Screening for
Mental Health Needs
Hope M. Siler, MSW, LSW
ASPEN Project Regional Director
www.wvaspen.com
OBJECTIVES
• Participants will be introduced to
SAMHSA’s “Preventing Suicide: A High
School Toolkit”
• Participants will learn the significance of
suicide as a public health concern
• Participants will learn to utilize tools for
screening for mental health (PHQ-9, ASAP-20)
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Preventing Suicide:
A Toolkit for High Schools
This tool will help schools and communities:
• Assess their ability to prevent suicide among
students and respond to suicides that may occur
• Understand strategies that can help students
who are at risk for suicide
• Understand how to respond to the suicide of a
student or other member of the school
community
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Preventing Suicide:
A Toolkit for High Schools
• Identify suicide prevention programs and
activities that are effective for individual schools
and respond to the needs and cultures of each
school’s students
• Integrate suicide prevention into activities that
fulfill other aspects of the school’s mission, such
as preventing the abuse of alcohol and other
drugs.
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Why Suicide Prevention in Schools?
Many high school students reported that
they had seriously considered suicide in
the past year
CDC, 2010a
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Why Suicide Prevention in Schools?
Suicide is the third leading cause of death
among teenagers in the United States
CDC, 2009
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Why Suicide Prevention in Schools?
One out of every 53 high school students
(1.9 percent) reported having made a
suicide attempt that was serious enough to
be treated by a doctor or a nurse
CDC, 2010a
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Why Suicide Prevention in Schools?
1. Maintaining a safe school environment is
part of a school’s overall mission.
–
Many activities designed to prevent violence,
bullying, and the abuse of alcohol and other drugs
can also reduce suicide risk among students
(Epstein & Spirito, 2009).
–
Programs that improve school climate and promote
connectedness help reduce risk of suicide, violence,
bullying, and substance abuse
(Resnick et al., 1997; Blum, McNeely, & Rinehart, 2002).
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Why Suicide Prevention in Schools?
1. Maintaining a safe school environment is
part of a school’s overall mission.
–
Efforts to promote safe schools and adult caring
also help protect against suicidal ideation and
suicide attempts among LGB youth (Eisenberg &
Resnick, 2006).
–
Some activities designed to prevent suicide and
promote student mental health can reinforce the
benefits of other student wellness programs.
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Why Suicide Prevention in Schools?
1. Maintaining a safe school environment is part of a
school’s overall mission.
2. Students’ mental health can affect their
academic performance.
– 1 out of 5 high school students receiving grades
of mostly D’s and F’s attempted
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Why Suicide Prevention in Schools?
1. Maintaining a safe school environment is part of a school’s overall
mission.
2. Students’ mental health can affect their academic performance.
3. A student suicide can significantly impact
other students and the entire school
community.
– Knowing what to do following a suicide is critical to
helping students cope with the loss and prevent
additional tragedies that may occur.
– Adolescents can be susceptible to suicide contagion
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Why Suicide Prevention in Schools?
1. Maintaining a safe school environment is part of a school’s overall
mission.
2. Students’ mental health can affect their academic performance.
3. A student suicide can significantly impact other students and the
entire school community.
4. Schools have been sued for negligence for
the following reasons
– Failure to notify parents if their child appears to be suicidal
– Failure to get assistance for a student at risk of suicide
– Failure to adequately supervise a student at risk
(Doan, Roggenbaum, & Lazear, 2003; Juhnke, Granello, & Granello, 2011;
Lieberman, 2008–2009; Lieberman, Poland, & Cowan, 2006)
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How Schools Can Prevent Suicides
•
Protocols for helping students at risk of
suicide
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How Schools Can Prevent Suicides
• Protocols for helping students at risk of
suicide
• Protocols for responding to suicide death
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How Schools Can Prevent Suicides
• Protocols for helping students at risk of
suicide
• Protocols for responding to suicide death
• Staff education training
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www.wvaspen.com
How Schools Can Prevent Suicides
• Protocols for helping students at risk of
suicide
• Protocols for responding to suicide death
• Staff education training
• Parent education
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www.wvaspen.com
How Schools Can Prevent Suicides
• Protocols for helping students at risk of
suicide
• Protocols for responding to suicide death
• Staff education training
• Parent education
• Student education
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www.wvaspen.com
How Schools Can Prevent Suicides
• Protocols for helping students at risk of
suicide
• Protocols for responding to suicide death
• Staff education training
• Parent education
• Student education
• Screening
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Chapter 1
GETTING STARTED
The two essential components that every
school should have in place are:
• Protocols for helping students at possible
risk of suicide (PREVENTION)
• Protocols for responding to a suicide death
(POSTVENTION)
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Chapter 1
GETTING STARTED
Step 1. Engage administrators, school
boards, and other key players.
