,
2001, for a comprehensive review).The magni-
tude of the increase appears to be proportional
to the amount of publicity given to the story
and the prominence of the placement of the
story in the newspaper (e.g., Bollen & Phillips,
1981; Motto, 1970; Phillips, 1974, 1979;
Wasserman, 1984).The impact of suicide sto-
ries on subsequent completed suicides has been
reported to be greatest for teenagers (Phillips&
Carstensen, 1986).Despite this ample body of
literature supportive of the hypothesis that sui-
cides dramatized in the media encourage imita-
tion, a few studies did not report an association
between media reports and subsequent suicides
(e.g., Berman, 1988; Phillips & Paight, 1987)
or found only an association among adoles-
cent, not adult, suicides (Kessler, Downey,
Stipp, & Milavsky, 1989).
Research has indicated that “outbreaks” or
clusters of completed suicides in the United
States occur primarily among teenagers and
young adults, with only sporadic and minimal
effects beyond 24 years of age (Gould,
Wallenstein, & Kleinman, 1990; Gould,
Wallenstein, Kleinman, O’Carroll, & Mercy,
1990). Similar age-specific patterns have been
reported for clusters of attempted suicides
(Gould, Petrie, Kleinman, & Wallenstein,
1994).Estimates of the percentage of teenage
suicides that occur in clusters average between
GOULD AND KRAMER 11

1 % and 2%, with considerable variation by Hicks, Parides, & Gould, 1995) is the only
state and year, yielding estimates from less psychological autopsy study of youth suicide,
than 1 % to 13% (Gould, Wallenstein, & to date, to examine the association of sexual
Kleinman, 1990). Overall, the evidence to orientation and suicide. Homosexuality was
date suggests that suicide contagion is a real defined as having had homosexual experi-
effect (see Velting & Gould, 1997, for a com- ences or having declared a homosexual orien-
prehensive review). An ongoing psychological tation. Three suicide victims and no controls
autopsy study funded by the National Insti- met these criteria. This difference was not sta-
tute of Mental Health, which is examining 5 3 tistically significant. All three suicide victims
suicide clusters that occurred in the United demonstrated evidence of significant psychi-
States between 1988 through 1996, should atric disorder before death, and in no instance
soon be able to identify the factors that initiate did the suicide directly follow an episode of
a suicide “outbreak” (Gould, 1999). stigmatization. Given the opportunities for
underreporting by informants, the psycholog-
Socioenvironmental Factors. S o c i o e c o- ical autopsy paradigm is somewhat limited in
nomic Status - Little information is available its capacity to assess the role of sexual orienta-
in the psychological autopsy literature on the tion.
association of socioeconomic status (SES)and Recent epidemiologic studies suggest a sig-
suicide. In the two studies with available in- nificant association between sexual orienta-
formation, Brent et al. (1988)reported no dif- tion and nonlethal suicidal behavior. In a
ference between suicide victims and suicidal survey of Minnesota high school students,
inpatients in socioeconomic status, and Gould Remafedi, French, Story, Resnick, & Blum
et al. (1996) reported a differential ethnic ef- (1998) reported a significantly higher rate of
fect in a comparison between suicide victims suicide attempts among gay/bisexual males
and community controls. Only African Amer- compared to heterosexual males. Utilizing the
ican suicide victims had a significantly higher Youth Risk Behavior Survey (YRBS) in Mas-
SES than their general population counter- sachusetts, Faulkner and Cranston (1998)and
p a r t s . Specifically, t h e r e w a s a n Garofalo and colleagues (1998) also found
overrepresentation of the middle class and an higher rates of suicide attempts among homo-
underrepresentation of the poorest strata sexual and bisexual adolescents. Studying a
among the African American suicides. New Zealand birth cohort t o age 21,
Fergusson, Horwood, & Beautrais (1999)
Socioenvironmental Factors. School a n d found that gay, lesbian, and bisexual young
Work Problems - Difficulties in school, neither people were at a significantly increased risk
working nor going to school, and not going to for suicidal behavior. A comprehensive review
college pose significant suicide risks (Gould et of this issue is provided by McDaniel and
al., 1996). Youngsters who are “drifting”-not Purcell in this supplement.
affiliated with either a school or work institu-
tion-appear to be at substantial risk for com- Socioenvironmental Factors. B i o 1o g i c a 1
pleting suicide. Shaffer (1974)noted that manyRisk Factors - There is evidence that abnor-
suicides among children under the age of 15 malities in the serotonergic system are associ-
took place after a period of absence from ated with suicide, as well as with impulsivity
school and that a similar phenomenon had and aggression (e.g., Blumenthal, 1990; Mann
been reported for children who had attempted & Stoff, 1997). Low levels of serotonin
suicide (Teicher & Jacobs, 1966), suggesting among suicide attempters have been found to
that social isolation associated with absence be predictive of future completed suicide
from school may facilitate suicidal behavior. (Asberg, Nordstrom, & Traskman-Bendz,
1986). This dysregulation in the serotonergic
Socioenvironmental Factors. Sexual Orien- system appears to occur in a range of psychiat-
tation - The New York study (Shaffer, Risher, ric disorders. The examination of biological
12
factors associated with suicide has largely
been limited to studies of adults. (See Mann,
& Stoff, 1997, for a comprehensive review of
these studies.) The few studies examining chil-
dren and adolescents suggest a similar associa-
tion between serotonin abnormalities and
suicidal behavior, Pfeffer and colleagues
(1998)reported that whole blood tryptophan
levels were significantly lower in prepubertal
children with a recent history of a suicide at-
tempt. Greenhill et al. (1995)found a relation-
ship between serotonin measures and
medically serious suicide attempts within a
small sample of adolescent suicide attempter
inpatients with major depressive disorder.
Further research is needed to determine
whether serotonin-related measures can be
predictive of youth suicidal behavior.
EVIDENCE-BASED
PREVENTION IDEAS
Evidence-based prevention strategies derive
their “evidence” from two sources: research
on the risk factors for youth suicide (reviewed
in the previous sections); and evaluation re-
search of existing Prevention Programs. The
former research can focus prevention efforts
by providing a set of identified, modifiable
risk factors to target, while evaluation re-
search identifies the set of Programs that aP-
pear to be efficacious and feasible. The current
set of evidence-based prevention strategies in-
eludes Programs s u n ~ ~ r i z ebyd the CDC in
the mid-1990s (CDC, 1994), earlier reviews
(e.g.9 k m n a n & Jobes, 1995; Ckland 8~
Zigler, 1993; Shaffer & Craft, 1999; Shaffer
et al., 1988), descriptions of states’ initiatives
(Metha, Weber, Web, 19981, and surveys
of other countries’ national agendas (Taylor,
Kingdom, & Jenkins, 1997)-Each strategy is
evaluated with regard to the robustness of its
empirical foundation of targeted risk factors
and its evaluative data on efficacy.
Suicide prevention strategies have two gen-
era1 goals: case finding with accompanying re-
ferral and treatment and risk factor reduction
(CDC, 1994).Although some prevention pro-
grams incorporate both goals, each preven-
YOUTH SUICIDE PREVENTION
tion strategy will be discussed within the cate-
gory that best exemplifies its major goal.
Case Finding Strategies
Strategies to identify and refer suicidal youth
are based on the valid premise that suicidal ad-
olescents are under-identified (Kashani et al.,
1989; Shaffer & Craft, 1999; Shaffer,
Vieland, Garland, Robs, Underwood, &
Busner, 1990; Velez & Cohen, 1988), and
that potent risk factors have been established
that can be used to identify high-risk Youth.
Several strategies are intended to increase the
recognition and referral of suicidal youth.
These include school-based suicide awareness
curricula, screening, gatekeeper training, and
crisis centers and hotlines.
School-Based Suicide Awareness Curricula.
The most popular suicide prevention pro-
grams in the 1980s focused on suicide aware-
ness and were designed for high school
students, but were sometimes directed to
younger students. One underlying rationale of
these programs is based on the findings that
teenagers are more likely to turn to peers than
to adults for support in dealing with suicidal
thoughts (Hazel1 & King, 1996; Kalafat &
Elias, 1994; ROSS, 1985). A large proportion
of teenagers know a suicidal peer, yet the ma-
jority do not respond appropriately (Kalafat
& Elias, 1992).Thus, one major aim of these
programs is to increase awareness of suicidal
behavior to enable teenagers to identify at-risk
peers and to take responsible action, such as
turning to adults for help (Kalafat & Elias,
1994). Another aim is to facilitate self-disclo-
sure. The programs, ranging in time from one
class period to several hours, usually include
didactic presentations on suicide statistics,
“warning signs” of suicide, and mental health
resources. Often a videotape is used to illus-
trate a suicidal youngster and/or the conse-
quences of failing to help a suicidal peer
(Hazell & King, 1996). Detailed descriptions
of school-based suicide prevention education
programs are provided by Garland and Zigler
(1993), Shaffer et al. (1988) and Hazell and
King (1996). School-based programs that fo-
GOULD AND KRAMER
cus on skills training, (e.g., developing coping
strategies) have different benefits and risks
than the suicide awareness programs, and will
be discussed later.
The marked proliferation of suicide preven-
tion education programs in the 1980s (Gar-
land, Shatter, & White, 1989) prompted
several controlled studies to evaluate the effi-
cacy of this prevention strategy (Abbey,
Madesen, & Polland, 1989; Cliffone, 1993;
K a l a f a t & Elias, 1 9 9 4 ; Klingman &
Hochdorf, 1993; Orbach & Bar-Joseph,
1993; Shaffer et al., 1990; Shaffer, Garland,
Vieland, Underwood, & Busner, 1991; Spiri-
to, Overholser, Ashworth, Morgan, &
Bennedict-Drew, 1988; Vieland, Whittle,
Garland, Hicks, & Shaffer, 1991). While sev-
era1 studies have reported modest increases in
knowledge (Abbey et 1989; Kalafat &
Elias 1994; Overholser, Hemstreet, Spirito, &
Vyse, 1989; Spirit0 et a]., 1988), attitudes
(Cliffone, 1993; Kalafat & Elias, 994;
Overholser et ale,1989), and help-seeking be-
havior (Cliffone, 1993),others have reported
either no benefits (Shaffer et al., 1990, 1991;
Vieland et al., 1991) or detrimental effects
(Overholser et al., 1989; Shaffer et al., 1990).
Detrimental effects included a decrease in de-
sirable attitudes (Shaffer et al., 1991);a reduc-
tion in the likelihood of recommending
mental health evaluations to a suicidal friend
(Kalafat & Elias, 1994); more hopelessness
and maladaptive coping responses among
boys after exposure t o the curriculum
(Overholser et al., 1989); and negative reac-
tions among students most at risk for suicide
(i.e., those with a history of suicidal behavior)
(Shaffer et al., 1990). The negative responses
of adolescent suicide attempters to prevention
programs included their not recommending
the programs to other students, and their feel-
ing that talking about suicide in the classroom
“makes some kids more likely to try to kill
themselves” (Shaffer et al., 1990). Other limi-
tations of this prevention strategy are high-
lighted by: (1) the findings that only a
minority of students hold views requiring in-
tervention; that is, baseline knowledge and at-
titudes of students are generally sound
(Kalafat & Elias, 1994; Shaffer et al., 1991);
(2) research in health education, sex educa-
13
tion, in particular, (Kirby, 1985; McCormick,
Folcile, & Izzo, 1985), that reports that
changes in attitudes and knowledge are not
necessarily highly correlated with behavioral
change; ( 3 )research on suicide contagion, that
suggests that the format and content of some
programs might inadvertently stimulate imi-
tation (Velting & Gould, 1997); and (4) pre-
liminary research that indicates that the peer
networks of suicidal youth are not as exten-
sive or as supportive as those of nonsuicidal
youth (Hazel1 & King, 1996). Educational
programs that are designed to increase a peer’s
ability to recognize high-risk friends, there-
fore, may not be an effective strategy to iden-
tify the high-risk youth who have limited peer
networks.
