CAVEAT:

FIND THIS STUDY: March, et al. "Fluoxetine, Cognitive-Behavioral Therapy, and Their Combination for Adolescents With Depression." The Journal of the American Medical Association 292, no. 7 (August 18, 2004): 807-820.

RACIAL DISPARITIES IN MENTAL HEALTH SERVICES UTILIZATION

Racial and Ethnic Differences in Service Utilization

Among High-Risk Youths

STUDY AND RESULTS: Among 1,256 youths between the ages of 6 to 18, African-Americans, Latinos and Asian-American/Pacific Islanders were significantly less likely to use mental health services than non-Hispanic Whites. The study followed kids who received care in the publicly funded sector (including child welfare, special education and mental health services), a group traditionally at high risk for suicide and related behaviors. Although all the study groups utilized many mental health services, non-White youths were significantly less likely to use them as compared to White children. Specifically, minority youth were less likely to utilize mental health outpatient services, outpatient alcohol and drug abuse treatment, and inpatient psychiatric hospital treatment—precisely those programs that might help detect and then prevent suicide-related behavior.

Source: Garland, et al., 2005.

WHAT’S IMPORTANT: Although this study focused on a high-risk population, other studies have shown a similar under-utilization of mental health services by minority groups. A lack of access to public sector providers and services may be part of the problem.

FIND THIS STUDY: Garland, et al. "Racial and Ethnic Differences in Utilization of Mental Health Services Among High-Risk Youths." The American Journal of Psychiatry 162, no. 7 (July 2005): 1336-1343.

Dr. Robert A. King, professor at Yale University and a psychiatrist at the Yale Child Study Center, has conducted extensive research on adolescent suicide.

What are the biggest public misconceptions about teenage suicide?

There are three main misconceptions. First is the idea that suicide is something teenagers might do on a bad day or in response to some sort of stress. Although an upsetting episode is often the immediate precipitant to suicide, the vast majority of adolescents who commit suicide have relatively longstanding, diagnosable psychiatric disorders, especially depression and substance abuse. The second misconception is that asking kids about suicide will put the idea in their head or lead to an increased risk that they will attempt or commit suicide. Fairly good data now is available that shows that distressed or previously suicidal adolescents actually feel less distressed or suicidal following surveys that asked them about it, rather than more so. So, if parents or teachers are worried that a child may be suicidal, the best thing to do is to ask. The third misconception is that teenage suicide prevention should start in adolescence. Some of the most effective measures for long-term prevention begin in early childhood in programs such as Head Start, or even at the prenatal level with depression screening for pregnant mothers.

What should legislators know about how to prevent teenage suicide and where should they focus their attention?

Most studies show that a shotgun approach—teaching the warning signs of suicide or just saying no to teen suicide in an untargeted way—doesn’t have a positive effect. Some believe that [raising awareness about prevention strategies and the prevalence of suicidal behaviors] runs the risk of "normalizing" suicide, giving the impression that anyone might commit suicide on a bad day.

The important thing to focus on isn’t suicide per se. Instead, legislators may wish to support and fund early intervention programs for children, adequate prenatal screening programs, nurse visiting programs for mothers of young children at risk, and protective services, since child abuse is a big risk factor for adolescent suicide. Also important is mandating and funding adequate community mental health services for adolescents and kids—especially school-based mental health programs. Most data shows that the vast majority of kids who get any sort of mental health services get them in the school context—it’s where the kids are reachable and it’s where the staff are located. There is a lot of evidence that school-based suicide screening programs do identify kids who are not previously suspected of being at risk. However, a screening program is not effective unless you have the infrastructure within the school system or available in the community to treat the kids who are identified as at-risk. A first round of screening merely identifies kids who may be at-risk for suicidal behavior. If a percentage of kids during an initial screen report that they have had suicidal thoughts in the last year, you must have the capacity to do the second interview. It is necessary to sit down and talk with each child to identify those who are truly suicidal. Otherwise, suicide screening may cause more complexities than it solves.

In sum, what states can do is mandate mental health services in schools, develop guidelines for them, and fully fund them. The school systems—special education and psychological, mental health and preventive services in the schools—are vastly under-funded.

What do you think is the future of teen suicide research?

The field is going toward a much more rigorous approach of evaluating and testing community-, school- and individual-level interventions. There is an emerging focus on evidence-based practices: what interventions have been proven to work, which components of the interventions are most successful, what the long-term durability of the effectiveness is, and whether specific subgroups of kids do or do not benefit from different interventions. There is more effort by the federal government to coordinate this kind of research and to disseminate these programs. Previous suicide prevention programs emphasized the public service component of prevention—getting important information out to the public—but paid less attention to what actually worked or even to what may be harmful. We are moving away from that toward using evidence-based treatments and awareness programs.

