The IOM's Reducing Suicide report characterizes current mental health prevention programs as rooted in the "universal, selective, and indicated (USI) prevention model." This model considers three defined populations—the entire population is included in universal programs, specific high-risk groups are targeted by selective programs, and indicated programs address specific high-risk individuals. Universal programming assumes a basically healthy population and generally aims at protection against developing a disorder by offering, for example, enhanced coping skills and resiliency training. Examples of universal programs are educational programs to heighten awareness of a problem and mass-media campaigns intended to increase understanding of and attitudes about a particular issue.
Population-based programs often produce greater gains than programs targeting individuals because there are higher rates of program participation. For example, all the students in a given grade will be exposed to school-based drug prevention programs. Selective programs target subsets of populations that have been identified as at risk but are not yet diagnosed with a specific problem or disorder—persons who have a greater-than-average likelihood of developing mental disorders, such as adolescents with truancy or suspected substance abuse problems. Indicated programs are aimed at specific high-risk individuals who have evidenced early signs or symptoms of mental disorders, such as children diagnosed with attention deficit hyperactivity disorder (ADHD) who may be at greater risk of developing conduct disorders, or students who have engaged in disruptive or other disturbed behavior at school.
By recounting the histories, benefits, and scientific evaluation of mental health prevention programs, these reports offer a framework for developing and implementing mental health prevention programs and policies in a wide range of settings, including primary medical care practices and clinics, maternal and infant health and mental health programs, child care centers, school-based health centers, vocational training programs, social service agencies, parent education programs, and the media. Further, these reports disseminate the methods and results of effective programs, enabling mental health service providers and other stakeholders throughout the country to replicate these results in their local communities.
Adolescent Intervention Programs
One recommendation from the report of the President's New Freedom Commission on Mental Health was to "improve and expand school mental health programs." It cited research demonstrating that about 42% of students with serious emotional disturbances graduate from high school, compared with 57% of students with other disabilities. The commission believed this could be changed, because it found ample evidence that school mental health programs improved academic achievement—with improved test scores, fewer absences, and less discipline problems—by detecting mental health problems early and providing timely referral to appropriate treatment.
The commission observed that the concerted effort needed to deliver quality mental health services in schools entailed collaboration with parents and local providers of mental health care to support screening, assessment, and early intervention. It also asserted that mental health services must be integral parts of school health centers and that federal funds must be available to support the programs.
The report lauded the Columbia University TeenScreen program as a model program of screening and early intervention. The program ensures mental health screening of all students before they leave high school and early identification of students at risk for suicide or those with symptoms of depression or other mental illness. Evaluation of the program found it to be remarkably effective—identifying more than 60% of students later found to have recurrent mental health problems or mental disorders. Table 2.8 summarizes the goals, features, outcomes, and principal challenges faced during implementation of the TeenScreen program.
Participants complete a ten-minute paper-and-pencil or computerized questionnaire. The questionnaires cover anxiety, depression, substance and alcohol abuse, and suicidal thoughts and behavior. The TeenScreen program does not recommend any particular type of treatment for the teens who are identified by the mental health screening. Parents of students identified as at possible risk are notified and offered information and referral to local mental health services where they can obtain further evaluation. No student is screened without parental consent, and the results of the screen are confidential. Screening occurs in a range of venues, including schools, clinics, physicians' offices, and juvenile justice facilities.
TeenScreen is supported by thirty-four national organizations, including the American Academy of Child and Adolescent Psychiatry, American Federation of Teachers, and the President's New Freedom Commission on Mental
TABLE 2.8 Columbia University teen mental health screening program| TABLE 2.8 | |
|---|---|
| Columbia University teen mental health screening program | |
| aShaffer, D., Fisher, P., Lucas, C. P., Dulcan, M. K., & Schwab-Stone, M. E. (2000). NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): Description, differences from previous versions, and reliability of some common diagnoses. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 28-38. | |
| bShaffer, D. & Craft, L. (1999). Methods of adolescent suicide prevention. Journal of Clinical Psychiatry, 60, Supplement 2, 70-74. | |
| cLeslie McGuire, personal communication, June 24, 2003. | |
| SOURCE: "Figure 4.2. Model Program: Screening Program for Youth," in Achieving the Promise: Transforming Mental Health Care in America, President's New Freedom Commission on Mental Health, 2003, http://www.mentalhealthcommission.gov/reports/FinalReport/FullReport-05.htm (accessed December 15, 2005) | |
| Program | Columbia University TeenScreen® Program |
| Goal | To ensure that all youth are offered a mental health check-up before graduating from high school. TeenScreen® identifies and refers for treatment those who are at risk for suicide or suffer from an untreated mental illness. |
| Features | All youngsters in a school, with parental consent, are given a computer-based questionnaire that screens them for mental illnesses and suicide risk. At no charge, the Columbia University TeenScreen® Program provides consultation, screening materials, software, training, and technical assistance to qualifying schools and communities. In return, TeenScreen® partners are expected to screen at least 200 youth per year and ensure that a licensed mental health professional is on-site to give immediate counseling and referral services for youth at greatest risk. The Columbia TeenScreen® Program is a not-for-profit organization funded solely by foundations. When the program identifies youth needing treatment, their care is paid for depending on the family's health coverage. |
| Outcmes | The computer-based questionnaire used by TeenScreen® is a valid and reliable screening instrument.a The vast majority of youth identified through the program as having already made a suicide attempt, or at risk for depression or suicidal thinking, are not in treatment.b A follow-up study found that screening in high school identified more than 60% of students who, four to six years later, continued to have long-term, recurrent problems with depression and suicidal attempts.c |
| Biggest challenge | To bridge the gap between schools and local providers of mental health services. Another challenge is to ensure, in times of fiscal austerity, that schools devote a health professional to screening and referral. |
| Howother organazitions can adopt | The Columbia University TeenScreen® program is pilot-testing a shorter questionnaire, which will be less costly and time-consuming for the school to administer. It is also trying to adapt the program to primary care settings. |
| Website | www.teenscreeno.org |
| Sites where implemented | 69 sites (mostly middle schools and high schools) in 27 states |
Health, and is funded by private foundations and individuals. It operates by partnering with communities throughout the nation to implement local screening programs for youth. The local programs are developed in consultation with Columbia University to meet the specific needs and resources of each community. Programs range from one-day screening efforts to full-time, district-wide screening for all high school students. Columbia offers consultation, training, screening tools, and technical assistance to participating communities free-of-charge. By the close of 2005 TeenScreen operated eight national model programs and had developed partnerships to implement statewide screening programs with state agencies in Ohio, Florida, Pennsylvania, and Nevada.
TABLE 2.9
Suicide risk factors, protective factors, and national prevention strategy
- National Strategy for Suicide Prevention: AIM
- Awareness: promote public awareness of suicide as a public health problem
- Intervention: enhance services and programs
- Methodology: advance the science of suicide prevention
- Risk factors
- Male gender
- Mental disorders, particularly depression and substance abuse
- Prior suicide attempts
- Unwillingness to seek help because of stigma
- Barriers to accessing mental health treatment
- Stressful life event/loss
- Easy access to lethal methods such as guns
- Protective factors
- Effective and appropriate clinical care for underlying disorders
- Easy access to care
- Support from family, community, and health and mental health care staff
SOURCE: Adapted from "Figure 4.1. Surgeon General's Call to Action to Prevent Suicide—1999," in Mental Health: A Report of the Surgeon General, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, with NIH, 1999, http://www.mentalhealth.samhsa.gov/features/surgeongeneralreport/toc.asp (accessed December 15, 2005)
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