In light of the limitations of school-based
suicide curriculum Programs, em-
phasis has shifted toward Programs that em-
phasize skills training, including improvement
Of ‘Oping
and symptom management
for students. Moreover, to facilitate the identi-
fication and assistance of at-risk Youth> Pro-
grams are accentuating the education of
Personnel (administration, and
staff),rather than student%and the imPlemen-
tation Of screening programs in
Screening. A prevention strategy that has re-
ceived increased attention is case-finding
through direct screening of individuals.
Self-report and individual interviews are em-
ployed to identify youngsters who are at risk
for suicidal behavior (Eggert, Thompson,
Herting, Randell, & Marzza, 1998; Reynolds,
1991; Shaffer & Craft, 1999). School-wide
screenings, involving multistage assessments,
have focused on depression, alcohol- or sub-
stance-abuse problems, recent and frequent
suicidal ideation, a n d past suicide at-
tempts-factors consistently demonstrated as
suicide risks in psychological autopsy studies
and studies of suicide attempters. Although
this approach mainly has been implemented in
schools (Eggert et al., 1998; Reynolds, 1991;
Shaffer & Craft, 1999), it need not be limited
to this setting and could be implemented in
jails, substance abuse programs, and pediatri-
cians’ offices.
14
The few studies that have examined the clin-
ical efficacy of school-based screening proce-
dures have yielded encouraging results.
Reynolds’ (1991) screening of over 700 ado-
lescents in one high school in a small ur-
badsuburban city in the Midwest, using the
Suicidal Ideation Questionnaire, yielded
100% sensitivity (i.e., no “false negatives” or
youth incorrectly identified as not at risk) with
51% specificity (i-e.,many ‘‘falsepositives” or
youth incorrectly identified as at risk). In a
screening of 2,004 teenagers from eight N~~
York metropolitan area high schools, Shaffer
and Craft (1999) report that the Columbia
Teen Screen had a sensitivity of approxi-
mately 88% and specificity of 76%. Only
three screen-negative students were actually at
risk; however, there were 257 false-positive
screens. M~~~adolescents who were screened
as high risk for suicide were not known to 0th-
ers. only31% of teenagers with major de-
pressive disorder, 26% with recent and
frequent suicide ideation, and 50% of those
with a history of a suicide attempt were in
shaffer and Craft (1999) also re-
port that the direct screening procedure was
cost effective. Eggert et al. (1998) screened
58 1 students identified as potential dropouts
from Northwest urban high schools. Based on
results from the Suicide Risk Screen, sensitiv-
ity ranged from 91 % to 100% and specificity
from 54% to 60%. Youth who screened at
risk showed significantly higher levels of an-
ger, anxiety, and family distress and lower lev-
els of protective f a c t o r s ( s u c h a s
problem-solving coping skills, personal con-
trol, family support, and general support).
The large number of false positives yielded
in the screening of suicidal risk is a limitation
of any protocol that screens for a rare event
(Gould & Shaffer, 1991). False positives
could be minimized by employing a more
stringent cutoff criterion; however, the seri-
ousness of missing a suicidal individual pre-
dudes this scheme. Thus, a high tolerance for
false positives will be necessary for such en-
deavors (Eggert et al., 1998).
The necessity of a second-stage evaluation
in a screening procedure to assess who is not
actually at risk for suicide is highlighted by the
number of false positives (Shaffer & Craft,
YOUTH SUICIDE PREVENTION
1999). Second-stage assessments usually
employ systematic clinical evaluations, using
interviews such as the Suicidal Behaviors In-
terview (Reynolds, 1990) or the Diagnostic
Interview Schedule for Children (DISC) (now
available in a spoken, self-completion
[Voice-DISC] version) (Shaffer & Craft,
1999).
Although a screening strategy appears to be
quite Promising, a number of dilemmas still
need to be addressed. (1)Suicidal risk waxes
and Over as crises Occur and
abate, and as screenings may be
necessary in order to minimize false negatives
(Berman &Z Jobes 1995). ( 2 )School-wide S t U -
dent screening programs were rated high
school principals as significantly less accept-
able than curriculum-based and staff in-ser-
vice programs, most respondents in
this study reported either no or minimal expo-
sure to wide screening programs
Hemenway, 1999).( 3 )The ultimate
success of this strategy is dependent on the ef-
fectiveness of the referral. Considerable effort
must be made to assist the families and adoles-
cents in Obtaining if it is needed.
Gatekeeper Training. Another commonly
used prevention strategy involves the educa-
tion and training of “natural community help-
ers,” adults who come in contact with suicidal
youth in both schools (e.g., teachers, counsel-
ors, and coaches) and in the community (e.g.,
pediatricians, clergy, police, and recreation
staff),because they are often in a position to
be among the first to detect signs of suicidality
and offer assistance to adolescents in need.
Such prevention programs have been referred
to as “gatekeeper training” (CDC, 1994).Pro-
grams to train community helpers are based
on the premise that suicidal youth are
under-identified, and that the likelihood of
identification is increased by providing adults
with knowledge about suicide. In a study of
gatekeepers in Australia, almost 50% of
clergy and 25% of teachers reported that they
had been approached by suicidal teens (Leane
& Shute, 1998). Providing natural commu-
nity helpers with the knowledge to detect
those who may be at risk and the skills to re-
GOULD AND KRAMER
spond can be an important part of a compre-
hensive prevention program. Educational
programs to enhance awareness of youth sui-
cide also can be effectively targeted toward
parents.
The purpose of gatekeeper training is to de-
velop the knowledge, attitudes, and skills to
identify students at risk; to determine the lev-
els of risk; to manage the situations; and to
make a referral when necessary. Typically, the
training covers risk factors for suicide, how to
identify adolescents at risk, case studies of sui-
cidal youth, and information on referral tech-
niques a n d community mental health
resources (Garland & Zigler, 1993; Kalafat &
Elias, 1995). Some programs focus specifi-
cally on the skills and strategies that may assist
a gatekeeper in a preventive intervention
(Tierney, 1994). Finally, attitudes toward sui-
cide are also stressed, given the effect they may
have on community helpers’ behavior and re-
action to a suicidal student. Desirable atti-
tudes to be enhanced include taking a youth’s
suicidal statements seriously, accepting the
necessity of breaking a youth’s confidences,
and recognizing the importance of seeking
help from a mental health profesional.
Research examining the effectiveness of
gatekeeper training is limited, but the findings
are encouraging. In a training program fo-
cused on knowledge, attitudes, and suicide in-
tervention skills, a wide range of community
helpers showed significant improvement in in-
tervention skills, although it was not clear
whether their general knowledge of suicide
was changed (Tierney, 1994). Nevertheless,
this program demonstrated that skills could
be conveyed and then applied in an appropri-
ate situation. Shaffer et al. (1988)reported an
increase in knowledge and skills among edu-
cators after participation in a training pro-
gram. Furthermore, an education and training
program for school personnel yielded positive
effects on counselors’ attitudes, knowledge,
and referral practice (Garland & Zigler,
1993). Mackesy-Amiti, Fendrich, Libby,
Goldenberg, & Grossman (1996) reported
that school personnel, after participating in a
training program for suicide postvention,
showed significant improvement in their prep-
aration for coping with a crisis. The effective-
15
ness of educational programs for health care
professionals has been demonstrated by the
Gotland study in Sweden ( R u t z , von
Knorring, & Walinder, 1992) (a full descrip-
tion of which is detailed in the paper “Suicide
in the Medically 111” in this supplement). The
need for such training in the United States is
highlighted by a recent finding that among
600 family physicians and pediatricians in
North Carolina, 72% had prescribed a selec-
tive serotonin reuptake inhibitor (SSRI) for a
child or adolescent patient; yet only 8% of the
physicians said they had received adequate
training in the treatment of childhood depres-
sion, and only 16% reported that they felt
comfortable treating children for depression
(JAMA, 1999).
One advantage of a gatekeeper-oriented
curriculum program is that it does not carry
the same risk of imitation that may accom-
pany the adolescent-based education pro-
grams. Another benefit is that by training
school personnel and other adults who inter-
act with young people, community resources
can be expanded and a more supportive envi-
ronment for children and youth can be created
(Kalafat & Elias, 1995).
Crisis Centers And Hotlines. There is a suf-
ficient theoretical rationale for presuming that
telephone crisis services (“hotlines”) are a
valid strategy to help address the increasing
problem of teenage suicide. This theoretical
rationale has been articulated by Schneidman
and Farberow (1957) and summarized by
Shaffer et al. (1988). The rationale incorpo-
rates several premises:
1. Suicidal behavior is often associated with
a crisis. The psychological autopsy research
generally supports the existence of an associa-
tion of stressful life events, such as interper-
sonal losses and legal or disciplinary
problems, with suicide (Brent, Perper, Moritz,
& Baugher, 1993; Gould et al., 1996;
Marttunen et al., 1993; Rich, Fowler,
Fogarty, & Young, 1988; Runeson, 1990).
2. Suicide is usually contemplated with psy-
chological ambivalence. Surviving suicide at-
tempters often report that the wish to die
coexisted with wishes to be rescued and saved
16
(Shaffer et al., 1988), which can result in a
“cry for help” (Litman, Farberow,
Schneidman, Heilig, & Kramer, 1965).
3. “Cries for help” can be dealt with by
those with special training (Litman et al.,
1965).
Telephone crisis services offer several prac-
tical advantages: they are convenient, accessi-
ble, and available outside of usual office
hours, thereby providing the opportunity for
immediate support at a time of an individual’s
maximum distress. The anonymity of hotlines
may allow callers to admit embarrassing
things that they would not do elsewhere. They
offer the possibility of great efficiency because
they can potentially reach suicidal individuals
a t a “final common pathway” (Shaffer et al.,
1988).
Despite the wide availability of telephone
crisis services in the United States (American
Association of Suicidology [AAS], 1999;
Seeley, 1996; Shaffer et al., 1988),evidence of
their efficacy is equivocal (Lester, 1997).
Studies examining the impact of crisis hotlines
on mortality have largely employed ecological
designs and focused on adults. These ecologi-
cal studies have compared the suicide rates in
areas with and without a telephone crisis ser-
vice (“crisiscenter”) or in areas before and af-
ter the introduction of a crisis center. Several
studies (Barraclough, Jennings, & Moss,
1977; Bridge, Potking, Zung, & Soldo, 1977;
Jennings, Barraclough, & Moss, 1978; Lester,
1973,1974; Wiener, 1969)have found no sig-
nificant effects of hotlines on suicide rates. A
significant effect of Samaritan Suicide Preven-
tion Centers in England was found by Bagley
(1968), but the results were not replicated by
other researchers using more elaborate and
accurate statistical techniques (Barraclough,
Jennings, & Moss, 1977; Jennings et al.,
1978). More recently, Miller, Coombs,
Leeper, & Burton ( 1 9 8 4 ) examined
racelsexlage-specific suicide rates in U S .
counties with and without a crisis center, and
before and after the introduction of one. A sig-
nificant reduction (33% to 55%) in the sui-
cide rate in young White females was found,
but no evidence of an impact in other popula-
tion groups emerged. The findings of Miller et
al. (1984) are consistent with surveys of hot-
YOUTH SUICIDE PREVENTION
line users that indicate that young White fe-
males are the most frequent callers to these
services (King, 1977; Litman et al., 1965; Slem
& Cotler, 1973). Thus, the groups that utilize
the hotlines appear to be helped. The overall
limited impact of hotlines may be due to their
low utilization rate in high suicide risk groups
(e.g., males), assuming that hotlines provide
an appropriate and efficacious intervention
for this group.
Few studies have examined the utilization
or efficacy of hotlines among teenagers
(Boehm & Campbell, 1995; King, 1977; Slem
& Cotler, 1973). Slem and Cotler (1973)sur-
veyed 1,763 high school students to assess
their awareness and utilization of a multipur-
pose crisis hotline in their community.
Ninety-eight percent of the students were
aware of the hotline, and 5.6% had used it. Fe-
males constituted two-thirds of the callers.