– Explain why it is important to address suicide
risk among students.
– Highlight data and information specific to your
district, State, or tribe.
– Share your plans.
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SCHOOL STAFF RESPONSIBILITIES
Superintendent * Curriculum director * Principal
Assistant principal * Teachers * Technology staff
Health educator * Athletic staff * School nurse
School health coordinator * school counselor
Guidance counselor * School social worker
Student assistance program staff * pupil services
School psychologist * Special education staff
Members of the Crisis Response * school resource officer
School-based health center and/or mental health center staff
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Chapter 1
GETTING STARTED
Step 2. Bring people together to start the
planning process.
– Engage school staff.
– Engage community partners
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Chapter 1
GETTING STARTED
COMMUNITY PARTNERS
Community Youth Center
* Cultural Communities Leaders
Mental health providers * Community mental health agencies
* Crisis center workers
Healthcare providers * Community health department staff
Hospital, ER staff * EMT’s * Fire & Rescue personnel
First responders * Coroner
Police * Clergy * County social services staff
Child welfare providers * Juvenile justice professionals
Media representatives * Immigrant & Refugee organization staff
LGBT youth–serving program staff * YMCA * Boys & Girls Club
Substance abuse counselors
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Chapter 1
GETTING STARTED
Step 3. Provide key players with basic
information about youth suicide and
suicide prevention.
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RISK FACTORS
•
•
•
•
•
•
Behavioral Health Issues/Disorders
Personal Characteristics
Adverse/Stressful Life Circumstances
Risky Behaviors
Family Characteristics
Environmental Factors
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RISK FACTORS
• Behavioral Health Issues/Disorders
– Depressive disorders
– Substance abuse or dependence
– Conduct/disruptive behavior disorders
– Other disorders (anxiety, personality, etc.)
– Previous suicide attempts
– Self-injury (without intent to die)
– Genetic/biological vulnerability
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RISK FACTORS
• Personal Characteristics
–
–
–
–
–
–
–
–
–
–
–
Hopelessness
Low self-esteem
Loneliness
Social alienation and isolation, lack of belonging
Low stress and frustration tolerance
Impulsivity
Risk-taking, recklessness
Poor problem-solving or coping skills
Perception of self as very underweight or very overweight
Capacity to self-injure
Perception of being a burden
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RISK FACTORS
• Adverse/Stressful Life Circumstances
– Interpersonal difficulties or losses
– Disciplinary or legal problems
– Bullying, either as victim or perpetrator
– School problems
– Physical, sexual, and/or psychological abuse
– Chronic physical illness or disability
– Exposure to suicide of peer
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RISK FACTORS
• Risky Behaviors
– Alcohol or drug use
– Delinquency
– Aggressive/violent behavior
– Risky sexual behavior
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RISK FACTORS
• Family Characteristics
– Family history of suicide or suicidal behavior
– Parental mental health problems
– Parental divorce
– Death of parent or other relative
– Problems in parent-child relationship
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RISK FACTORS
• Environmental Factors
–
–
–
–
–
–
–
–
–
–
Negative social and emotional environment
Lack of acceptance of differences
Expression and acts of hostility
Lack of respect for the cultures of all students
Limitations in school physical environment
Weapons on campus
Poorly lit areas conducive to bullying and violence
Limited access to mental health care
Access to lethal means, particularly at home
Exposure to other suicides, leading to suicide
contagion
– Exposure to stigma and discrimination
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PROTECTIVE FACTORS
•
•
•
•
Individual Characteristics and Behaviors
Family and Other Social Support
School
Mental Health and Healthcare Providers
and Caregivers
• Access to Means
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WALL OF RESISTANCE
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There is HOPE. Ask for HELP. Choose LIFE.
