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Original Contribution |

Evaluating Iatrogenic Risk of Youth Suicide Screening Programs:  A Randomized Controlled Trial FREE

Madelyn S. Gould, PhD, MPH; Frank A. Marrocco, PhD; Marjorie Kleinman, MS; John Graham Thomas, BS; Katherine Mostkoff, CSW; Jean Cote, CSW; Mark Davies, MPH
[+] Author Affiliations

Author Affiliations: Division of Child and Adolescent Psychiatry (Dr Gould, Mss Mostkoff and Cote, and Mr Thomas) and Department of Epidemiology (Dr Gould), Columbia University and New York State Psychiatric Institute (Drs Gould and Marrocco, Ms Kleinman, and Mr Davies), New York, NY.

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JAMA. 2005;293(13):1635-1643. doi:10.1001/jama.293.13.1635.
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Context Universal screening for mental health problems and suicide risk is at the forefront of the national agenda for youth suicide prevention, yet no study has directly addressed the potential harm of suicide screening.

Objective To examine whether asking about suicidal ideation or behavior during a screening program creates distress or increases suicidal ideation among high school students generally or among high-risk students reporting depressive symptoms, substance use problems, or suicide attempts.

Design, Setting, and Participants A randomized controlled study conducted within the context of a 2-day screening strategy. Participants were 2342 students in 6 high schools in New York State in 2002-2004. Classes were randomized to an experimental group (n = 1172), which received the first survey with suicide questions, or to a control group (n = 1170), which did not receive suicide questions.

Main Outcome Measures Distress measured at the end of the first survey and at the beginning of the second survey 2 days after the first measured on the Profile of Mood States adolescent version (POMS-A) instrument. Suicidal ideation assessed in the second survey.

Results Experimental and control groups did not differ on distress levels immediately after the first survey (mean [SD] POMS-A score, 5.5 [9.7] in the experimental group and 5.1 [10.0] in the control group; P = .66) or 2 days later (mean [SD] POMS-A score, 4.3 [9.0] in the experimental group and 3.9 [9.4] in the control group; P = .41), nor did rates of depressive feelings differ (13.3% and 11.0%, respectively; P = .19). Students exposed to suicide questions were no more likely to report suicidal ideation after the survey than unexposed students (4.7% and 3.9%, respectively; P = .49). High-risk students (defined as those with depression symptoms, substance use problems, or any previous suicide attempt) in the experimental group were neither more suicidal nor distressed than high-risk youth in the control group; on the contrary, depressed students and previous suicide attempters in the experimental group appeared less distressed (P = .01) and suicidal (P = .02), respectively, than high-risk control students.

Conclusions No evidence of iatrogenic effects of suicide screening emerged. Screening in high schools is a safe component of youth suicide prevention efforts.

Figures in this Article

The President’s New Freedom Commission1 and the Children’s Mental Health Screening and Prevention Act2 recommend increased screening for suicidality and mental illness. The recent enactment of the Garrett Lee Smith Memorial Act3 further supports the development of youth suicide prevention and intervention programs. Despite the proliferation of screening programs in recent years (eg, Signs of Suicide,4 TeenScreen5), the current debate about possible iatrogenic effects of other suicide preventive interventions,6,7 and the belief that prevention programs may “spur troubled youngsters to try suicide,”8 the potential harm of screening for suicide remains unstudied.9,10

Screening strategies are based on the valid premise that suicidal adolescents are underidentified1115; have an active, often treatable, mental illness1618; and exhibit identifiable risk factors.11 Evidence for the clinical validity and reliability of school-based screening procedures has recently emerged. Use of the Suicidal Ideation Questionnaire (SIQ) in a midwestern US high school yielded a sensitivity ranging from 83% to 100%, with specificity from 49% to 70%.19 The Suicide Risk Screen’s use among 581 students in 7 high schools had a sensitivity ranging from 87% to 100%, with specificity from 54% to 60%.20 Among 2004 teenagers from 8 New York metropolitan-area high schools, Columbia TeenScreen exhibited a sensitivity of approximately 88% and specificity of 76%.14 Moreover, many high-risk adolescents, defined as those with a major depressive disorder, frequent suicidal ideation, or any previous suicide attempt, were previously unidentified. Recently, the Columbia Suicide Screen, completed by 1729 9th- to 12th-graders, had a sensitivity and specificity of 75% and 83%, respectively.21 Systematic clinical evaluations using interviews such as the Suicidal Behavior Interview22 and the Diagnostic Schedule for Children14 have provided the suicidal status criteria in these studies. An evaluation of the Signs of Suicide school-based suicide prevention program, which incorporates an educational component and suicide screen, reported high satisfaction by school personnel23 and a short-term decrease in students’ suicide attempts, although neither help-seeking behavior nor suicidal ideation was affected.24