What are some of the best practices for preventing teenage suicide?

In general, the most effective programs are targeted to adolescents who are suspected of being at risk for a variety of vulnerability factors. For example, kids who appear to be depressed, have substance abuse problems, and are in danger of dropping out—these are all high risks. In mental health settings, screening children whose parents are receiving treatment for depression is important. Those kids are doubly at risk not only because they have a parent who is seriously preoccupied or disabled with a psychiatric disorder, but also because they very well may carry the genetic vulnerability for the disorder. In this case, what works are cognitive behaviorally oriented programs that teach coping, interpersonal and social skills. Linking kids to appropriate community and ancillary services is important as well.

Are minorities or kids from low-income families more at risk?

As far as we know, poverty is not a risk factor over and above the risk of serious mental illness in parents. Once we control for risk factors at home—such as substance abuse—just being from a lower socio-economic class doesn’t seem to put a child more in danger of being prone to committing suicide. However, some important exceptions are relevant for state governments. For example, due to a combination of factors, the Native American population has tremendously high suicide rates. African Americans and nonwhites in general, with the exception of Native Americans, tend to have lower suicide rates than whites. Although we don’t yet understand why, it underscores the importance of having culturally competent and specific intervention programs.

Columbia University TeenScreen

The TeenScreen Program was developed in 1991 by Columbia University in response to research that shed light on the need for early intervention mental health services to prevent suicide. Columbia researchers discovered that 90 percent of youth who die from suicide suffered from a mental illness, and that 63 percent of those youth experienced symptoms for at least one year prior to their deaths. Kids with unidentified mental health concerns are less likely to seek treatment and are more likely to resort to dangerous coping behaviors—such as substance abuse, violence, risky sexual behavior, dropping out of school, and suicide. TeenScreen programs offer voluntary mental health screening to identify at-risk youth, address issues that confront kids with mental illness and help to connect teens with needed services. A preliminary study of one TeenScreen program presented at the American Academy of Child and Adolescent Psychiatry showed that 60 percent to 75 percent of those identified experienced depression or became suicidal in young adulthood. Follow-up research in 2004 showed that 100 percent of youth who met the Diagnostic Interview Schedule for Children (DISC) criteria for suicide risk were identified by TeenScreen’s instruments. TeenScreen requires sites to make connections with local clinical resources and develop a plan prior to program implementation to ensure that identified teens have access to mental health services following any results that indicate a need.

Map of TeenScreen Sites

The TeenScreen public health initiative has been implemented in different capacities in 43 states and the District of Columbia. TeenScreen partners with state agencies in some states—such as Florida, Nevada, Ohio and Pennsylvania—and local community programs in others. TeenScreen staff provide consultation, training, screening tools and technical assistance to independently- and locally-operated screening programs, educate local providers about the youths’ needs, and link mental health services by connecting mental health providers and community resources, particularly schools. To apply for implementation assistance and training from the TeenScreen program, jurisdictions must develop a proposal that indicates an existing network of community support and resources, program location and staff, and funding sources.

Schools are key sites for early identification ,and school-based health centers offer mental health providers several resources, such as accessible venues for screening programs and service coordination. The Erie, Pennsylvania school district is a model for school-based programming, offering voluntary district-wide screening to more than 1,100 entering ninth graders each fall.

The programs offer paper-and-pencil and computerized screening formats to identify child and adolescent depression and other disorders, available in both English and Spanish. All TeenScreen programs require active parental consent, and youth assent and are confidential. The results are not clinical evaluations, but, rather, indicate a child’s likelihood of being at risk or having a significant problem.

The director of Columbia University’s TeenScreen Program, Laurie Flynn, notes that TeenScreen programs have the ability to respond to local needs; responsiveness and flexibility are hallmark qualities of the program. The program adopts a "learning-by-doing" approach to working with different organizations with distinctive cultures and maintains a collaborative work ethic that allows staff to manage programs in a variety of settings and to collaborate effectively with state and local officials. Florida offers an excellent example of putting existing resources and staff to use. The Florida Office of Drug Control, directed by James McDonough, has partnered with TeenScreen, fitting suicide prevention activity directly into existing substance abuse prevention activity in the state. This initiative has spread TeenScreen programs to more than 50 sites in Florida, which supports Florida’s greater public health mission of reducing the state suicide rate by one-third.