Sixty-eight percent of users stated that calling
the hotline was helpful. The proportion of sui-
cidal users was unspecified. Recently, Boehm
and Campbell (1995)reviewed the calls made
to a hotline service specifically targeting ado-
lescents. Of the 11,152 calls made during a 5
112 year period, 441 (4%) concerned suicide.
The majority of these suicide callers were fe-
male (65%) and more likely to be 15- or
16-years-old than other ages. Family difficul-
ties, issues of self-esteem, and drugs and alco-
hol were prominent problems discussed by
suicide callers. In a study of help-seeking be-
haviors among 497 adolescents from three
high schools in a large metropolitan area in
the Midwest, Offer, Howard, Schonert, &
Ostrov (1991)reported that only 1.8% of 111
disturbed adolescents and 2.3% of 386
nondisturbed adolescents had called a crisis
hotline in the past year. The reasons for the
calls were unspecified.
In general, there is a dearth of information
about the efficacy of telephone crisis services
for teenagers and whether they adequately ad-
dress the specific risk factors among the higher
risk groups. Hotline services might be an im-
portant resource for teenagers at risk for sui-
cide in that hotlines appear to help the groups
who utilize them (Miller et al., 1984),and they
may provide help for a n o t h e r w i s e
underserved population (King, 1977); how-
GOULD AND KRAMER
ever, few teenagers utilize crisis hotlines
(Litman et al., 1965; Offer et al., 1991)despite
their endorsement of hotlines as a more ac-
ceptable resource than mental health centers
(Kalafat & Elias, 1994). Moreover, teenagers
are less likely than adults to be aware of hot-
lines (Greer & Anderson, 1979) and those
who do call tend not to be those at highest risk
for suicide (i.e., males). Identification of fac-
tors that might optimize the utilization of hot-
lines by high-risk teenagers and examination
of the efficacy of these crisis services, already
widely available in the United States, are cru-
cia1 next steps. A project to address these is-
sues, funded by the CDC, is currently
underway (Gould, 2000b).
Risk Factor Reduction Strategies
Programs designed to minimize the risk fac-
tors for suicide usually involve Primary Pre-
vention or universal models that are geared
for the general population- These include re-
strictions of lethal means; media education;
postvention/crisis interventions; and skills
training (e.g., symptom management and
competency enhancement) for youth.
Restrictions of Lethal Means. The underly-
ing rationale for restricting lethal means as a
suicide prevention strategy is that suicidal in-
dividuals are often impulsive, they may be am-
bivalent about killing themselves, and the risk
period for suicide is transient (Miller &
Hemenway, 1999).Restricting access to lethal
methods during this period may prevent sui-
cides. Restriction of access must consider a
number of complexities. Both physical avail-
ability and sociocultural acceptability are im-
portant determinants of choice of suicide
method (Cantor & Baume, 1998);there is also
variation in method preference by gender and
nationality (NCHS, 20OOc;WHO, 1999).The
means-restriction strategies with the greatest
potential impact on reducing suicide are those
that target the more commonly and preferred
methods within a specific population (Cantor
& Baume, 1998).Thus, restrictions of specific
methods of suicide are likely to have different
17
effects in different population subgroups and
locales.
In the United States, the most common
method for committing suicide is by firearm.
Accordingly, restricting access to firearms is a
recommended prevention measure (Berman
& Jobes, 1995; Garland & Zigler, 1993).This
strategy is supported by the research finding
that the presence of firearms in the home is a
significant risk factor for youth suicide (Brent
et al., 1988, 1991; Brent, Perper, Moritz,
Baugher, Schweers, et al., 1993),as well as for
adult suicide (Kellermann et al., 1992). Nu-
merous studies have examined the relation-
ship between firearms legislation and firearm
suicides (see Miller & Hemenway, 1999, for a
recent comprehensive review). These studies
have been cross-sectional comparisons of dif-
ferent nations (e.g., Sloan, Rivara, Reay, Fer-
ris, & Kellermann, 1990) or regions, states or
cities within the United States (e.g., Boor &
Bair, 1990)with different levels of gun owner-
ship restrictions, or longitudinal studies evalu-
ating differences before and after the
implementation of gun control laws (e.g.,
Loftin, McDowell, Wierseman, & Coffey,
1991).Several studies suggest that restrictions
on guns can reduce the overall suicide rate, as
well as firearm-related suicides (e.g., Boor &
Bair, 1990; Carrington & Moyer, 1994;
Lester & Murrell, 1980, 1986; Loftin et al.,
1991; Medoff & Magaddino, 1983), while
others have found no overall effect (Rich et al.,
1990) or equivocal results (Cantor & Slater,
1995; Cummings, Koepsell, Grossman,
Savarino, & Thompson, 1997; Sloan et al.,
1990). The equivocal findings largely re-
flected age-specific effects (Cantor & Slater,
1995; Sloan et al., 1990), in that restrictive
gun laws had a greater impact on adolescents
and young adults. Overall, the evidence pro-
vided by the studies suggests that gun legisla-
tion does have an impact on suicide mortality.
The longitudinal evaluations of the Washing-
ton, D.C. (e.g., Loftin et al., 1991) and Cana-
dian (e.g., Carrington & Moyer, 1994)
restrictive gun control laws epitomize the
overall findings from these studies. Loftin arid
colleagues (1991) examined homicides and
suicides committed between 1968 through
1987. The 1976 adoption of a restrictive
18 YOUTH SUICIDE PREVENTION

handgun policy in the District of Columbia doses may be less lethal than firearms, they
was associated with a decline in homicides have quite different implications for lethality
(25YOreduction) and in suicides (23YOreduc- depending on the agent. The selective seroto-
tion) in which guns were used. No such de- nin re-uptake inhibitors (SSRIs) and other
cline was seen in adjacent metropolitan areas newer antidepressants are considerably safer
where restrictive licensing was not enacted. A in overdose t h a n tricyclics ( K a p u r ,
study by Carrington and Moyer (1994) ex- Mieczkowski, & Mann, 1992); however, the
tended the time period examined by Rich and differential action among SSRIs (e.g., sedating
colleagues (1990). While Rich et al. had not or disinhibiting) must be considered when
found a decline in suicide rates for the 5 years prescribing for suicidal individuals. Conse-
after the 1978 Canadian firearms regulation, quently, education programs for health prac-
Carrington and Moyer did report a decrease titioners regarding safer prescribing practices
in the age-adjusted suicide levels in the 12 for high-risk patients is a recommended sui-
years after the law was enacted. cide prevention strategy.
-.
A concern often raised with regard to the ef- Other restrictions include the reduc-
fectiveness of means restriction is the likeli- tion of carbon monoxide of automo-
hood that method substitution will occur. In bile exhaust. Clarke and Lester (1987)
other word% people will substitute an avail- reported that following the introduction of
able method for the one that is now restricted. emission controls in the mid-l960s, the rate of
Some evidence of method substitution exists car exhaust suicides declined in the United
(Lester 8L LeenaarS, 1993; Lester States. Further means restrictions could be in-
1982; Rich et al., 1990); however, method troduced by carbon monoxide to shut
substitution does not appear to be an inevita- the engine off at a toxic level (Cantor &
ble reaction to firearms restriction (Cantor & Baume, 1998); however, since suicide by car
’later, 1995; Carrington 8c MoYer, 1994; exhaust account for a small proportion of all
Lester Murrell, 1986; Loftin et a’., 1991). suicides in the United States, this means of re-
Moreover, even if some individuals do substi- striction would not be expected to have a large
tute other methods, the chances of survival impact on the overall suicide rate (Lester &
may be greater if the new methods are less le- Frank, 1989). Potential restrictions regarding
thal (Cantor & Baume, 1998). hangings per se seem limited (Cantor &
Although firearm restriction is a plausible Baume, 1998). This limitation is particularly
approach to suicide Prevention, the cultural troubling because hanging is the second most
belief in an individual’s right to “keep and prevalent method of suicide in the united
bear arms” probably makes it an States and accounts for the major rise in sui-
for segments Of American society. cide since the early 1980s in Australia (Cantor
Less controversial prevention measures in- & Baume, 1998).
volve education about means restriction to
parents of high-risk youth. For example,
Kruesi ( 999) demonstrated that injury pre- Media Education. Given the substantial evi-
vention education in emergency rooms led dence for suicide contagion a recommended
parents to take new action to limit to le- suicide prevention strategy involves educating
thal means, such as locking up their firearms. reporters, editors, and film and television pro-
Furthermore, firearm education programs ducers about contagion, in Order to yield me-
could be directed to parents of youth with al- dia stories that minimize harm. Moreover, the
cohol and other substance problems. This media’s positive role in educating the public
strategy is supported by the finding that sui- about risks for teen suicide and shaping atti-
cidal teenagers are more likely to use firearms tudes about suicide should be encouraged
when intoxicated (Brent et al., 1991). (Gould, 2001).
Means restriction strategies also need to be The only systematic research on the imple-
considered for methods of suicide preferred by mentation of media guidelines has been con-
women, such as overdoses. Although over- ducted in Austria (Etzersdorfer et al., 1992;
GOULD AND KRAMER
Sonneck, Etzersdorfer, & Nagel-Kuess,
1994). Following implementation of media
guidelines for news reporting by the Austrian
Association for Suicide Prevention in 1987, a
significant decline ( 7 % ) in suicide rates oc-
curred within the first year. In the 4-year pe-
riod following the implementation, the suicide
rate decreased by 20%. In the United States,
the CDC published a set of recommendations
on reporting of suicide that emerged from a
national workshop (CDC, 1994).The recom-
mendations generally include descriptions of
factors that should be avoided because they
increase attention to the media reports and are
more likely to induce contagion (e.g., front
page coverage). Also included are suggestions
on how to increase the usefulness of the report
(e.g., describing treatment resources). Regret-
tably, no evaluation studies have been con-
ducted on these recommendations. Given the
success of this prevention strategy in Austria,
efforts to systematically evaluate its efficacy in
the United States are warranted.
Postvention f Crisis Intervention. A b r o a d
range of psychological sequelae are likely to
occur among individuals in the aftermath of a
suicide by a family member, friend, fellow stu-
dent, or community member. These deleteri-
ous effects can include suicidality, the onset or
exacerbation of psychiatric disorders (e.g.,
PTSD, major depressive disorder, etc.), and
other symptoms related to pathological be-
reavement (Brent, Perper, Moritz, Allman, et
al., 1993; Brent, Perper, Moritz, Friend, et al.,
1993). The underlying rationale for
postventionkrisis intervention is that a timely
response to these outcomes among the survi-
vors is likely to reduce subsequent morbidity
and mortality. The major goals of postvention
programs are to assist survivors in the grief
process, identify and refer those individuals
who may be at risk following the suicide, pro-
vide accurate information about suicide while
attempting to minimize suicide contagion,
and implement a structure for ongoing pre-
vention efforts (Hazell, 1993; Underwood &
Dunne-Maxim, 1997).
By providing young people with these skills,
The number of postvention programs has it is hoped that an immunization effect can be
increased substantially in recent years (Catone produced against suicidal feelings and behav-
19
& Schatz 1991; Hazell, 1991; Hill, 1984;
Shaffer et al., 1988; Siehl, 1990; Wenckstern
& Leenars, 1991), often from public concern
over suicide clusters, but there is little system-
atic research in this area (Shaffer et al., 1988).
The existing research o n school-based
postvention programs is limited (Hazell &
Lewin, 1993; Hill, 1984; Shaffer et al., 1988).
An aim of an ongoing project funded by the
National Institute of Mental Health (Gould,
2000a) is to develop research based adminis-
trative guidelines and intervention programs
to be implemented in schools in order to facili-
tate a timely and efficacious crisis response.
Community-based postvention strategies
are exemplified by the response plans for the
prevention and containment of suicide clus-
ters developed by the CDC (CDC, 1988). In
addition to involving family and schools,
CDC recommendations include the response
of a larger segment of the population, such as
police, clergy, government officials, media,
and healthcare providers. Optimally a re-
sponse plan is developed prior to the occur-
rence of any crisis. It incorporates suggestions
for identifying and referring high-risk individ-
uals, containment of contagion, and develop-
ment of long-term strategies to reduce the risk
of suicide in the community. To date, system-
atic evaluations of a community response pro-
gram have not been published.