Studies have identified potential strengths of school-based screening without assessing potential shortcomings. The US Preventive Services Task Force cited a similar deficit when reviewing suicide screening by primary care clinicians.9 A pervasive concern is whether asking a child or adolescent about suicidal thoughts and behavior may trigger subsequent suicidal ideation and behavior. This article addresses this concern by examining whether asking about suicidal ideation and behavior during a screening program creates immediate or persistent distress or increases suicidal ideation among high school students generally or among high-risk students with depression symptoms, substance use problems, or previous suicide attempts, specifically.

Research Design

A randomized experimental design was conducted during a 2-day screening strategy. Classes within each of 6 high schools were randomized to either an experimental or a control group. Each school had an approximately equal number of students in each group. The experimental group received a first screening survey with a set of questions assessing suicidal ideation and behavior; the control group received the same first survey but without suicide questions. A measure of transient distress was given at the beginning and end of the first survey and repeated at the beginning of a second survey administered 2 days after the first. Both groups received the same second survey with suicidal ideation or behavior questions (Table 1). During a subsequent safety review, a project child psychiatrist, psychologist, or social worker interviewed adolescents reporting serious distress, serious suicidal ideation, or any suicide attempt to assess imminent suicide risk and the need for further evaluation and possible treatment. Referrals were arranged with parents by project social workers.

Sample

This study targeted adolescents who were aged 13 through 19 years, in grades 9 to 12, and attending 6 high schools in Nassau, Suffolk, and Westchester counties in New York State. Five schools were public coeducational schools and 1 was a parochial all-boys’ school. These schools were identified from our earlier screening program.25 To examine as sensitive an issue as iatrogenic risks of screening programs, we had to recruit schools in which we had previously gained school administrators’ trust. However, students in the current study had not participated in our previous screening because they were not yet in high school.

We assessed 2342 of 3635 students (64.4% participation rate) from the fall of 2002 through the spring of 2004. Reasons for nonparticipation included parental refusals (61.9%), student refusals (14.3%), and absences (23.7%). The experimental and control groups consisted of 1172 and 1170 students, respectively (Figure). The ethnic distribution of the participating sample was 80.3% white, 5.1% black, 7.3% Hispanic, 3.8% Asian, and 3.5% other. A total of 58.1% of the students were boys (the inclusion of an all-male parochial school explains the high percentage of boys). The mean (SD) age of participating students was 14.8 (1.2) years. There were no significant differences between experimental and control groups or between participants and nonparticipants in sex, age, and race/ethnicity. Participants reported race/ethnicity according to options defined by the investigator. For nonparticipants, demographic information was obtained from school records by school administrators. Race/ethnicity was assessed because it is among the demographic factors related to the epidemiology of suicidal behavior.

Figure. Flow of Participants Through the Study
Graphic Jump Location

The attrition rate from the first to the second survey did not significantly differ between the experimental (6.0%) and control groups (7.1%) (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.60-1.16; P = .28). Furthermore, attrition rates were not significantly related to sex (girls, 7.2%; boys, 6.0%) (OR, 1.01; 95% CI, 0.64-1.60; P = .97) or race/ethnicity (black, Hispanic, Asian and other groups, 5.4%; white, 6.8%) (OR, 1.01; 95% CI, 0.53-1.94; P = .97), nor was there an interaction between these demographics and randomization group on attrition (OR for sex × randomization, 0.86; 95% CI, 0.44-1.68; P = .65; OR for ethnicity × randomization, 1.2; 95% CI, 0.49-2.95; P = .69). Study dropouts were older (mean [SD], 15.5 [1.3] years) than those who participated both days (14.8 [1.2] years) (OR, 1.57; 95% CI, 1.28-1.91, P<.001), but there was no differential relationship of age by randomization group on attrition (OR for age × randomization, 1.02; 95% CI, 0.79-1.32; P = .88). The relationship of attrition to clinical risk factors is discussed later.