Nearly every state has an existing Suicide Prevention Plan, called for in former Surgeon General David Satcher’s 1999 landmark report, Call to Action to Prevent Suicide. TeenScreen can help jurisdictions build on their state suicide prevention plans to best use existing resources and staff. For example, in 2004, Ohio was able to focus existing resources to screen 1,500 student in five counties; 27 additional counties plan to implement TeenScreen programs in 2005. A public-private partnership—the statewide Suicide Prevention Foundation led by Michael Hogan, director of the Ohio Department of Mental Health—will soon be under way, working to increase the number of youth identified as at-risk for suicide and offering mental health services to those identified. Using existing infrastructure avoids duplicative efforts, thus reducing potential costs of new programs and enhancing efforts already implemented by states. Furthermore, state grants for youth suicide prevention, available through the federal Garrett Lee Smith Act, are expected to facilitate state efforts to integrate teen suicide prevention into greater public health plans. For more information, visit www.teenscreen.org.

Addressing Teen Suicide Among American Indian Youth

The suicide rates for native American youth are 1.5 to 3 times higher than that of other ethnicities in the United States and suicide is the second leading cause of death for Indian youth between the ages of 15 and 24. Research shows that interventions that are culturally competent and developed for a target group are more effective at preventing suicide.   

Trend Graph and Map

Minnesota, where the suicide rate for American Indian males is two times higher than for any other racial or ethnic group, is looking to prevent suicides among its native population. Recent disturbing events in the state include the shootings at Red Lake Reservation where a 16-year-old high school student killed nine people, then himself, in March 2005. In 2004, 69 teenagers on the reservation attempted suicide. The long histories of suppression, the challenges of maintaining their culture, and poor economies with limited opportunities contribute to the increased suicide rate for this population.

In 2000, the Minnesota Department of Health issued a report on suicide prevention that included a state suicide prevention plan. In 2001, the Minnesota Legislature provided the department with $1.1 million annually to implement the state plan with the primary purpose of funding community-based programs for high-risk populations. As part of the plan implementation, the department convened the American Indian Suicide Prevention Work Group to support the suicide prevention efforts. The group has discussed critical issues relevant to suicide prevention for American Indians, including the historical perspective of American Indians, the role of community and government, and strategies for decreasing the suicide rate for American Indian youth. Some of the relevant factors include involving the people in the community who already are addressing the problem, addressing traditional beliefs and practices, and paying attention to historical abuses.

The work group findings have provided valuable information to the state about how it can focus its efforts to prevent suicide in American Indian communities. The work group members held community-wide discussions about suicide prevention and presented its findings to tribal leaders and to the larger state-wide suicide prevention group. A recent response in Minnesota to the shootings at Red Lake Reservation is the creation of a suicide hotline that targets Native American youth and is supported by 30 Minnesota agencies and community groups. 

The National Strategy for Suicide Prevention provides a framework for action for suicide prevention and a guide for developing an array of services and programs. The site includes fact sheets, reports, relevant national and state news, conference announcements, and resources about appropriate identification of risk and treatment; http://www.mentalhealth.samhsa.gov/suicideprevention/.

The Suicide Prevention Resource Center makes available state-specific data and prevention activities. It is a resource on evidence-based practices to help states and communities increase their capacity to develop, implement and evaluate suicide prevention programs; http://www.sprc.org/aboutsprc/index.asp.  

Refer to the Centers for Disease Control and Prevention for statistics on suicide at http://www.cdc.gov/nchs/fastats/suicide.htm.

The National Adolescent Health Information Center at the University of California, San Francisco, has an updated fact sheet on suicide in adolescents and young adults; http://nahic.ucsf.edu/downloads/Suicide.pdf.  

Reports

The 1999 Surgeon General’s Call to Action to Prevent Suicide introduces a blueprint for addressing suicide—Awareness, Intervention, and Methodology (AIM). These recommendations and their supporting conceptual framework are essential steps toward a comprehensive National Strategy for Suicide Prevention; http://www.mentalhealth.samhsa.gov/suicideprevention/calltoaction.asp.

The New York State Office of Mental Health and the New York State Suicide Prevention Council produced Saving Lives in New York: Suicide Prevention and Public Health, which outlines how the state can respond to suicide as a statewide public health crisis; http://www.omh.state.ny.us/omhweb/savinglives/.

The National Governors Association’s Youth Suicide Prevention: Strengthening State Policies and School-Based Strategies provides an overview of prevention strategies and related state activities; http://www.nga.org/cda/files/0504suicideprevention.pdf.

This issue of State Health Lawmakers’ Digest was produced with the generous support of The John D. and Catherine T. MacArthur Foundation.

For questions on this issue, please contact Michelle Herman at 202.624.3583 michelle.herman@ncsl.org.

For complimentary copies, please contact Faith Chang at 202.624.3585 faith.chang@ncsl.org.