Skills Training. I n c o n t r a s t t o s u i c i d e
awareness curricula in schools, skills training
programs emphasize the development of
problem-solving, coping, and cognitive skills,
based on the research indicating that suicidal
youth have deficits in these areas (e.g.,
A s a r n o w e t al., 1 9 8 7 ; C o l e , 1 9 8 9 ;
Rotheram-Borus et al., 1990). Curricula for
skills training programs cover such areas as
coping skills enhancement, self-awareness,
self-esteem and self-efficacy enhancement,
communication skills, problem-solving and
decision-making skills, drug information,
stress management, and development of posi-
tive healthy adolescent behaviors.
20
iors. Self-destructive behaviors may be pre-
vented through the acquisition of better
strategies to cope with stress and problems.
The reduction of tendencies toward suicide, as
well as risk factors for suicide (e.g., depres-
sion, hopelessness, and drug abuse), are tar-
geted outcomes for skills training programs.
These programs are often provided in the con-
text of a health education curriculum or
within a broader, more comprehensive pre-
vention program.
The effectiveness of skills training programs
has been evaluated and supported by a few
studies of school-based programs with both
normal and high-risk students. A health edu-
cation curriculum, stressing self-esteem en-
hancement, coping skills, and healthy decision
making, was one component of a comprehen-
sive suicide prevention program implemented
in the Dade County (FL) Public Schools
( Z e n e r e & Lazarus, 1 9 9 7 ) . T h e
multicomponent nature of the program made
it difficult to disentangle the specific effects of
the skills training, and a number of method-
ological limitations, noted by the authors
(such as no control school), precluded defini-
tive conclusions; however, this program pri-
marily involved the skills training component
and appeared to be potentially effective in the
prevention of suicidal behavior.
Evaluation of another school-based preven-
tion program also found evidence for the ef-
fectiveness of training in the development of
coping strategies (Orbach & Bar-Joseph,
1 9 9 3 ) . Using experimental and
nonexperimental groups, the authors exam-
ined the effect of the prevention program on
suicidal tendencies, depression, hopelessness,
coping, and the strength of ego identity. In
general, the outcome measurements indicated
that the experimental program led to a reduc-
tion of suicidal tendencies and an increase in
ego identity cohesion and ability to cope with
problems. The measurement of hopelessness
was mixed, but did show some reduction. This
program demonstrated that suicide preven-
tion can affect internal processes related to
suicidal behavior (Orbach & Bar-Joseph,
1993).
-
Another cognitive-oriented prevention pro-
gram was designed to impact processes related
YOUTH SUICIDE PREVENTION
to a high risk of stress and self-destructive be-
haviors (Klingman & Hochdorf, 1993). This
program was found both feasible and effica-
cious in yielding a positive effect on attitudes,
emotions, knowledge, and awareness of dis-
tress coping skills. Although this program did
not measure the change in self-destructive be-
havior, the researchers speculate that it may
have had an immunization or stress inocula-
tion effect on coping with distress (Klingman
& Hochdorf, 1993).
In a sample of students at high risk for
school failure or dropout, Eggert et al. (1995)
found a reduction in risk factors for suicide
and an enhancement of protective factors af-
ter the implementation of a school-based pre-
vention program involving life-skills training
and social support perspectives. School failure
or dropout is a reported risk factor for suicide
(Gould et al., 1996). Eggert et al. (1995)
showed a reduction in suicide-risk behaviors,
depression, hopelessness, stress, and anger,
and an increase in self-esteem and social sup-
port resources, following the intervention and
for the subsequent 5 months. This program
demonstrated the feasibility of identifying
high-risk students and enrolling them in an ac-
ceptable prevention program; however, the
specific aspects of the program responsible for
risk reduction remain unclear.
These studies yield data that are encourag-
ing about the potential effectiveness of
skills-based prevention efforts. Moreover, un-
like school-based suicide awareness pro-
grams, the focus of these programs is not
directly on suicide, which reduces the likeli-
hood of contagion. Skills-based prevention
programs need not be limited to school set-
tings, they can be incorporated into commu-
nity centers, runaway shelters, and other
locales more apt to reach a high-risk young
adult population. For skills training to be
most effective, it needs to be implemented
early in the child’s development and should in-
volve not only the child but the parent. Future
research should incorporate measurements
that assess long-term outcome and directly
evaluate suicidality. In addition, control
groups need to be used more effectively to as-
sess the role of the intervention in the preven-
tion of suicide.
GOULD AND KRAMER
BENEFIT ASSESSMENT OF
RECOMMENDATIONS
The benefit assessment of suicide prevention
recommendations incorporates several evalu-
ation indices (Hazell & King, 1996). Table 1
presents a synthesis of the benefit assessment
of each evidence-based prevention idea pre-
sented in this paper. The robustness of data is
considered with regard to the available re-
search on the underlying rationale for the pre-
vention strategy and on formal evaluation
studies. Efficacy is assessed with regard to the
outcome(s ) provided in the published evalua-
tion studies, such as decreases in suicidal
ideation, attempts, and completed suicide; en-
hancement of protective factors; and changes
in attitudes and knowledge. Implementation
considerations are evaluated with regard to
the acceptability of the programs. An evalua-
tion of the efficiency of the program is based
on the extent to which it successfully reaches
high-risk individuals. Ideally, estimates of
time and cost would be considered in an evalu-
ation of efficiency since this information is
necessary in implementing programs and in
determining the benefidcost ratio; however,
this information has not been included in most
of the published literature. Ethical and safety
implications are paramount in evaluating a
program. In fact, these form the consummate
evaluation criterion, in that a suicide preven-
tion program should do no harm. Finally, the
magnitude of the effect would be optimally es-
timated by the population attributable risk
percent (PAF), also called the etiologic frac-
tion, which is defined as the percentage of sui-
cides that would be eliminated in the total
population if the exposure to the risk factor
targeted by the intervention was prevented in
the population (Kelsey, Whittemore, Evans,
& Thompson, 1996; Lewis, Hawton, &
Jones, 1997). This estimate requires informa-
tion on the risk ratio of the targeted risk fac-
tor(s) and the percentage of exposure to the
risk factor in the population. For most preven-
tion strategies, this information is not avail-
able. Estimates of PAF also must consider the
multiple risk factors targeted by a prevention
program, as well as the co-occurrence of most
21
risk factors. Given the imprecision in the as-
sumptions that must be made, it is premature
to provide PAF estimates; therefore, the mag-
nitude of effect is based on the outcome data
provided in the published reports.
Based on the available empirical data, rul-
ing out any prevention strategy is probably
premature; however there is sufficient evi-
dence to suggest that we should proceed cau-
tiously with school-based suicide awareness
curriculum programs.
CONCLUSIONS
During the past 15 years, our knowledge base
about the risk factors for youth suicide has in-
creased enormously. The time is ripe to link
research to the practice of suicide prevention.
The next generation of evidence-based pre-
vention practices should include a focus on
multiple risk factors, since it is generally rec-
ognized that suicide has many causes that are
probably interactive (Moscicki, 1995; Shaffer
et al., 1988). Evaluation protocols, designed
at the inception of a prevention program,
should be an integral component of any pro-
gram. One ongoing dilemma in the evaluation
of prevention programs, however, is that no
widely accepted measurement of the actual ef-
fectiveness of such programs is available.
Given the low base rate of completed suicide,
mortality statistics cannot be used effectively
as outcome measures, unless the assessment
involves a very large-scale prevention effort.
Nevertheless, assessments of help-seeking be-
havior, risk factors (such as depression and
substance abuse), and suicidal attempts and
ideation can be employed in evaluation ef-
forts. A major challenge is to identify direct
outcomes of specific components of preven-
tion programs. Attention also should be di-
rected toward designing prevention programs
that reach high-risk populations, such as
young males because marked gender differ-
ences with regard to resistance to suicide pre-
vention efforts have become evident (Hazell
&King, 1996; Overholser et al., 1989; Spirit0
et al., 1988).In general, females respond more
positively to prevention efforts; they are more
likely than males to show an understanding of
 h,
N

Evidence-based
prevention
ideas
Ow findingstrat&s
School-BasedSuicide
Awareness Curriculum
Screening
Gatekeeper Training
Crisis Centers and Hotlines
TABLE 1
Benefit Assessment of Suicide Prevention Recommendations
Robustness of data
Under1 in Implementation Ethifal Estimated
ranonaL of Evaluation considerations/ implications/ ma itude
- Program data Efficacy acceptability Efficiency safety ORffeCt
Some research Several evaluation Equivocal findings Evidence of Not particularly Serious concerns Minor increase in
available on studies acceptability efficient. Majority
raised. Some shifts in knowledge and
tanager's of students arc not
desirable attitudes, attitude shifts
attitudes about at high risk nor have
some evidence of
helpseeking behavior inappropriate increase in
attitudes maladaptive coping
responses, possibility
of contagion
Extensive research on Few evaluation Shown to identify Some evidence that Many false positives Assistance in referrals If targets of screening
risk factors available studies high risk students, implementation identified to adequate - depression,
from psychological but unknown impact might meet resistance treatment necessary. substance abuse and
autopsy studies and on suicide rates Confidentiality issues suicide attempts - are
studies of attempters treated then potential
impact on reducing
suicides is
considerable.
some mearch Few evaluation Evidence Of h w l - Evidence of Repetition of training No safety issues Not yet known
available on studies edge gain and reduc- acceptability program appears raised
gatekeepers' tion of necessary
experimceswith gender-specific sui-
suicidal youth cide rates
Psychological Several ecological Equivocal. Widely available, but Not reaching highest Training of volunteer Decline of over 1/3 in *
autopsy studies studies on adult Race-age-sex specific less apt to be used by risk groups counselors is critical suicide rates reported
indicate that suicide suicides. Few studies effects boys for young white
is often associated on youth suicide females 2
with a stress event VY

3
2
Risk factor reduction struteEies:
Restriction of lethal means Several studies Numerous ecological Majority of studies Second Amendment Reaches large No safety issues 23% reduction in
indicate availability studies-both indicate that weapon rights limit population of raised firearm suicides re-
of firearms in homes cross-sectional and restriction has impact acceptability high-risk youth ported. Method
significantly increases longitudinal on suicide mortality within segments of substitution appears
risk of completed public to be minimal
suicide
Media education Numerous studies Few evaluation Efficacy demon. Media might be Reaches large N o safety issues 7% reduction in sui-
indicate existence of studies strated reluctant to partici- proportion of raised cides reported in first
suicide contagion pate. Turn over of population year and 20% over 4
editorial staff and years post-guidelines
journalists would
require repetition of
educational
programs
Postventiodcrisis Several studies have Few evaluation Efficacy not yet Response plan needs High risk students N o safety issues Not yet known
intervention examined sequelae to studies demonstrated to be in place prior to are not necessarily raised
suicide exposure crisis; yet motivation identified without
for development of- systematic screening
ten occurs after crisis
Skills training Some research Few evaluation Some reduction in Evidence of Majority of general No safety issues Not yet known
available on coping studies risk factors and acceptability population targeted raised
and problem-solving enhancement of pro- is not at risk
deficits in suicidal tective factors
youth. Ample risk reported
factor research

N
w
24
suicidal behavior, to seek help for themselves,
and to refer someone else for counseling
(Spirit0 et al., 1988). Similarly, females are
more apt to call a telephone crisis service. The
need for gender-specific suicide prevention
strategies must be underscored in our future
efforts. Finally, the most effective national
agenda to prevent suicide should include strat-
egies to improve individual clinical care. Such
REFERENCES
American Association of Suicidology. (1999). Suicide
prevention and crisis intervention centers. Washing-
ton, DC: Author.
Abbey, K., Madsen, C., & Polland, R. (1989).Short-term
suicide awareness curriculum. Suicide and Life-Threat-
ening Behavior, 19,216-227.
Adcock, A. G., Nagy, S., & Simpson, J. A. (1991). Se-
lected risk factors in adolescent suicide attempts. Ado-
lescence, 26, 817-828.