Students were recruited with an “opt-out” procedure for parents and active written assent for youth. Two mailings with an information sheet describing survey content and procedures, a response form, and a stamped response envelope were sent to parents 6 and 4 weeks before survey administration, providing parents opportunities to refuse their children’s participation. Student written assent was obtained immediately before the survey. Parents and students were informed that the research was designed “to develop good screening programs and test different methods of screening to minimize distress in high school students,” and that “alternative formats of the survey will be used, but over the course of 2 class periods, on separate days, the same questions will be asked of all students.” The schools’ principals and guidance directors, cognizant of project aims, randomization procedures, and survey content, approved recruitment and consent procedures. The study procedures, consistent with the Family Educational Rights and Privacy Act and the Protection of Pupil Rights Amendment, were approved by the institutional review board of the New York State Psychiatric Institute/Columbia University Department of Psychiatry.

Outcome Measures

Profile of Mood States. The Profile of Mood States (POMS) is a self-administered adjective checklist measuring transient mood states.26 Factor analyses of its 65 items, coded on a 5-point scale,2630 yielded 6 factors: “tension-anxiety,” “depression-dejection,” “anger-hostility,” “fatigue-inertia,” “confusion-bewilderment,” and 1 positive state, “vigor-activity.” The POMS has demonstrated excellent internal consistency and has proven sensitive to short- and long-term change.3139 The present study used an abbreviated version of the POMS, previously developed and validated in a sample of nearly 2000 adolescents. Confirmatory factor analysis supported the factorial validity of a 24-item 6-factor model.39 We used 3 of the 4 top loading items on each factor. The POMS-A has demonstrated criterion and construct validity, and its “right now” time frame is sensitive to short-term mood changes.39 The POMS-A measured at the end of the first survey and at the beginning of the second survey assessed immediate and persistent distress, respectively.

Suicidal Ideation Questionnaire. The SIQ-JR assesses suicidal thoughts and is designed for large-scale, school-based screenings of adolescents.40 The 15-item SIQ-JR uses a 7-point Likert-type scale, ranging from 0 (“I never had this thought”) to 6 (“This thought was in my mind almost every day”), assessing the frequency of specific suicidal thoughts during the past month. It assesses a wide range of thoughts related to death and dying, passive and active suicidal ideation, and suicidal intent. The SIQ-JR, designed for seventh- to ninth-graders, accommodated the ninth graders in our sample. Reliability of the SIQ-JR is high, ranging from 0.91 to 0.964042 for internal consistency and from 0.87 to 0.93 for test-retest reliability (0.89 overall; 0.87 for adolescent girls and 0.93 for adolescent boys).42 The SIQ-JR has demonstrated criterion validity,22,40,42,43 construct validity in community41,42,4447andclinical samples,43,4851 and predictive validity.41

Interim Depression and Suicidal Ideation. During the second survey, 2 questions directly assessed participants’ subjective experiences of depression and suicidal ideation after the first survey: “Since the first survey, have you felt depressed? . . . have you thought about killing yourself?” These were coded on a 5-point scale, ranging from 0 (not at all) to 5 (a lot). According to clinical judgment, “a little” suicidal ideation was included as a yes response for the dichotomized item, whereas “somewhat,” “quite a bit,” and “a lot” defined yes for depression. These questions were added to the study after data collection began, and data are available for 4 schools.

