Evidence Base
Here you’ll be able to review the research literature and comprehensive lit review.
Evidence-based literature is based on rigorous research and analysis, using well-designed studies and data. It provides reliable information that is supported by empirical evidence rather than mere opinions or anecdotes. This ensures accuracy and minimizes the risk of misinformation or biased claims.
Literature Review
Suicide Universal Screening, Risk Assessment, and Safety Planning with Youth
Suicide is a pressing public health concern, particularly among adolescents and young adults who face an increased risk of suicidal ideation and attempts. In order to address this critical issue, it is important to explore effective suicide prevention strategies within the school setting, where students spend a significant portion of their time. This literature review examines the role of school-based suicide prevention programs, the benefits of mental health screenings, the importance of adult relationships in mitigating suicidality, and the barriers schools may face in implementing these initiatives. By understanding the current research and evidence-based practices, schools can play a vital role in identifying at-risk students, providing necessary support, and ultimately reducing the incidence of suicide among youth.
Longitudinal reports suggest that adolescents who experience a suicidal attempt have a long-term increased risk of reattempts later in life (Barzilay et al., 2019; Cha et al., 2018). Research indicates that youth relationships with adults can be a significant protective factor for suicidality. Given that suicidality disproportionately impacts adolescents and young adults as the second leading cause of death, it is appropriate and advantageous for institutions with adults regularly connected to youth, such as school personnel, to facilitate suicide prevention efforts (Breux & Boccio, 2019; Kalafat, 2003).
In a randomized controlled trial with a 12-month follow-up, Barzilay et al. (2019) collected self-reports from 11,110 high-school students enrolled in a school-based suicide prevention program. This multinational European study found that thwarted belongingness to parents predicted increased suicidal ideation one year later (Barzilay et al., 2019). This suggests that feelings of belongingness with adults could be a protective factor for youth experiencing suicidal ideation. This aligns with other school-based suicide prevention programs, including Sources of Strength, that argue the importance of getting suicidal students connected to trusted adults. Specifically, school-based suicide prevention programs such as Sources of Strength increased student perceptions of adult support and acceptability in help-seeking (Wyman et al., 2010).
Across the literature regarding suicide prevention in schools, researchers argue that, because students spend the majority of their waking hours at schools, school personnel are well-positioned to assess suicidal risks and other mental health risks (Connors et al., 2022; Hoover et al., 2021; Horowitz et al., 2009). Mental health screenings in schools can offer several benefits, including identifying students in need of support, increasing coordination and access to mental health services, and supporting both health and educational outcomes in youth (Weist et al., 2007). A nonrandomized trial of a multi-stage suicide screening program among 9th graders found that suicide screenings decreased suicidal ideation and attempt rates while increasing the use of mental health services among youth (Torcasso & Hilt, 2016).
A recent meta-analysis by Walsh, McMahon, and Herring (2022) explored adolescent suicidal ideation and attempts related to school-based suicide prevention programs. Results found that school-based suicide prevention programs can significantly decrease suicidal ideation and attempts among students. Schools were encouraged to focus on scaling, adopting, implementing, and sustaining school-based suicide prevention programs (Walsh et al., 2022). Early detection screenings for suicidal ideation can effectively identify at-risk teens without causing significant distress (Robinson et al., 2011). However, a 2003 research study examining school psychologists' impressions of suicide prevention programs revealed the erroneous belief that screenings can lead to suicidal thinking when there is no empirical evidence to support this. Further education is needed to address potential concerns among school personnel (Eckert et al., 2003).
School-based interventions focused on training school personnel can improve schools' suicide safety (Breux & Boccio, 2019). School counselors have a legal and ethical obligation to prevent suicides in youth and may be held responsible if schools and their staff do not take action (Berman, 2009). O'Neil et al. (2021) outlined critical considerations for school-based suicide assessment, emphasizing the importance of collaborative, trauma-informed links to services instead of relying solely on emergency services. Schools have ethical and legal obligations to protect the welfare of students, which includes assessing suicide.