Andrews, J. A., & Lewinsohn, P. M. (1992). Suicidal at-
tempts among older adolescents: prevalence and
co-occurence with psychiatric disorders. Journal of the
American Academy of Child and Adolescent Psychia-
try, 31, 655-662.
Andrews, V. C., Garrison, C. Z., Jackson, K. L., Addy, C.
L., & McKeown, R. E. (1993). Mother-adolescent
agreement on the symptoms and diagnoses of adoles-
cent depression and conduct disorders. Journal of the
American Academy of Child and Adolescent Psychia-
try, 3 2 , 731-738.
Andrus, J. K., Fleming, D. W., Heumann, M. A., Wassell,
J. T., Hopkins, D. D., & Gordon, J. (1991). Surveil-
lance of attempted suicide among adolescents in Ore-
gon, 1988. American ]ournal of Public Health, 87,
1067-1069.
Apter, A., Bleich, A., King, R., Kron, S., Fluch, A., Kotler,
M., & Cohen, D. J. (1993). Death without warning? A
clinical postmortem study of suicide in 43 Israeli ado-
lescent males. Archives of General Psychiatry, 50,
138.142.
Asarnow, J., Carlson, G., & Guthrie, D. (1987). Coping
strategies, self-perceptions, hopelessness, and per-
ceived family environments in depressed and suicidal
children. Journal of Consulting and Clinical Psychol-
ogy, 55, 361-366.
Asberg, M., Nordstrom, P., & Traskman-Bendz, L.
(1986). Biological factor in suicide. In A. Roy, (Ed.),
Suicide (pp. 47-71). Baltimore: Williams and Wilkins.
Bagley, C. (1968).The evaluation of a suicide prevention
scheme by an ecological method. Social Science and
Medicine, 2 , 1-14.
Barraclough, B. M., Jennings, C., & Moss, J. R. (1977).
Suicide prevention by the Samaritans. The Lancet, 2,
237-239.
Barraclough, B. M., Shepherd, D., & Jennings, C. (1977).
Do newspaper reports of coroners’ inquests incite peo-
YOUTH SUICIDE PREVENTION
efforts would involve the development of criti-
cal care management protocols for emergency
rooms, the establishment of optimal treat-
ment protocols for psychiatric disorders and
for the treatment of teenage suicide attempt-
ers, and the implementation of public policy
to increase access to mental health care.
ple to commit suicide? British ]ournal of Psychiatry,
737,528-532.
Beautrais, A. L., Joyce, P. R., & Mulder, R. T. (1996).
Risk factors for serious suicide attempts among youths
aged 13 through 24 years. Journal o f the American
Academy o f Child and Adolescent Psychiatry, 35,
1174-1182.
Berkson, J. (1946).Limitations of the application of four-
fold table analysis to hospital data. Biometrics Bulle-
tin, 2, 47-53.
Berman, A. L. (1988). Fictional depiction of suicide in
television films and imitation effects. American]ournal
of Psychiatry, 145,982-986.
Berman, A. L., & Jobes, D. (1995).A population perspec-
tive: Suicide prevention in adolescents (age 12-18).Sui-
cide and Life-Threatening Behavior, 25, 143-154.
Beskow, J., Runeson, B., & Asgard, U. (1990).Psycholog-
ical autopsies: Methods and ethics. Suicide and
Life-Threatening Behavior, 20, 307-323.
Biblarz, A., Brown, R. M., Biblarz, D. N., Pilgrim, M., &
Baldree, B. F. (1991).Media influence on attitudes to-
ward suicide. Suicide and Life-Threatening Behavior,
27,374-384.
Bird, H. R., Yager, T., Staghezza, B., & Gould, M. S.
(1990). Impairment in the epidemiological measure-
ment of childhood psychopathology in the community.
Journal of the American Academy of Child and Adoles-
cent Psychiatry, 29, 796-803.
Blumenthal, S. J. (1990). Youth suicide: Risk factors as-
sessment, and treatment of adolescent and young adult
suicidal patients. Psychiatric Clinics ofNorth America,
13, 511-556.
Blumenthal, S., & Bergner, L. (1973). Suicide and news-
papers: A replicated study. American Journal o f Psy-
chiatry, 230, 468-471.
Boehm, K. E., & Campbell, N. B. (1995). Suicide: A re-
view of calls to an adolescent peer listening phone ser-
vice. Child Psychiatry and Human Development, 26,
61-66.
Bollen, K. A,, & Phillips, D. P. (1981). Suicidal motor ve-
hicle fatalities in Detroit: A replication. American Jour-
nal of Sociology, 87,404-412.
Bollen, K. A., & Phillips, D. P. (1982). Imitative suicides:
A national study of the effect of television news stories.
American Sociological Review, 47, 802-809.
Boor, M., & Bair, J. H. (1990). Suicide rates, handgun
GOULD AND KRAMER
control laws, and sociodemographic variables. Psycho-
logical Reports, 66, 923-930.
Boyd, J. H. (1983).The increasing rate of suicide by fire-
arms. N e w England Journal of Medicine, 308,
872-874.
Boyd, J. H., & Moscicki, E. K. (1986). Firearms and
youth suicide. American Journal of Public Health, 76,
1240-1242.
Brent, D. A. ( 1 995). Risk factors for adolescent suicide
and suicidal behavior: Mental and substance abuse dis-
orders, family environmental factors, and life stress.
Suicide and Life-Threatening Behavior, 25, 52-63.
Brent, D. A. (1996). Familial factors in suicide and sui-
cidal behavior. Lifesavers: The Quarterly Newsletter
of the American Suicide Foundation, 8, 2-3.
Brent, D. A., Perper, J. A., & Allman, C. J. (1987).Alco-
hol, firearms, and suicide among youth: Temporal
trends in Allegheny County, PA., 1960 - 1983. Journal
of the American Medical Association, 257,3369-3372.
Brent, D. A., Perper, J. A. Allman, C. J., Moritz, G. M.,
Wartella, M. E., & Zelenak, J. Z . (1991).The presence
and accessibility of firearms in the homes of adolescent
suicides: A case-control study.Journal o f the American
Medical Association, 266,2989-2995.
Brent, D. A., Perper, J. A., Goldstein, C. E., Kilko, D. J.,
Allan, M. J., Allman, C. J., & Zelenak, J. P. (1988).
Risk factors for adolescent suicide: A comparison of
adolescent suicide victims with suicidal inpatients. Ar-
chives of General Psychiatry, 45,581-588.
Brent, D. A., Perper, J. A., Moritz, G., Allan, C., Friend,
A., Roth, B. S., Schweers, J., Balach, L., & Baugher, M.
(1993).Psychiatric risk factors for adolescent suicide:
A case control study. Journal of the American Acad-
emy of Childand Adolescent Psychiatry, 32,521-529.
Brent, D. A., Perper, J. A., Moritz, G. M., Allman, B. S.,
Schweers, J., Roth, C., Balach, L., & Canobbio, R.
(1993).Bereavement or depression? The impact of the
loss of a friend to suicide. Journal of the American
Academy of Child and Adolescent Psychiatry, 32,
1189-1 197.
Brent, D. A., Perper, J. A., Moritz, G., Baugher, M., Roth,
C., Balach, L., & Schweers, J. (1993). Stressful life
events, psychopathology and adolescent suicide: A case
control study. Suicide and Life-Threatening Behavior,
2.3, 179-187.
Brent, D. A,, Perper, J. A., Moritz, G. M., Baugher, M.,
Schweers, J., & Ross, C. (1993).Firearms and adoles-
cent suicide: A community case control study. Ameri-
can JournalofDiseases of Children, 147,1066-1071.
Brent, D. A., Perper, J. A., Moritz, G. M., Friend, A.,
Schweers, J., Allman, C. J., McQuiston, L., Boylan, M.
B., Roth, C., & Balach, L. (1993).Adolescent witness
to a peer suicide. Journal o f the American Academy of
Child and Adolescent Psychiatry, 32, 1184-1 188.
Brent, D. A., Perper, J. A., Moritz, G., Liotus, L.,
Schweers, J., Balach, L., & Roth, C. (1994).Familial
risk factors for adolescent suicide: A case-control
study. Acta Psychiatrica Scandinavica, 89, 52-58.
Brent, D. A., Perper, J. A., Moritz, G. M., Liotus, L.,
Schweers, J., & Canobbio, R. (1994). Major depres-
sion or uncomplicated bereavement? A follow-up of
youth exposed to suicide. Journal of the American
Academy of Child and Adolescent Psychiatry, 3.3,
231-239.
Bridge, T. P., Potkin, S. G., Zung, W. W., & Soldo, B. J.
25
(1977).Suicide prevention centers. Ecological study of
effectiveness. Journal of Nervous and Mental Disease,
164, 18-24.
Cantor, C. H., & Baume, P. J. (1998).Access to methods
of suicide: What impact? Australian and N e w Zealand
Journal of Psychiatry, 31, 8-14.
Cantor, C. H., & Slater, P. J. ( 1 995). The impact of fire-
arm control legislation on suicide in Queensland: Pre-
liminary findings. Medical Journal of Australia, 162,
583-585.
Carrington, P. J., & Moyer, S. (1994).Gun control and
suicide in Ontario. Journal of Psychiatry, 1 5 1 ,
606-608.
Catone, W. V., & Schatz, M. T. (1991).The crisis mo-
ment: A school’s response to the event of suicide.
School Psychology International, 12, 17-23.
Centers for Disease Control. (1988).CDC Recommenda-
tions for a community plan for the prevention and con-
tainment of suicide clusters. Morbidity and Mortality
Weekly Report, 37, 1-12.
Centers for Disease Control. (1991). Attempted suicide
among high school students-United States, 1990. Mor-
bidity and Mortality Weekly Report, 40, 633-635.
Centers for Disease Control and Prevention. (1994).Pro-
grams for the prevention of suicide among adolescents
and young adults; and Suicide contagion and the re-
porting of suicide: Recommendations from a national
workshop. Morbidity and Mortality Weekly Report,
43(No. RR-6), 1-18.
Centers for Disease Control and Prevention. (1998).
Youth risk behavior surveillance-United States, 1997.
Morbidity and Mortality Weekly Report, 47 (No.
SS-3), 1-89.
Clarke, R. V., & Lester, D. (1987). Toxicity of car ex-
hausts and opportunity for suicide: Comparison be-
tween Britain and the United States. Journal of
Epidemiology and Community Health, 41, 114.120.
Cliffone, J. (1993).A classroom presentation to adoles-
cents. Social Work, 38, 197-203.
Cole, D. A. (1988).Hopelessness, social desirability, de-
pression, and parasuicide in two college student sam-
ples. Journal of Consulting and Clinical Psychology,
56, 131-136.
Cole, D. A. (1989). Psychopathology of adolescent sui-
cide: Hopelessness, coping beliefs, and depression.
Journal of Abnormal Psychology, 98,248-255.
Cummings, P., Koepsell, T. D., Grossman, D. C.,
Savarino, J., & Thompson, R. S. (1997).The associa-
tion between the purchase of a handgun and homicide
or suicide. American Journal of Public Health, 87,
974-978.
Davidson, L. E., Rosenberg, M. L., Mercy, J. A., Franklin,
J., & Simmons, J. T. (1989).An epidemiologic study of
risk factors in two teenage suicide clusters. Journal of
the American Medical Association, 262, 2687-2692.
Demetriades, D., Murray, J., Myles, D., Chand, L.,
Sathyaragiswaran, L., Noguchi, T., Bongard, F. S.,
Vryer, G. H., & Gaspard, D. J. (1998).Epidemiology
of major trauma and trauma deaths in Los Angeles
County. Journal of the American College of Surgery,
187, 373-383.
Dubow, E. F., Kausch, D. F., Blum, M. C., Reed, J., &
Bush, E. (1989).Correlates of suicidal ideation and at-
tempts in a community sample of junior high and high
26
school students. Journal of Clinical Child Psychology,
18, 158-166.