Risk Status Measures

Depression Symptoms. The Beck Depression Inventory (BDI)52 assessed cognitive, behavioral, affective, and somatic components of depression. Loss of libido was not assessed. The BDI’s use in more than 200 studies includes those with adolescent samples.5355 Each response ranged from 0 (“symptom not present”) to 3 (“symptom is severe”). Deleting the suicidal ideation question from the control group’s first survey necessitated omitting this item from both groups’ total scores, lowering the maximum total score to 57; therefore, we used a cutoff point of 15 rather than 16, recommended to detect possible depression in normal populations.52

Substance Use Problems. The Drug Use Screening Inventory (DUSI),5658 designed to screen for alcohol or drug use and problems among teenagers, has demonstrated good reliability and discriminant validity and sensitivity and has published normative cutoff scores.5763 A total score combined all 15 items from the substance use scale (assessing the degree of involvement and severity of consequences from alcohol and drug use), 3 alcohol or drug items on the school performance adjustment scale, and 1 additional aggression item assessing the clinically predictive problem of breaking things or getting into fights while under the influence of alcohol or drugs.18 A cutoff point of at least 5 dichotomized total scores according to the recommended cutoff points, roughly corresponding to 10% of the sample.60

Suicide Attempt History. Seven questions asking about lifetime and recent suicide attempts were derived from the depression module of the Diagnostic Interview Schedule for Children64 and an earlier suicide screen.21 These items have demonstrated good construct validity.21,65 The assessment of an attempt included questions about occurrences, injuries sustained, medical care sought, and hospitalization.66 Any attempt (regardless of timing, injury, or medical attention) categorized a student as “high risk.” For purposes of parallel measurement, attempt history was derived from the second-day survey for the experimental and control groups. Agreement on attempt history between the first- and second-day surveys for the experimental group was high (κ= 0.79; SE, 0.05).

Analytic Strategy

The primary sampling unit was school and the secondary sampling unit was student within school. Thus, we first examined the extent of within-school clustering to determine whether this clustering variable warranted inclusion in the analyses. The sample clusters (school) had little impact on the outcomes (POMS, SIQ-JR) or risk modifiers (depression symptoms, substance use problems, suicide attempt history), as indicated by the intraclass coefficients, which were all close to zero. Therefore, the use of mixed-effects linear models to account for the clustering variable of school was unnecessary. School was included as a covariate in all analyses.

The primary tests of the a priori hypotheses about immediate distress, persistent distress, and suicidal ideation involved comparisons of the experimental and control groups on the outcome measures. Multivariable linear regression models were estimated to determine the significance of randomization status (ie, experimental or control group) on immediate distress (POMS-A2, end of first survey), persistent distress (POMS-A3, beginning of second survey), or suicidality (SIQ-JR). The total POMS-A1 score (beginning of first survey) was used as a covariate in the analyses of POMS-A2 and POMS-A3 by design because an expected high correlation between the pre-POMS and post-POMS scores (A1-A2 r = 0.87, P<.001; A1-A3 r = 0.76, P<.001) yields a substantial increase in statistical power to test the primary hypotheses. Another series of models included each risk modifier separately (depression symptoms, substance use problems, suicide attempt history), the risk × randomization group interaction term, and randomization group to test whether some students were more susceptible to distress or suicidality from the suicide questions.

Logistic regression models were estimated to examine the main and interactive effects on interim depression and suicide. Significance levels were set at 5%. For continuous variables, there was ample statistical power (≥95%) to detect small main effects (≥15%) and small interaction effects (≥25%). For dichotomous variables, there was adequate power (≥80%) to detect a small OR (≥1.4) for a main effect and an interaction OR of 2 for a rare risk factor (approximately 5% prevalence) and an outcome in excess of 10% prevalence.

Applying the Consolidated Standards of Reporting Trials67 statement principles, there was no post hoc adjustment for baseline differences between the randomized conditions because such adjustment is likely to bias the estimated treatment effect.68 The DUSI score was the only baseline variable to differ between the experimental and control groups (mean [SD], 1.2 [2.4] and 1.0 [2.1], respectively, P<.001, which reflects a minimal effect size [0.1]). The statistical analyses were conducted using SPSS statistical software, version 12 (SPSS Inc, Chicago, Ill).

Attrition

Attrition rates (Table 2) were not significantly related to randomizationgroup (P = .28), depression symptoms (P = .66), substance use problems (P = .35), or suicide attempt history (P = .52), nor were there any significant interactions between risk status and randomization group. Baseline scores on the POMS, SIQ-JR, BDI, and DUSI were not associated with attrition, nor did they interact with randomization group. The lack of differential attrition provides evidence that our subsequent analyses and interpretations are not vulnerable to this potential threat to the study’s internal validity and suggests that the experimental group’s high-risk students were no more distressed than those in the control group.