Suicide Prevention Lifeline 1-800-273-TALK (8255)
WARNING SIGNS
“IS PATH WARM”
•
•
•
•
•
•
•
•
•
•
I…ideation
S…substance abuse
P…purposelessness
A…anxiety
T…trapped
H…hopelessness
W…withdrawal
A…anger
R…recklessness
M…mood changes (sudden, positive or negative)
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Suicide Crisis Episode
Risk
Imminent
Risk Level
Crisis
Peaks
Crisis
Begins
Crisis
Diminishes
Hazard
Encountered
Stable
Years
Stable
Days
Hours
Days Years
Plus or minus three weeks
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There is HOPE. Ask for HELP. Choose LIFE.
Suicide Prevention Lifeline 1-800-273-TALK (8255)
The Many Paths to Suicide
Fundamental Risk
Cause of Death
Acute Risk
Poison
Biological
WALL
RESISTANCE
Environmental
OF
Personal/Psychological
Increased
hopelessness
serious
contemplation
Firearm
Hanging
Jumping
Autocide
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There is HOPE. Ask for HELP. Choose LIFE.
Suicide Prevention Lifeline 1-800-273-TALK (8255)
Stopping the chain reaction anywhere = PREVENTION
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NATIONAL DATA
Ages 13-19
• 2009, 1,852 young people died by suicide
• Suicide is the 3rd leading cause of death
• For every completed suicide death, there is 100200 attempts (1 every 60 seconds)
• For every suicide death, there is at least 6
survivors left behind
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NATIONAL DATA
YRBS Report
• 1/53 high school students reported having made
a suicide attempt that was serious enough to be
treated by a doctor or nurse
• 1/16 high school students reported having
attempted suicide at lease once.
• 1/9 had made a plan about how to attempt
suicide
• 1/7 reported having seriously considered
attempting suicide during the preceding 12
months
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West Virginia Data
15-24 Years
There is HOPE.
Ask for HELP.
Choose LIFE.
2000-2009
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Suicide Prevention Lifeline 1-800-273-TALK (8255)
Suicide:
West Virginia Suicides by county
Ages 15-24
2000-2009
Rate per 100,000 Population
Hancock
4 (12.26)
A PREVENTABLE
DEATH IN OUR STATE
Brooke
4 (12.56)
Ohio
WV Average Rate 13.2/100,000
320 Deaths by Suicide
7 (10.81))
Marshall
12 (29.79)
Wetzel
Monongalia
3 (15.30)
10 (3.97)
Tyler
Marion
5 (46.92)
Harrison Taylor
0 (0.00)
Wood
Dodd- 13
ridge
Ritchie
10 (9.68)
3 (18.15)
Preston
11 (12.38)
Pleasants
Morgan
6
(16.39)
Barbour
18 (10.32)
2 (20.60)
Fayette
2 (6.79)
16 (27.19)
0 (0.00)
Greenbrier
10.07 – 11.34
0.00 – 9.89
8 (20.23))
Logan
9 (20.92)
Raleigh
10 (10.55)
Mingo
3 (8.81)
Pendleton
12.26 – 16.39
5 (15.89)
Boone
Hardy
3 (20.28)
Pocahontas
4 (14.53)
5 (9.63)
6 (9.75)
3 (26.51)
Nicholas
Lincoln
2 (7.78)
Jefferson
18.15 – 46.92
Webster
4 (30.34)
Kanawha
47 (20.96))
Wayne
1 (13.19)
2 (16.07)
Lewis
Clay
Hampshire
Grant
Tucker
1 (13.66) Cal- Gilmer 2 (10.22)
houn 2 (12.97)
Upshur Randolph
Jackson
2
4 (10.52)
3 (8.30)
(22.25)
3 (9.01)
Roane
Braxton
1 (5.34)
2 (11.34)
Putnam
Cabell 10 (16.14)
7 (20.00))
1 (9.88) (15.36)
4 (19.02)
Mason
Mineral
5 (26.13)
4 (34.13))
Wirt
3 (10.07)
Berkeley
11 (9.89)
Wyoming
Summers
1 (3.47)
2 (13.69)
Monroe
0 (0.00)
Mercer
McDowell
2 (6.68)
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12 (160.5)
There is HOPE. Ask for HELP. Choose LIFE.