Dyer, J.A.T., & Kreitman, N. (1984). Hopelessness, de-
pression, and suicidal intent in parasuicide. British
Journal of Psychiatry, 144, 127-133.
Eggert, L. L., Thompson, E. A., Herting, J. R., & Nicho-
las, L. J. (1995). Reducing suicide potential among
high-risk youth: Tests of a school-based prevention
program. Suicide and Life-Threatening Behavior, 25,
276-296.
Eggert, L. L., Thompson, E. A., Herting, J. R., Randell, B.,
& Mazza, J. (1998, November). ldentifyingandassess-
ing youth at risk for suicidal behaviors. Paper pre-
sented a t w o r k s h o p o n Suicidality in Youth:
Development the Knowledge Base for Youth at Risk,
National Institute of Mental Health, Bethesda, MD.
Etzersdorfer, E., Sonneck, G., & Nagel-Kuess, S. (1992).
Newspaper reports and suicide. N e w England Journal
o f Medicine, 327, 502-503.
Faulkner, A. H., & Cranston, K. (1998). Correlates of
same-sex behavior in a random sample of Massachu-
setts high school students. American Journal of Public
Health, 88,262-266.
Fekete, S., & Schmidtke, A. (1995).The impact of mass
media reports on suicide and attitudes toward self-de-
struction: Previous studies and some new data from
Hungary and Germany. In B. L. Mishara (Ed.), Thelm-
pact o f Suicide. New York: Springer.
Felts, W. M., Chenier, T., & Barnes, R. (1992). Drug use
and suicide ideation and behavior among North
Carolina public school students. American Journal of
Public Health, 82, 870-872.
Fergusson, D. M., Horwood, L. J., & Beautrais, A. L.
(1999). Is sexual orientation related to mental health
problems and suicidality in young people. Archives of
General Psychiatry, 56, 876-880.
Fergusson, D. M., & Lynskey, M. (1995).Childhood cir-
cumstances, adolescent adjustment, and suicide at-
tempts in a New Zealand birth cohort. Journal o f t h e
American Academy of Child and Adolescent Psychia-
try, 34, 612-622.
Fleiss, J. L. (1981). Statistical methods for rates and pro-
portions. New York: John Wiley & Sons.
Ganzeboom, H . B . G., & d e H a a n , D. ( 1 9 8 2 ) .
Gepubliceerde zelfmoorden en verhoging van sterfte
d o o r zelfmoord en ongelukken in Nederland
1972-1980. Mens en Maatschappij, 57,55-69.
Garland, A., Shaffer, D., &Whittle, B. A. (1989). A na-
tional survey of school-based, adolescent suicide pre-
vention programs. Journal of the American Academy
of Child and Adolescent Psychiatry, 28, 931-934.
Garland, A. F., & Zigler, E. (1993). Adolescent suicide
prevention: Current research and social policy implica-
tions. American Psychologist, 48, 169-182.
Garofalo, R., Wolf, R., Cameron, M. S., Kessel, S., Pal-
frey, J., & DuRant, R. H. (1998).The association be-
tween health risk behaviors and sexual orientation
among a school-based sample of adolescents. Pediat-
rics, 101, 895-902.
Garrison, C. Z . , McKeown, R. E., Valois, R. F., & Vin-
cent, M. L. (1993).Aggression, substance use, and sui-
cidal behaviors in high school students. American
Journal of Public Health, 83, 179-184.
Gibbons, R. D., Clark, D. C., & Fawcett, J. A. (1990). A
statistical method for evaluating suicide clusters and
YOUTH SUICIDE PREVENTION
implementing cluster surveillance. American Joimuzl
of Epidemiology, 132, 183-191.
Gibson, J.A.P., & Range, L. M. (1991). Are written re-
ports of suicide and seeking help contagious? High
schoolers’ perceptions. Journal of Applied Social Psy-
chology, 21, 1517-1523.
Gould, M. S. (1999).Psychological autopsy of cluster sui-
cides in adolescents. Grant R01 MH47559-04S2. Na-
tional lnstitute o f Mental Health.
Gould, M. S . (2000a). Epidemiologic sequelae of suicide
in schools. Grant R01 MH52827-04. National lnsti-
tute of Mental Health.
Gould, M. S. (2000b).The evaluation of interventions to
prevent suicide: An evaluation of telephone crisis ser-
vices for adolescents. Collaborative Agreement
#U8l/CCU216089-01. Centers for Disease Control
and Prevention.
Gould, M. S. (2001). Suicide and the media. In H.
Hendin, & J. J. Mann (Eds.), Suicide Prevention: Clini-
cal and Scientific Aspects, Annals o f the N e w York
Academy of Sciences, New York: New York Academy
of Sciences.
Gould, M. S., Fisher, P., Parides, M., Flory, M., &
Shaffer, D. (1996). Psychosocial risk factors of child
and adolescent completed suicide. Archives of General
Psychiatry, 53, 1155-1162.
Gould, M. S., Forman, J., Kleinman, M., & Wallenstein,
S. (1995). Psychological autopsy of cluster suicides in
adolescents. Paper presented at the meeting of the
American Academy of Child and Adolescent Psychia-
try, New Orleans, LA:
Gould, M. S., King, R., Greenwald, S., Fisher, P.,
Schwab-Stone, M., Kramer, R., Flisher, A. J., Good-
man, s., Canino, G., & Shaffer, D. (1998). Psychopa-
thology associated with suicidal ideation and attempts
among children and adolescents. Journal of the Ameri-
can Academy of Child and Adolescent Psychiatry, 37,
9 15-923.
Gould, M. S., Petrie, K., Kleinman, M., & Wallenstein, S.
(1994).Clustering of attempted suicide: New Zealand
National Data. International Journal of Epidemiology,
23, 1185-1189.
Gould, M. S., & Shaffer, D. (1986).The impact of suicide
in television movies: Evidence of imitation. N e w Eng-
land Journal o f Medicine, 3 15, 690-694.
Gould, M. S., & Shaffer, D. (1991). Epidemiology and
child psychiatry. In R. Michels, A. M. Cooper, S. B.
Guze, L. L. Judd, G. L. Klerman, A. J. Solnit, & A. J.
Stunkard, (Eds.), Psychiatry. New York: Lippincott.
Gould, M.S., Shaffer, D., & Kleinman, M. (1988), The
impact of suicide in television movies: Replication and
commentary. Suicide and Life-Threatening Behavior,
18, 90-99.
Gould, M. S., Wallenstein, S., & Kleinman, M. (1990).
Time-space clustering of teenage suicide. American
Journal of Epidemiology, 131, 71-78.
Gould, M. S., Wallenstein, S., Kleinman, M. H.,
O’Carroll, P., & Mercy, J. (1990). Suicide clusters: An
examination of age-specific effects. American Journal
of Public Health, 80, 21 1-212.
Greenhill, L., Waslick, B., Parides, M., Fan, R., Shaffer,
D., & Mann, J. J. (1995). Biological studies in suicidal
adolescent inpatients. Scientific Proceedings of the An-
nual Meeting of the American Academy of Child and
Adolescent Psychiatry, 1 1 , 124.
GOULD AND KRAMER
Greer, S., & Anderson, M. (1979). Samaritan contact
among 325 parasuicide patients. British Journal of
Psychiatry, 135,263-268.
Grunbaum, J. A., Basen-Engquist, K., & Pandey, D.
(1998). Association between violent behaviors and
substance use among Mexican-American and non-His-
panic White high school students. Journal o f Adoles-
cent Health, 23, 153-159.
Hafner, H., & Schmidtke, A. (1989). Increase of suicide
due to imitation of fictional suicide on television. In B.
Cooper, & T. Helgason (Eds.), Epidemiology and Pre-
vention of Mental Disorders. London: Routledge.
Harkavy-Friedman, J. M., Asnis, G. M., Boeck, M., &
DiFiore, J. (1987). Prevalence of specific suicidal be-
haviors in a high school sample. American Journal o f
Psychiatry, 144, 1203-1206.
Hawton, K., Simkin, S., Deeks, J. J., O’Connor, S., Keen,
A., Altman, D. G., Philo, G., 81 Bulstrode, C. (1999).
Effects of a drug overdose in a television drama on pre-
sentations to hospital for self poisoning: Time series
and questionnaire study. British MedicalJournal,3 18,
972-977.
Hazell, P. (1991). Postvention after teenage suicide: An
Australian experience. Journal of Adolescence, 24,
335-342.
Hazell, P. (1993). Adolescent suicide clusters: Evidence,
mechanisms and prevention. Australian and New Zea-
land Journal of Psychiatry, 27, 653-665.
Hazell, P.,&King, R. (1996).Arguments for and against
teaching suicide prevention in schools. Australian and
New Zealand /ournal of Psychiatry, 30,633-642.
Hazell, P., & Lewin, T. (1993). An evaluation of
postvention following adolescent suicide. Suicide and
Life-Threatening Behavior, 23, 101-109.
Hill, W. H. (1984). Intervention and postvention in
schools. In H. S. Sudak, A. B. Ford, & N. B. Rushforth,
(Eds.), Suicide in the Young. Boston: John Wright PSG
Inc.
Holding, T. A. (1974).The B.B.C. ‘Befrienders’ series and
its effects. British Journalof Psychiatry, 224,470-472.
Holding, T. A. (1975). Suicide and ‘The Befrienders’.
British Medical Journal, 3 , 751-753.
Ishii, K. (1991). Measuring mutual causation: Effect of
suicide news on suicides in Japan. Social Science Re-
search, 20, 188-195.
JAMA (1999). SSRI use common in children. Journal of
the American Medical Association, 281, 1882.
Jennings, C., Barraclough, B. M., & Moss, J. R. (1978).
Have the Samaritans lowered the suicide rate? A con-
trolled study. Psychological Medicine, 8, 413-422.
Jobes, D. A., Berman, A. L., & Josselson, A. R. (1987).
Improving the validity and reliability of medical-legal
certifications of suicide. Suicide and Life-Threatening
Behavior, 17, 310-325.
Joffe, R. T., Offord, D. R., & Boyle, M. H . (1988). On-
tario Child Health Study: Suicidal behavior in youth
aged 12-16 years. American Journal of Psychiatry,
145, 1420-1423.
lonas, K. (1992). Modelling and suicide: A test of the
Werther effect. British Jo-umal of Social Psychology,
3 1 , 295-306.
Kalafat, J., & Elais, M. (1992). Adolescents’ experience
with and response to suicidal peers. Suicide and
Life-Threatening Behavior, 22, 315-321.
Kalafat, J., & Elais, M. (1994). An evaluation of a
27
school-based suicide awareness intervention. Suicide
and Life-Threatening Behavior, 24, 224-233.
Kalafat, J., & Elais, M. (1995). Suicide prevention in an
educational context: Broad and narrow foci. Suicide
and Life-Threatening Behavior, 25, 123.133.
Kandel, D. (1988). Substance use, depressive mood, and
suicidal ideation in adoelscence and young adulthood.
In A. R. Stiffman, & R. A. Feldman, (Eds.), Advance-
ment in Adolescent Mental Health. Greenwich, CT:
JAI press.
Kandel, D. B., Raveis, V. H., & Davies, M. (1991). Sui-
cidal ideation in adolescence: Depression, substance
abuse, and other risk factors.Journa1 of Youth and Ad-
olescence, 20,289-309.
Kapur, S., Mieczkowski, M. A., & Mann, J. J. (1992).An-
tidepressant medication and the relative risk of suicide
attempt and suicide. Journal of the American Medical
Association, 268, 3441-3445.
Kashani, J. H., Goddard, P., & Reid, J. C. (1989). Corre-
lates of suicidal ideation in a community sample of chil-
dren and adolescents. Journal of the American
Academy of Child and Adolescent Psychiatry, 28,
912-917.
Kellermann, A. L., Rivera, F. P., Somes, G., Reay, D. T.,
Francisco, J., Gillentine Banton, J., Prodzinski, J.,
Fligner, C., & Hackman, B. B. (1992). Suicide in the
home in relation to gun ownership. NetvEnglandJour-
nal of Medicine, 327,467-472.