Table Graphic Jump LocationTable 2. Attrition Rates as a Function of Randomization Group and Risk Status
Impact on Distress

Experimental and control groups did not significantly differ in distress levels immediately after the first survey (POMS-A2) or 2 days later (POMS-A3) (Table 3), nor were there any differences on the 6 POMS-A subscales. Rates of depressive feelings in the 2-day period between the surveys were not significantly different between the experimental (13.3%) and control (11.0%) groups (P = .19).

Table Graphic Jump LocationTable 3. Distress and Suicidal Ideation by Randomization Group
Impact on Suicidal Ideation

The experimental group reported no more suicidality after the survey than the control group (Table 3). Neither SIQ-JR scores in the second survey nor rates of interim suicidal thoughts between the first and second surveys were significantly higher among the experimental group (4.7%) than among the control group (3.9%; P = .49).

Differential Impact on High-Risk Students

Depression Symptoms. Students with depression symptoms above the cutoff score of 15 on the BDI reported more distress and suicidal ideation than students below the cutoff score in both experimental and control groups (Table 4). However, being exposed to suicide questions in the first survey did not exacerbate distress or suicidal ideation among depressed students. On the contrary, the direction of the significant depression by randomization group interactions on POMS-A2 (β = −1.58; 95% CI = −2.78 to −0.38; P = .01) and POMS-A3 (β = −2.00; 95% CI = −3.52 to −0.48; P = .01) indicated that among depressed youth, the experimental group had slightly lower distress scores than the control group.

Table Graphic Jump LocationTable 4. Distress and Suicidal Ideation by Randomization Group and Depression Symptoms

Substance Use Problems. Students with substance use problems had significantly higher rates of interim depression symptoms (P = .047) and interim suicidal ideation (P<.001) and scored higher on the SIQ-JR (P<.001) than those without these problems; however, none of the interactions reached statistical significance (Table 5).

Table Graphic Jump LocationTable 5. Distress and Suicidal Ideation by Randomization Group and Substance Use Problems

History of Suicide Attempt. Students with previous suicide attempts reported significantly more distress and suicidal ideation (Table 6). The significant interactions on the SIQ-JR (β = −5.33; 95% CI = −9.40 to −1.26; P = .01) and interim suicidality (OR = 0.17; 95% CI = 0.04-0.72; P = .02) indicated that among previous suicide attempters, the experimental group had less suicidal ideation than the control group.

Table Graphic Jump LocationTable 6. Distress and Suicidal Ideation by Randomization Group (Experimental or Control) and Suicide Attempt History

This article described 2342 adolescents from 6 high schools in New York State participating in a school-based suicide screening program. Half the students were randomized to receive questions about suicidal ideation and behavior in the first screening survey. The other half did not receive these questions until a second screening survey 2 days later. There was no evidence of an iatrogenic effect of asking about suicide. Neither distress nor suicidality increased among the entire population of surveyed students or high-risk students who were asked about suicidal ideation or behavior. On the contrary, the findings suggested that asking about suicidal ideation or behavior may have been beneficial for students with depression symptoms or previous suicide attempts.

The lack of detrimental effects in the present study contrasts with findings reported for some suicide-prevention programs,13,69 such as suicide awareness curricula programs of the 1980s. These usually included didactic presentations on suicide statistics, “warning signs” of suicide, and mental health resources. Often a videotape depicted a suicidal youngster or the consequences of failing to help a suicidal peer.70 Although several studies reported modest increases in knowledge of symptoms,69,7173 helpful attitudes,69,74,75 and help-seeking behavior,74 others reported either no benefits13,76 or detrimental effects.13,69 Detrimental effects included a decrease in desirable attitudes,77 a reduction in the likelihood of recommending mental health evaluations to a suicidal friend,72 more hopelessness and maladaptive coping responses among boys after exposure to the curriculum,69 and negative reactions among students most at risk for suicide (ie, those with a history of suicidal behavior).13 Adolescent suicide attempters said they would not recommend suicide-curriculum programs to other students, reporting that talking about suicide in the classroom “makes some kids more likely to try to kill themselves.”13 Our findings show that detrimental effects should not be inappropriately applied to all school-based suicide-prevention strategies, such as screening programs.

