Comprehensive approaches to youth suicide prevention

This issue of the Asia-Pacific Psychiatry dedicated to suicide prevention contains three articles that present a road map for more robust and systematic approaches to addressing the scourge of suicide among children, adolescents, and young adults. As has been previously reported. More than 60 000 children and adolescents aged 10– 19 across the world died from suicide in 2016, and suicide represents the third leading cause of death in 15–19-year-olds, after road injury and interpersonal violence (causes that can often overlap with suicide; World Health Organization, 2019). Additionally, the prevalence of child and adolescent suicide has been on a persistent upward trend since the 1990s, seeming to stabilize during the late 2010's but later aggravated during the COVID pandemic. For example, in addition to articles referenced in this issue, the U.S. Center for Disease Control and Prevention (Yard et al., 2021) reported an estimated increase in emergency room visits by youth ages 12 to 17 for suicide attempts of 22.3% higher during summer 2020 and 39.1% higher during winter 2021 than during the corresponding periods in 2019 in the United States, with the majority of the increase in adolescent girls. Though suicide at any age is a tragic outcome, it is even more tragic when it has become a growing epidemic which prematurely ends promising lives. It behooves all of us in pediatric mental health to mount all possible efforts toward reversing this trend, particularly using a public health model with clear universal, secondary, and tertiary levels of prevention. The article by Wasserman et al. (2021) directly touches on the topic of suicide prevention in this age group, presenting a narrative review of current knowledge on risk and protective factors and effectiveness of interventions. Although the comprehensive review of risk factors in this article is quite impressive, its core lies in the sections addressing preventive interventions. The authors identify the existence of various evidence-based awareness and skills training programs aimed at universal prevention with youth populations, particularly in school-based settings. They cite programs such as Signs of Suicide (SOS), Youth Aware of Mental Health (YAM), and the Good Behavior Game (GBG) ask promising, but also site the SEHER trial in India as well as other work supporting the implementation of school based mental health promotion interventions in low-and-middle income countries. The latter are quite important, especially given an anticipated increase in risk for suicidality in developing nations as their youth face the various social and developmental pressures encountered in developed nations. An example of this is Turkey, for which studies such as Dalkilic et al. (2013) suggest an increasing risk of suicidality among adolescents, accompanied by increasing substance use, depression, and pressures resulting with urbanization. Wasserman et al. (2021) cited the use of Gatekeeper programs and screening interventions in their review, but were much more positive about the effectiveness of screeners such as the Columbia Suicide Screen for teens than that of Gatekeeper programs. However, the stigma surrounding the topic of suicide in child and adolescent populations makes implementing systematic schoolwide screening as interventions controversial and unfeasible With school authorities. The most feasible implementation of screening interventions is at the secondary prevention level, where gatekeeper programs have trained peers, teachers, other school staff, and even parents in the identification of risk factors. A newer systematic screen which is gaining increasing recognition and use with the adolescent population is the Columbia Suicide Severity Rating Scale and Screener(C-SSRS), which have psychometrics predictive of future attempts and it is simple enough to be administered by lay interviewers or even peer to peer. In fact, the C-SSRS has found widespread news in health care settings, both in at risk psychiatric populations for secondary prevention but also with medical surgical populations. (Posner et al., 2011; Pumariega, Good, et al., 2020; Pumariega, Millsaps, & Richardson, 2020). The authors also cited interventions for high-risk youth both in school settings and in clinical settings, such as Coping and Support Training and Dialectic Behavioral Therapy, which can complement universal and secondary levels of prevention, focusing interventions on youth at high risk. Cognitive behavioral therapy for suicide prevention (CBT-SP), a newer intervention centered around safety planning and the use of cognitive and dialectical therapy techniques to address suicidal thoughts, should also be considered at this level (Bryan, 2019). The added value of the C-SSRS is that it can reliably identify youth at high risk who should be candidates for this level of intervention. One facet not directly addressed in the Wasserman et al. (2021) article is the future use of electronic records data to more accurately identify individuals at risk of suicide. Although this is an approach that is not yet been applied to child and adolescent suicide prevention, it is already being utilized for the identification of adults at risk of suicide (Walsh et al., 2021). The very knowledge base around risk factors reviewed in this article can be directly applied to analysis of electronic health records and possibly even school records to identify youth at risk. Though this has great potential it also comes with some level of controversy around potential violation of privacy and stigmatization of identified youngsters. The article by Edwards et al. (2021) on the role of families and carers in suicide prevention fills a gap in the Wasserman et al article. Families are not only associated with risk factors for suicide but are also associated with protective factors and supports that decrease DOI: 10.1111/appy.12484