In conclusion, school-based suicide prevention programs and mental health screenings have demonstrated significant potential in identifying and supporting at-risk students. By fostering positive relationships with adults, such as school personnel, and implementing comprehensive suicide prevention initiatives, schools can create a protective environment that reduces the risk of suicidal ideation and attempts among adolescents. However, it is crucial to address barriers such as limited resources, training gaps, and stigma to ensure effective implementation. Government agencies, educators, and mental health professionals must collaborate to provide the necessary resources and support to schools, enabling them to fulfill their ethical and legal obligations in protecting the well-being of students. With a comprehensive and evidence-based approach, schools can play a pivotal role in preventing youth suicide and promoting mental well-being in educational settings.
References
Arora, P. G., Collins, T. A., Dart, E. H., Hernández, S., Fetterman, H., & Doll, B. (2019). Multi-tiered systems of support for school-based mental health: A systematic review of depression interventions. School Mental Health, 11(2), 240–264. https://doi.org/10.1007/s12310-019-09314-4
Barzilay, S., Apter, A., Snir, A., Carli, V., Hoven, C. W., Sarchiapone, M., Hadlaczky, G., Balazs, J., Kereszteny, A., Brunner, R., Kaess, M., Bobes, J., Saiz, P. A., Cosman, D., Haring, C., Banzer, R., McMahon, E., Keeley, H., Kahn, J. P., … Wasserman, D. (2019). A longitudinal examination of the interpersonal theory of suicide and effects of school‐based suicide prevention interventions in a multinational study of adolescents. Journal of Child Psychology and Psychiatry, 60(10), 1104–1111. https://doi.org/10.1111/jcpp.13119
Berman, A. L. (2009). School-based suicide prevention: Research advances and practice implications. School Psychology Review, 38(2), 233–238. https://doi.org/10.1080/02796015.2009.12087834
Cha, C.B., Franz, P.J.M., Guzman, E., Glenn, C.R., Kleiman,E.M., & Nock, M.K. (2018). Annual Research Review: Suicide among youth epidemiology,(potential) etiology, and treatment. Journal of Child Psychology and Psychiatry, 59, 460–482.
Connors, Moffa, K., Carter, T., Crocker, J., Bohnenkamp, J. H., Lever, N. A., & Hoover, S. A. (2022). Advancing mental health screening in schools: Innovative, field‐tested practices and observed trends during a 15‐month learning collaborative. Psychology in the Schools, 59(6), 1135–1157. https://doi.org/10.1002/pits.22670
Eckert, T. L., Miller, D. N., DuPaul, G. J., & Riley-Tillman, T. C. (2003). Adolescent suicide prevention: School psychologists' acceptability of school-based programs. School Psychology Review, 32(1), 57–76. https://doi.org/10.1080/02796015.2003.12086183
Hoover, & Bostic, J. Q. (2021). Best Practices and Considerations for Student Mental Health Screening in Schools. Journal of Adolescent Health, 68(2), 225–226. https://doi.org/10.1016/j.jadohealth.2020.11.004
Horowitz, Ballard, E. D., & Pao, M. (2009). Suicide screening in schools, primary care, and emergency departments. Current Opinion in Pediatrics, 21(5), 620–627. https://doi.org/10.1097/MOP.0b013e3283307a89
Kalafat, J. (2003). School approaches to youth suicide prevention. American Behavioral Scientist, 46(9), 1211–1223. https://doi.org/10.1177/0002764202250665
Large, Ryan, C. J., Carter, G., & Kapur, N. (2017). Can we usefully stratify patients according to suicide risk? BMJ, 359, j4627–j4627. https://doi.org/10.1136/bmj.j4627
McCabe, E. M., Jameson, B. E., & Strauss, S. M. (2021). Mental health screenings: Practices and patterns of these and other health screenings in U.S. school districts. The Journal of School Nursing, 105984052110566. https://doi.org/10.1177/10598405211056647
O’Neill, Goldston, D. B., Kodish, T., Yu, S. H., Lau, A. S., & Asarnow, J. R. (2021). Implementing Trauma-Informed Suicide Prevention Care in Schools: Responding to Acute Suicide Risk. Evidence-Based Practice in Child and Adolescent Mental Health, 6(3), 379–392. https://doi.org/10.1080/23794925.2021.1917019