Kelsey, J. L., Whittemore, A. S., Evans, A. S., & Thomp-
son, W. D. (1996). Methods in Observational Epide-
miology. New York: Oxford University Press.
Kessler, R. C., Downey, G., Stipp, H., & Milavsky, R.
(1989). Network television news stories about suicide
and short-term changes in total U.S. suicides. Journal
o f Nervous and Mental Disorders, 177,551-555.
King, G. D. (1977).An evaluation of the effectiveness of a
telephone counseling center. American Journal of
Community Psychology, 5, 75-83.
Kirby, D. (1985). Sexuality education: A more realistic
view of its effects. Journal of School Health, 55,
421-424.
Klingman, A., & Hochdorf, 2. (1993). Coping with dis-
tress and self harm: The impact of a primary prevention
program among adolescents. Journal of Adolescence,
16, 121-140.
Kruesi, M.J.P., Grossman, J., Pennington, J. M., Wood-
ward, P. J., Duda, D., & Hirsch, J. G. (1999). Suicide
and violence prevention: Parent education in the emer-
gency department. Journal of the American Academy
o f Child and Adolescent Psychiatry, 38, 250-255.
Leane, W., & Shute, R. (1998). Youth suicide: The
knowledge and attitudes of Australian teachers and
clergy. Suicide and Life-Threatening Behavior, 28,
165-173.
Lester, D. (1973). Prevention of suicide. Journal of the
American Medical Association, 225, 992.
Lester, D. (1974). Effect of suicide prevention centers on
suicide rates in the United States. Health Service Re-
ports, 89, 37-39.
Lester, D. (1997).The effectiveness of suicide prevention
centers: A review. Suicide and Life-Threatening Behav-
ior, 27, 304-310.
Lester, D., & Frank, M. L. (1989).The use of motor vehi-
cle exhaust for suicide and the availability of cars. Acta
Psychiatrica Scundanavica, 79, 238-240.
28
Lester, D., & Leenaars, A. (1993).Suicide rates in Canada
before and after tightening firearm control laws. Psy-
chological Reports, 72, 787-790.
Lester, D., & Murrell, M. (1980). The influence of gun
control laws on suicidal behavior. Journal of Psychia-
try, 137,121-122.
Lester, D., & Murrell, M. (1982).The preventive effect of
strict gun control laws on suicide and homicide. Suicide
and Life-Threatening Behavior, 12, 131-141.
Lester, D., & Murrell, M. (1986). The influence of gun
control laws on personal violence.Journa1 of Commu-
nity Psychology, 14,315-318.
Lewinsohn, P. M., Rohde, P., & Seeley, J. R. (1994).
Psychosocial risk factors for future adolescent suicide
attempts. Journal of Consulting and Clinical Psychol-
ogy, 62,297-305.
Lewinsohn, P. M., Rohde, P., and Seeley, J. R. (1996).Ad-
olescent suicidal ideation and attempts: Prevalence,
risk factors, and clinical implications. Clinical Psychol-
ogy Science and Practice 3(1), 25-36.
Lewis, G.,Hawton, K., &Jones, P. (1997). Strategies for
preventing suicide. British Journal of Psychiatry, 271,
351-354.
Litman, R.E., Farberow, N. L., Schneidman, E. S., Heilig,
S. M., & Kramer, J. A. (1965). Prevention telephone
service. Journal of the American Medical Association,
192, 107-111.
Loftin, C., McDowall, D., Wiersema, B., & Cottey, T. J.
(1991). Effects of restrictive licensing of handguns on
homicide and suicide in the District of Columbia. New
EnglandJournal of Medicine, 325, 1615-1620.
Mackesy-Amiti, M. E., Fendrich, M., Libby, S.,
Goldenberg, D., & Grossman, J. (1996).Assessment of
knowledge gains in proactive training for postvention.
Suicide and Life-Threatening Behavior, 26, 161-174.
Mann, J. J., & Stoff, D. M. (1997). A synthesis of current
findings regarding neurobiological correlates and
treatment of suicidal behavior. Annals of the New
York Academy o f Sciences, 836, 352-363.
Marttunen, M. J., Aro, H. M., Henriksson, M. M., &
Lonnqvist, J. K.(1991). Mental disorders in adolescent
suicide. Archives of General Psychiatry, 48, 834-839.
Marttunen, M. J., Aro, H. M., Henrikksson, M. M., &
Lonnqvist, J. K. (1994). Psychosocial stressors more
common in adolescent suicides with alcohol abuse
compared with depressive adolescent suicides.Journal
of the American Academy of Child and Adolescent
Psychiatry, 33,490-497.
Marttunen, M. J., Aro, H. M., & Lonnqvist, J. K. (1993).
Precipitant stressors in adolescent suicide. Journal o f
the American Academy of Child and Adolescent Psy-
chiatry, 32, 1178-1 183.
McConaughy, S. H.,& Achenbach, T. ( 1 9 9 4 ) .
Comorbidity of empirically based syndromes in
matched general population and clinical samples.Jour-
nal of Child Psychology and Psychiatry, 35,834-839.
McCormick, N., Folcik, J., & Izzo, A. (1985).Sex-educa-
tion needs and interests of high school students in a ru-
ral New York county. Adolescence, 20, 581-592.
Medoff, M. H., & Magaddino, J. P. (1983). Suicides and
firearm control laws. Evaluation Review, 7 , 357-372.
Metha, A., Weber, B., &Webb, D. (1998). Youth suicide
prevention: A survey and analysis of policies and ef-
forts in the 50 states. Suicide and Life-Threatening Be-
havior, 28, 150-164.
YOUTH SUlCIDE PREVENTION
Miller, H. L., Coombs, D. W., Leeper, J. D., & Barton, S.
N. (1984). An analysis of the effects of suicide preven-
tion facilities on suicide rates in the United States.
American Journal o f Public Health, 74, 340-343.
Miller, D. N., Eckert, T. L., DuPaul, G. J., &White, G. P.
(1999).Adolescent suicide prevention: Acceptability of
school-based programs among secondary school prin-
cipals. Suicide and Life-Threatening Behavior, 29,
72-85.
Miller, M., & Hemenway, D. (1999). The relationship
between firearms and suicide: A review of the litera-
ture. Aggression and Violent Behavior, 4, 59-75.
M o n k , M . ( 1 9 8 7 ) . Epidemiology of suicide.
Epidemiologic Reviews, 9, 51-69.
Moscicki, E. K. (1995). Epidemiology of suicidal behav-
ior. Suicide and Life-ThreateningBehavior, 25,22-35.
Motto, J. A. (1970). Newspaper influence on suicide. Ar-
chives o f General Psychiatry, 23,143-148.
National Center for Health Statistics. (2000a). Deaths:
Final data for 1998. U.S. Department of Health and
Human Services. In S. L. Murphy (Ed.). Vol. 48, No.
11.
National Center for Health Statistics, (2000b).Suicide rates
per 100,000 living population (all ages) 1998 [GMWK
2911, http://www.cdc.gov/nchs/data/gm291~1.PDF,
U.S. Department of Health and Human Services.
National Center for Health Statistics, ( 2 0 0 0 ~ )Deaths
.
from 282 selected causes by 5-year age groups, race,
and sex: Each state and the District of Columbia,
1995-1998 (Worktable GMK 1111. Available:
http://www.cdc.gov/hchs/data/98gm3.U.S. Depart-
ment of Health and Human Services.
Nelson, F. (1987). Evaluation of a youth suicide preven-
tion school program. Adolescence, 88, 813-825.
O’Carroll, P. W.(1989). A consideration of the validity
and reliability of suicide mortality data. Suicide and
Life-Threatening Behavior, 19, 1-16.
O’Donnell, I., &Farmer, R. (1995).The limitations of of-
ficial suicide statistics. British Journal of Psychiatry,
166,458-461.
Offer, D., Howard, K. I., Schonert, K. A., & Ostrov, E.
(1991).To whom do adolescents turn for help? Differ-
ences between disturbed and non disturbed adoles-
cents. Journal of the American Academy of Child and
Adolescent Psychiatry, 30, 623-630.
Orbach, I., & Bar-Joseph, H. (1993). The impact of a sui-
cide prevention program for adolescents on suicidal
tendencies, hopelessness, ego identity, and coping. Sui-
cide and Life-Threatening Behavior, 23, 120-129.
Overholser, J. C.,Hemstreet, A., Spirito, A., & Vyse, S.
(1989).Suicide awareness programs in the schools: Ef-
fect of gender and personal experience. Journal of the
American Academy of Child and Adolescent Psychia-
try, 28, 925-930.
Pfeffer, C. R., McBride, A., Anderson, G. M., Kakuma,
T., Fensterheim, L., & Khait, V. (1998). Peripheral se-
rotonin measures in prepubertal psychiatric inpatients
and normal children: Associations with suicidal behav-
ior and its risk factors. Biological Psychiatry, 44,
568-577.
Phillips, D. (1974). The influence of suggestions on sui-
cide; substantive and theoretical implications of the
Werther effect. American Sociological Review, 39,
340-354.
Phillips, D. (1979). Suicide, motor vehicle fatalities, and
GOULD AND KRAMER
the mass media: Evidence toward a theory of sugges-
tion. American Journal of Sociology, 84, 1150-1174.
Phillips, D. (1980). Airplane accidents, murder, and the
mass media: Towards a theory of imitation and sugges-
tion. Social Forces, 58, 1001-1004.
Phillips, D., & Carstensen, L. L. (1986). Clustering of
teenage suicides after television news stories about sui-
cide. N e w England Journal of Medicine, 315,685-689.
Phillips, D., & Paight, D. J. (1987). The impact of tele-
vised movies about suicide: A replicative study. N e w
England Journal of Medicine, 31 7,809-81 1 .
Phillips, D. P., & Ruth, T. E. (1993).Adequacy of official
suicide statistics for scientific research and public pol-
icy. Suicide and Life-Threatening Behavior, 23,
307-319.
Reifman, A., & Windle, M. (1995). Adolescent suicidal
behaviors as a function of depression, hopelessness, al-
cohol use, and social support: A longitudinal investiga-
tion. American Journal of Community Psychology, 23,
329-354.
Reinherz, H. A., Giaconia, R. M., Silverman, A. B., Fried-
man, A., Pakiz, B., Frost, A. K., & Cohen, E. (1995).
Early psychosocial risks for adolescent suicidal
ideation and attempts. Journal of the American Acad-
emy of ChildandAdolescent Psychiatry, 34,599-61 1.
Remafedi, G., French, S., Story, M., Resnick, M. D., &
Blum, R. (1998). The relationship between suicide risk
and sexual orientation: Results of a population-based
study. American Journal of Public Health, 88, 57-60.
Reynolds, W. M. (1990). Development of a semi-struc-
tured clinical interview for suicidal behaviors in adoles-
cents. Psychological Assessment, 2 , 382-390.
Reynolds, W. M. (1991). A school-based procedure for
the identification of adolescents at risk for suicidal be-
haviors. Family Community Health, 14, 64-75.
Rich, C. L., Fowler, R. C., Fogarty, L. A., & Young, D.
(1988). San Diego Suicide Study: 111. Relationships be-
tween diagnoses and stressors. Archives of General
Psychiatry, 45,589-592.
Rich, C. L., Young, D., & Fowler, M. D. (1986). San
Diego Suicide Study: I. Young vs old subjects. Archives
of General Psychiatry, 45, 577-582.
Rich, C. L., Young, J. G., Fowler, R. C., Wagner, J., &
Black, N. A. (1990). Guns and suicide: Possible effects
of some specific legislation. American Journal o f Psy-
chiatry, 147,342-346.
Riggs, S., Alario, A. J., & McHorney, C. (1990). Health
risk behaviors and attempted suicide in adolescents
who report prior maltreatment. The Journal of Pediat-
rics, 116, 815-821.
Rihmer, Z., Rutz, W., & Pihlgren, H. (1995).Depression
and suicide on Gotland. An intensive study of all sui-
cides before and after depression-training program for
general practitioners. Journal of Affective Disorders,
35, 147-152.