Suicide Prevention Lifeline 1-800-273-TALK (8255)
Chapter 1
GETTING STARTED
Step 4: Develop your overall strategy.
– Assess your current policies, programs and
school culture
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No one is safe from the risk of suicide –
wealth,
education,
intact family, or
popularity
cannot protect us from this risk
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www.wvaspen.com
Chapter 2
PROTOCOLS FOR HELPING STUDENTS
AT RISK FOR SUICIDE
WHY IS IT IMPORTANT TO BE
PREPARED TO HELP STUDENTS AT
RISK OF SUICIDE?
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Chapter 2
PROTOCOLS FOR HELPING STUDENTS
AT RISK FOR SUICIDE
Why is it important to be prepared…?
• Maintain a safe and secure school environment
• Promote the behavioral health of students, which
enhances their academic performance
• Avoid liability related to suicides or suicide
attempts by students
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www.wvaspen.com
Chapter 2
PROTOCOLS FOR HELPING STUDENTS
AT RISK FOR SUICIDE
•
•
•
•
•
•
•
•
Suicide risk resources
Self-injury and suicide risk information
Guidelines for notifying parents
Parent contact acknowledgement form
Guidelines for student referrals
Student suicide risk documentation form
Protocol for responding to a student suicide attempt
Guidelines for facilitating a student’s return to school
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www.wvaspen.com
Chapter 3
•
•
•
•
•
•
•
•
•
•
•
•
AFTER A SUICIDE
Immediate response protocol
Sample script for office staff
Sources of postvention consultation
Guidelines for working with the family
Guidelines for notifying staff
Sample announcements
Sample letter to families
Talking points for students and staff after a suicide
Guidelines for Memorialization
Guidelines for working with the media
Long-term response protocol
Guidelines for anniversaries of a death
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Chapter 3
AFTER A SUCIDE
• Key Terms:
– Survivor: a person who has experienced the suicide
of a family member, friend, or colleague
– Attempt survivor: a person who attempts suicide but
does not die
– Postvention: refers to programs and interventions for
survivors following a death by suicide
– Suicide contagion: is “a process by which the
suicide or suicidal behavior of one or more persons
influences others to commit or attempt suicide”
(Davidson and Gould, 1989)
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Chapter 4
STAFF EDUCATION & TRAINING
• All staff should be…
– Aware of risk of suicide
– Aware that the school is taking steps to
reduce suicide risks
– Trained to recognize the warning signs
– Able to take action if they become aware of a
student who displays suicide warning signs
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Chapter 4
STAFF EDUCATION & TRAINING
• NREPP (National Registry for Evidenced-Based Prevention Practices)
Gatekeeper Trainings:
– Lifelines
• BPR (Best Practice Registry) Gatekeeper Trainings:
– QPR (Question, Persuade, Refer)
– More Thank Sad
– safeTALK
– ASIST
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Chapter 5
PARENT/GUARDIAN EDUCATION & OUTREACH
• Education and outreach programs
– NREPP (National Registry for Evidenced-Based Prevention Practices)
• Lifelines
– BPR (Best Practice Registry)
• Not My Kid (17-minute video online)
• Facts For Parents (handout)
– Designed to educate and gain support for
implementation of initiatives
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Chapter 5
PARENT/GUARDIAN EDUCATION & OUTREACH
• Effective programs should include…
– Identifying students at possible risk and referring
them to appropriate services
– Responding appropriately to a suicide death
– Providing training and suicide awareness education
for staff
– Educating parents regarding suicide risk and mental
health promotion
– Educating and involving students in mental health
promotion and suicide prevention efforts
– Screening students for suicide risk
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Chapter 6
STUDENT PROGRAMS
• Types of programs (3):
– Curricula for all students
• Provide information about suicide prevention
• Promote positive attitudes
• Increase student’ ability to recognize if they or their
peers are at risk for suicide
• Encourage students to seek help for themselves
and their peers
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Chapter 6
STUDENT PROGRAMS
• Types of programs:
– Skill-building programs for at-risk students
• Help protect at-risk students from suicide by
– Building their coping, problem-solving, and cognitive
skills
– Addressing related problems such as depression and
other mental health issues, anger, and substance abuse
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Chapter 6
STUDENT PROGRAMS
• Types of programs:
– Peer leader programs
• Teach selected students skills to identify and help
peers who may be at risk.