Robinson, J., Pan Yuen, H., Martin, C., Hughes, A., Baksheev, G. N., Dodd, S., Bapat, S., Schwass, W., McGorry, P., & Yung, A. R. (2011). Does screening high school students for psychological distress, deliberate self-harm, or suicidal ideation cause distress – and is it acceptable? Crisis, 32(5), 254–263. https://doi.org/10.1027/0227-5910/a000087
Soneson, E., Howarth, E., Ford, T., Humphrey, A., Jones, P. B., Thompson Coon, J., Rogers, M., & Anderson, J. K. (2020). Feasibility of school-based identification of children and adolescents experiencing, or at-risk of developing, mental health difficulties: A systematic review. Prevention Science, 21(5), 581–603. https://doi.org/10.1007/s11121-020-01095-6
Stein, B. D., Kataoka, S. H., Hamilton, A. B., Schultz, D., Ryan, G., Vona, P., & Wong, M. (2009). School personnel perspectives on their school’s implementation of a school-based Suicide Prevention Program. The Journal of Behavioral Health Services & Research, 37(3), 338–349. https://doi.org/10.1007/s11414-009-9174-2
Torcasso, G., & Hilt, L. M. (2016). Suicide prevention among high school students: Evaluation of a nonrandomized trial of a multi-stage suicide screening program. Child & Youth Care Forum, 46(1), 35–49. https://doi.org/10.1007/s10566-016-9366-x
Walsh, E. H., McMahon, J., & Herring, M. P. (2022). Research review: The effect of school‐based suicide prevention on suicidal ideation and suicide attempts and the role of intervention and contextual factors among adolescents: A meta‐analysis and meta‐regression. Journal of Child Psychology and Psychiatry, 63(8), 836–845. https://doi.org/10.1111/jcpp.13598
Weist, M. D., Rubin, M., Moore, E., Adelsheim, S., & Wrobel, G. (2007). Mental health screening in schools. Journal of School Health, 77(2), 53–58. https://doi.org/10.1111/j.1746-1561.2007.00167.x
Wyman, P. A., Brown, C. H., Lomurray, M., Schmeelk-Cone, K., Petrova, M., Yu, Q., Walsh, E., & Wang, W. (2010). An Outcome Evaluation of the Sources of Strength Suicide Prevention Program Delivered by Adolescent Peer Leaders in High Schools. American Journal of Public Health, 100(9), 1653–1661. doi: 10.2105/ajph.2009.190025
Counterarguments Against Universal Screening:
There are important counterarguments that need to be discussed regarding the utility of universal screening for suicidality in schools. The US Preventive Services Task Force (USPSTF) conducted a systematic review and concluded that the evidence is insufficient to assess the balance of benefits and harms of screening for suicide risk in children and adolescents owing to a lack of evidence (US Preventive Services Task Force et al., 2022). They also found the evidence to be insufficient for screening for Major Depressive Disorder (MDD) in children aged 11 years or younger (US Preventive Services Task Force et al., 2022). These findings raise questions about the effectiveness and potential harm of implementing such screening programs.
Response to the USPSTF Findings:
While the USPSTF findings warrant consideration, it's crucial to recognize that the effectiveness of universal screening may not be adequately reflected in their conclusions. The lack of evidence should not be equated with evidence of ineffectiveness. The absence of well-designed studies should serve as a call to action for more research rather than a dismissal of the concept of universal screening.
Moreover, the USPSTF's approach primarily focuses on established evidence and may not fully account for the rapidly evolving landscape of mental health research and suicide prevention strategies. Recent studies, as previously mentioned, indicate the potential benefits of school-based suicide prevention programs and mental health screenings, suggesting that they can significantly decrease suicidal ideation and attempts among students (Walsh, McMahon, & Herring, 2022; Robinson et al., 2011). These findings challenge the notion that there is insufficient evidence to support screening.