Roberts, R. E., & Chen, Y. (1995). Depressive symptoms
and suicidal ideation among Mexican-origin and An-
glo adolescents. Journal of the American Academy of
Child and Adolescent Psychiatry, 34, 81-90.
Roberts, R. E., Chen, Y., & Roberts, C. R. (1997).
Ethoncultural differences in prevalence of adolescent
suicidal behaviors. Suicide and Life-Threatening Be-
havior, 27,208-217.
Rogers, J., Sheldon, A., Barwick, C., Letofsky, K., &
29
Lancee, W. (1982).Help for families of suicide. Cana-
dian Journal of Psychiatry, 27,444-448.
Rosenberg, M. L., Davidson, L. E., Smith, J. C., Berman,
A. I-., Buzbee, H., G a n t n e r , G., Gay, G. A.,
Moore-Lewis, B., Mills, D. H., Murray, D., O’Carroll,
P. W., & Jobes, D. (1988). Operational criteria for the
determination of suicide. Journal o f Forensic Sciences,
33, 3.445-1456.
Ross, C. P. (1985). Teaching children the facts of life and
death: Suicide prevention in the schools. In M. L. Peck,
N. L. Farberow, & R. E. Litman, (Eds.), Youth Suicide.
New York: Springer.
Rotheram-Borus, M. J., & Trautman, P. D. (1988).
Hopelessness, depression and suicidal intent among
adolescent suicide attempters. Journal of the American
Academy of Child and Adolescent Psychiatry, 27,
700-704.
Rotheram-Borus, M. J., Trautman, P. D., Dopkins, S. C.,
& Shrout, P. E. (1990).Cognitive style and pleasant ac-
tivities among female adolescent suicide attempters.
Journal of Consulting and Clinical Psychology, 58,
554-561.
Runeson, B. (1989). Mental disorder in youth suicide:
DSM-111-R Axes I a n d 11. A c t a Psychiatrica
Scandinavica, 79, 490-497.
Runeson, B. (1990). Psychoactive substance use disorder
in youth suicide. Alcohol, 25, 561-568.
Rutz, W., von Knorring, L., & Walinder, J. (1992).
Long-term effects of an educational program for gener-
al practitioners given by the Swedish Committee for the
Prevention and Treatment of Depression. Acta
Psychiatrica Scandanavica, 85, 83-88.
Safer, D. (1997).Self-reported suicide attempts by adoles-
cents. Annals of Clinical Psychiatry, 9,263-269.
Sainbury, P. (1983). Validity and reliability of trends in
suicide statistics. World Health Quarterly, 339-348.
Schmidtke, A., & Hafner, H. (1988). The Werther effect
after television films: New evidence for an old hypothe-
sis. Psychological Medicine, 18, 665-676.
Schneidman, E. S., & Farberow, N. L. (1957). Clues to
suicide. New York: Blakison.
Schulsinger, F. (1980). Biological psychopathology. An-
nual Review of Psychology, 31, 583-606.
Seeley, M. F. (1996). Hotlines as discrete services. Part 2.
Crisis, 17, 155-156.
Shaffer, D. (1974).Suicide in childhood and early adoles-
cence. Journal of Child Psychology and Psychiatry, 15,
2 75-2 9 1.
Shaffer, D., & Craft, L. (1999). Methods of adolescent
suicide prevention. Journal of Clinical Psychiatry, 60,
70-74.
Shaffer, D., Fisher, P., Hicks, R. H., Parides, M., &
Gould, M. (1995). Sexual orientation in adolescents
who commit suicide. Suicide and Life-Threatening Be-
havior, 2.5, 64-71.
Shaffer, D., Garland, A., Gould, M., Fisher, P., &
Trautman, P. (1988). Preventing teenage suicide: A
critical review. Journal of the American Academy of
Child and Adolescent Psychiatry, 27, 675-687.
Shaffer, D., Garland, A., Vieland, V., Underwood, M. M.,
& Busner, C. (1991).The impact of curriculum-based
suicide prevention program for teenagers. Journal of
the American Academy of Child and Adolescent Psy-
chiatry, 30, 588-596.
Shaffer, D., Gould, M. S., Fisher, P., Trautman, P.,
30
Moreau, D., Kleinman, M., & Flory, M. (1996).Psy-
chiatric diagnosis in child and adolescent suicide. Ar-
chives o f General Psychiatry, 53, 339-348.
Shaffer, D., Gould, M., & Hicks, R. (1994).Worsening
suicide rate in Black teenagers. American Journal of
Psychiatry, 1 5 1 , 1810-1812.
Shaffer, D., Vieland, V., Garland, A., Rojas, M., Under-
wood, M. M., & Busner, C. (1990).Adolescent suicide
attempters. Response to suicide-prevention programs.
Journal of the American Medical Association, 264,
3151-3155.
Shafii, M., Carrigan, S., Whittinghill, J. R., & Derrick, A.
(1985). Psychological autopsy of completed suicide in
children and adolescents. American Journal of Psychi-
atry, 142, 1061-1064.
Siehl, P. M. (1990).Suicide postvention: A new disaster
plan: What a school should do when faced with a sui-
cide. School Counselor, 38, 52-57.
Slem, C. M., & Cotler, S. (1973).Crisis phone services:
Evaluation of a hotline program. American Journal of
Community Psychology, 1,219-227.
Sloan, J. H., Rivara, F. P., Reay, D. T., Ferris, J. A., &
Kellermann, A. L. (1990). Firearm regulations and
rates of suicide. A comparison of two metropolitan ar-
eas. N e w EnglandJournalofMedicine, 322,369-373.
Smith, K., & Crawford, S. (1986). Suicidal behavior
among “normal” high school students. Suicide and
Life-Threatening Behavior, 16, 313-325.
Smith, J. C., Mercy, J. A., &Warren, C. W. (1985).Com-
parison of suicides among Anglos and Hispanics in five
Southwest states. Suicide and Life-Threatening Behav-
ior, 15, 14-26.
Sonneck, G., Etzersdorfer, E., & Nagel-Kuess, S. (1994).
Imitative suicide on the Viennese subway. Social Sci-
ence and Medicine, 38,453-457.
Spirito, A., Brown, L., Overholser, J., & Fritz, G. (1989).
Attempted suicide in adolescence: A review and cri-
tique of the literature. Clinical Psychology Review, 9,
335-363.
Spirito, A., Overholser, J., Ashworth, S., Morgan, J., &
Bennedict-Drew, C. (1988). Evaluation of a Suicide
Awareness Curriculum for High School Students.Jour-
nal of Amercian Academy of Child and Adolescent
Psychiatry, 27, 705-711.
Stack, S. A. (1989).The effect of publicized mass murder
and murder-suicides on lethal violence. Social Psychia-
try and Psychiatric Epidemiology, 24,202-208.
Stack, S . A. (1990a).A reanalysis of the impact of non-ce-
lebrity suicides: A research note. Social psychiatry and
Psychiatric Epidemiology, 25, 269-273.
Stack, S. A. (1990b).Audience receptiveness, the media
and aged suicide. Journal ofAgingStudies, 4,195-209.
Stack, S. A. (1991). Social correlates of suicide by age:
Media impacts. In A. A. Leenaars (Ed.), Life span per-
spectives of suicide: Time-lines in the suicide process
(pp. 187-213).New York: Plenum Press.
Stack, S. A. (1993).The media and suicide: A nonadditive
model, 1968-1980. Suicide and Life Threatening Be-
havior, 23, 63-66.
Stack, S. A. (1996).The effect of the media on suicide: Ev-
idence from Japan, 1955-1985. Suicide and Life
Threatening Behavior, 26, 132-142.
Sudman, S., & Bradburn, N. M. (1974).Response effects
in surveys. Chicago: Aldine Publishing Company.
Swanson, J. W., Linskey, A. O., Quintero-Salinas, R.,
YOUTH SUICIDE PREVENTION
Pumariega, A. J., & Holzer 111, C. E. (1992).A bina-
tional school survey of depressive symptoms, drug use,
and suicidal ideation. Journal of the American Acad-
emy of Childand Adolescent Psychiatry, 31,669-678.
Taylor, S. J., Kingdom, D., & Jenkins, R. (1997).How are
nations trying to prevent suicide? An analysis of na-
tional suicide prevention strategies. Acta Psychiatrica
Scandanavica, 95,457-463.
Teicher, J. D., & Jacobs, J. (1966). Adolescents who at-
tempt suicide. American Journal of Psychiatry, 122,
1248-1257.
Tierney, R. J. (1994).Suicide intervention training evalu-
ation: A preliminary report. Crisis, 15, 69-76.
Turner, C. F., Lessler, J. T., & Devore, J. W. (1992).Ef-
fects of mode of administration and wording on report-
ing of drug use. In C. F. Turner, J. T. Lessler, & J. C.
Gfroerer (Eds.), Survey measurement of drug use:
Methodological studies (pp. 177-220). Washington,
DC: Goverment Printing Office.
Underwood, M. M., & Dunne-Maxim, K. (1997).Man-
aging sudden traumatic loss in the schools: New Jersey
Adolescent Suicide Prevention Project (pp. 1-134).
Piscataway, NJ: University Behavioral Healthcare.
Velez, C. N., & Cohen, P. (1988). Suicidal behavior and
ideation in a community sample of children: Maternal
and youth reports. Journal of the American Academy
of Child and Adolescent Psychiatry, 27,349-356.
Velting, D. M., & Gould, M. (1997).Suicide contagion.
In R. Maris, S . Canetto, & M. M. Silverman (Eds.), An-
nual Review of Suicidology, 1997. New York:
Guilford.
Velting, D. M., Rathus, J. H., & Asnis, G. M. (1998).
Asking adolescents to explain discrepancies in self-re-
ported suicidality. Suicide and Life-Threatening Be-
havior, 28, 187-196.
Vieland, V., Whittle, B., Garland, A., Hicks, R., &
Shaffer, D. (1991). The impact of curriculum-based
suicide prevention programs for teenagers: An
18-month follow-up. Journal of the American Acad-
emy of Child and Adolescent Psychiatry, 30,811-815.
Wallace, L.J.D., Calhoun, A. D., Powell, K. E., O’Neil, J.,
& and James, S. P. (1996). Homicide and suicide
among Native Americans, 1979-1992. Violence Sur-
veillance Series, No. 2. Atlanta, GA: Centers for Dis-
ease Control and Prevention, National Center for
Injury Prevention and Control.
Walter, H. J., Vaughan, R. D., Armstrong, B., Krakoff, R.
Y., Maldonado, L. M., Tiezzi, L., & McCarthy, J. F.
(1995). Sexual, assaultive, and suicidal behaviors
among urban minority junior high school students.
Journal of the American Academy of Child and Adoles-
cent Psychiatry, 34,73-80.
Wasserman, 1. M. (1984).Imitation and suicide: A re-ex-
amination of the Werther effect. American Sociological
Review, 49, 427-436.
Weissman, M. M., Fendrich, M., Warner, V., &
Wickramaratne, P. (1992). Incidence of psychiatric
disorder in offspring at high and low risk for depres-
sion. Journal of the American Academy of Child and
Adolescent Psychiatry, 31,640-648.
Wenckstern, S., & Leenaars, A . (1991). Suicide
postvention: A case illustration in a secondary school.
In A. Leenaars, & S. Wenckstern (Eds.), Suicide Pre-
vention in Schools. New York: Hemisphere.
COULD AND KRAMER 31

Wiener, I. W. (1969).The effectiveness of a suicide pre- World Health Organization. (1999). World Health Sta-
vention program. Mental Hygiene, 53,357-363. tistics Annual 1995. Geneva: WHO.
Windle, M., Miller-Tutzauer, C., & Domenico, D. Zenere, F. J., & Lazarus, P. J. (1997).The decline of youth
(1992).Alcohol use, suicidal behavior, and risky activi- suicidal behavior in an urban, multicultural public
ties among adolescents.Joumaf of Research on Adoles- school system following the introduction of a suicide
cence, 2, 317-330. prevention and intervention program. Suicide and
Life-Threatening Behavior, 27, 387-403.