• Some teach connectedness among students and
also between students and staff
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Chapter 7
SCREENING
• Ideas for maximizing parental response rate
• Screening programs
– NREPP (National Registry of Evidenced-Based Prevention Practices)
• www.sprc.org/bpr/section-i-evidence-basedprograms
• SOS Signs of Suicide
– BPR (Best Practice Registry)
• www.sprc.org/bpr/section-iii-adherence-standards
• More Than Sad
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Chapter 7
SCREENING
• Identifying Students at Risk, Alternatives:
– Academic achievement
– Effort
– Conduct
– Attendance
– Negative report card comments
– Code of student violations
– Involvement with school police
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Chapter 7
SCREENING
• Active Parental Consent
– Definition: a student can participate only if the parent
gives explicit permission, in writing
– Pros: ensures parents are informed and their
approval is obtained. This engagement increases the
likelihood that parents will help their child obtain
treatment, if it is needed.
– Cons: often difficult to get responses from parents
and takes more staff time; fewer students likely to be
screened.
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PHQ-9 Screening Questionnaire
•The Patient Health Questionnaire Modified for
Teens (PHQ-9 Modified) can be used with patients
between the ages of 12 and 18 and takes less
than five minutes to complete and score.
•Patients should be informed of their confidentiality
rights before the PHQ-9 Modified is administered.
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PHQ-9 Screening Questionnaire
SCORING…
• For every “X”
–
–
–
–
Not at all = 0
Several days = 1
More than half the days = 2
Nearly every day = 3
• Add up all the “X”ed boxes = total score
• Total score > 11 are POSITIVE
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PHQ-9 Screening Questionnaire
• Regardless of the PHQ-9 Modified total
score, endorsement of serious suicidal
ideation OR past suicide attempt
(questions 12 and 13 on the screen)
should be considered a positive screen.
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PHQ-9 Screening Questionnaire
INTERPRETATION…
• The questionnaire indicates only the
likelihood that a youth is at risk for
depression or suicide; its results are not a
diagnosis or a substitute for a clinical
evaluation.
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PHQ-9 Screening Questionnaire
DEPRESSION…
• The overall score on the PHQ-9 Modified
provides information about the severity of
depression, from minimal depression to
severe depression.
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PHQ-9 Screening Questionnaire
• Total Score: Depression Severity
• 1–4: Minimal depression
• 5–9: Mild depression
• 10–14: Moderate depression (≥ 11 = Positive
Score)
• 15–19: Moderately severe depression
• 20–27: Severe depression
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ASAP-20
Adolescent Suicide Assessment Protocol
• 20 items divided into 5 subgroups
–
–
–
–
–
Historical items (#1-4)
Clinical items (#5-9)
Specific suicidality items (#10-12)
Context items (#13-18)
Protective factor items (#19-20)
• Other considerations
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ASAP-20
Adolescent Suicide Assessment Protocol
Actions Taken
1. Continue monitoring risk factors
2. Notify family
3. Notify/consult with supervisor
4. Recommend/refer to outpatient treatment
5. Recommend/refer to psychiatric consult/med evaluation
6. Contract for NO SUICIDAL behaviors
7. Recommend elimination of access to firearms/poisons
8. Notify legal authorities &/or CPS of risk to self/or others
9. Recommend/refer to day treatment
10. Recommend/refer to crisis unit/voluntary hospitalization
11. Initiate involuntary hospitalization
12. Other:
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ASAP-20
Adolescent Suicide Assessment Protocol
• SCORING…
–
–
–
–
No
=0
Mild
=1
Moderate = 2
Severe = 3
– Risk level (total score of all 20 items)
• Low
= 0-15
• Medium = 16-19
• High
= 20+
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QUESTIONS or THOUGHTS
RESOURCES
wvsuicidecouncil.org
wvaspen.com
sprc.org
afsp.org
spanusa.org
suicidology.org
jasonfoundation.org
thetrevorproject.org
jedfoundation.org
Suicide Prevention Lifeline
1-800-273-TALK (8255)
www.wvaspen.com
Your willingness to listen and to help
can rekindle hope.
HOPE MAKES ALL THE DIFFERENCE.