Response to Concerns Raised by Stone (2021):
Addressing the concerns raised by Stone (2021) about the limitations and dangers of school counselors assessing suicide risk in students is essential. While these concerns are valid, it's important to emphasize that the goal of universal screening is not to replace professional mental health assessments but to complement them.
Ethical Concerns: Universal screening should not be seen as a replacement for medical professionals but as a first step in identifying students who may need further evaluation. It is not intended to usurp the skills of mental health professionals but to identify students who require their expertise promptly. Ethical concerns can be mitigated by ensuring that screening is conducted with sensitivity, and all identified cases are referred for professional evaluation.
Inaccuracy of Assessments: While assessments may have limitations, they can serve as an initial indicator of potential risk. The aim is not to make definitive diagnoses but to identify those who might benefit from further assessment and support. Advances in screening tools and procedures can improve accuracy over time.
Dangers of Labeling Risk: Universal screening does not categorize students into high, medium, or low risk in the same way clinical assessments might. Instead, it identifies signs of distress or potential risk, prompting a follow-up by trained professionals who can provide a comprehensive evaluation.
Challenges in Assessing Preadolescents: Indeed, assessing preadolescents for suicide risk is challenging, but this challenge underscores the need for age-appropriate screening tools and the involvement of qualified mental health professionals.
Role Clarity: School counselors can play a vital role in connecting students with appropriate resources and support. They are not meant to replace mental health professionals but can facilitate access to them, ensuring that students receive timely assistance.
While there are valid counterarguments against universal screening, it's crucial to approach them as opportunities for improvement rather than reasons to dismiss the concept. Universal screening can be a valuable part of a broader suicide prevention strategy in schools, provided it is implemented thoughtfully, in collaboration with mental health professionals, and with a focus on identifying at-risk students and connecting them to the necessary support and care.
Lustig, S., Kaess, M., Schnyder, N., Michel, C., Brunner, R., Tubiana, A., Kahn, J.-P., Sarchiapone, M., Hoven, C. W., Barzilay, S., Apter, A., Balazs, J., Bobes, J., Saiz, P. A., Cozman, D., Cotter, P., Kereszteny, A., Podlogar, T., Postuvan, V., … Wasserman, D. (2022). The impact of school-based screening on service use in adolescents at risk for mental health problems and risk-behaviour. European Child & Adolescent Psychiatry, 32(9), 1745–1754. https://doi.org/10.1007/s00787-022-01990-z
Gijzen, M. W. M., Rasing, S. P. A., Creemers, D. H. M., Engels, R. C. M. E., & Smit, F. (2022). Effectiveness of school-based preventive programs in suicidal thoughts and behaviors: A meta-analysis. Journal of Affective Disorders, 298, 408–420. https://doi.org/10.1016/j.jad.2021.10.062
Hughes, J. L., Horowitz, L. M., Ackerman, J. P., Adrian, M. C., Campo, J. V., & Bridge, J. A. (2023). Suicide in young people: Screening, risk assessment, and intervention. BMJ. https://doi.org/10.1136/bmj-2022-070630
Doyle, R. L., & Fite, P. J. (2022). Informant discrepancies in suicidality screening tools among school age youth. Child Psychiatry & Human Development. https://doi.org/10.1007/s10578-022-01412-w
US Preventive Services Task Force, Mangione, C. M., Barry, M. J., Nicholson, W. K., Cabana, M., Chelmow, D., Coker, T. R., Davidson, K. W., Davis, E. M., Donahue, K. E., Jaén, C. R., Kubik, M., Li, L., Ogedegbe, G., Pbert, L., Ruiz, J. M., Silverstein, M., Stevermer, J., & Wong, J. B. (2022). Screening for Depression and Suicide Risk in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. JAMA, 328(15), 1534–1542. https://doi.org/10.1001/jama.2022.16946
Stone, C. (2021). Suicide assessments: The Medical Profession Affirms School Counselors’ Truth. Suicide Assessments: The Medical Profession Affirms School Counselors’ Truth - American School Counselor Association (ASCA). https://www.schoolcounselor.org/Magazines/July-August-2021/Suicide-Assessments-The-Medical-Professional-Affir