Our findings also show that extensive research supporting an imitative effect of suicide reports in the media11,7880 does not apply to screening survey questions. Furthermore, the evidence that previous suicidal behavior may enhance the imitative effect of media reports81,82 cannot be extrapolated to suicide-screening surveys.

The present study has several advantages for addressing the impact of screening programs. First, the randomized experimental design involved the direct manipulation of the suicide question exposure. Second, an ecologically valid setting (high schools) was used, rather than a laboratory setting, enabling generalization to the actual settings of suicide-screening programs. Third, several outcome indicators exhibited consistent results. Fourth, the large sample yielded ample statistical power to detect interactions between the experimental condition and depression symptoms, substance use problems, and a suicide attempt history.

The study also has important limitations. First, we used suburban schools with predominantly white populations of limited socioeconomic diversity so that the results cannot be generalized to urban, more ethnically or socioeconomically diverse settings. The schools were recruited from an earlier “postvention” screening project, involving schools with a student who had recently completed suicide and demographically matched comparison schools without such students. Three postvention and 3 comparison schools participated in the present study. In thegreater New York metropolitan area, most adolescents who complete suicide are white; consequently, our project was composed of a largely white population. Design considerations also dictated our implementation of the postvention project in the suburban counties surrounding New York City, rather than in New York City (which has a more ethnically diverse population) because lengthy delays in the adjudication of suicides in the New York City Medical Examiner’s office precluded the timely implementation of the postvention protocol.

Second, our recruitment from an earlier postvention study might suggest that postvention influenced the results, thus limiting generalizability. However, the average interval since the index suicide was 72 months, ranging from 64 to 84 months, making the influence of the suicide less likely. Moreover, there were no significant interactions between postvention status and randomization group on distress or suicidal ideation, indicating that past postvention did not affect outcome.

Third, our participation rate was low, common to other suicide-screening protocols.21 Despite no significant differences between participants and nonparticipants in demographic factors (eg, sex, grade level, ethnicity), the same cannot be said about clinical factors (eg, risk status, BDI and SIQ-JR scores).

Fourth, by design the experimental group was asked about suicidal ideation or behavior in the first and second surveys, whereas the control group was asked these questions once, raising the possibility that attenuation83,84 masked an iatrogenic effect. However, standardized differences between means from 2 administrations of the SIQ-JR, using data on its test-retest reliability,42 indicate minimal attenuation (effect size = −0.03). In the present study, there was a significant decrease in the SIQ-JR from the first survey (mean [SD] = 7.7 [11.1]) to the second survey (mean [SD] = 6.5 [11.5]; t = −5.05; P<.001). If attenuation had masked an iatrogenic effect, this large a decrease (effect size = −0.11) would not have been expected. A masked iatrogenic effect would have been more consistent with no decrease in scores. A comparison of the first administration of the SIQ-JR in the control group (second survey SIQ-JR) and the experimental group’s first survey SIQ-JR cannot inform this issue because the survey content preceding these assessments was not comparable.

Our findings can allay concerns about the potential harm of high school–based suicide screening. Universal screening for mental health problems and suicide risk should continue to be at the forefront of the national agenda for youth suicide prevention. Moreover, our findings should assure health professionals that they should not refrain from asking their patients about suicidality for fear of its inducement.

Corresponding Author: Madelyn S. Gould, PhD, MPH, New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032 (gouldm@childpsych.columbia.edu).

Author Contributions: Dr Gould had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Gould, Kleinman.

Acquisition of data: Gould, Marrocco, Thomas, Mostkoff, Cote.

Analysis and interpretation of data: Gould, Marrocco, Kleinman, Davies.

Drafting of the manuscript: Gould.

Critical revision of the manuscript for important intellectual content: Gould, Marrocco, Kleinman, Thomas, Mostkoff, Cote, Davies.

Statistical analysis: Gould, Kleinman, Davies.

Obtained funding: Gould.

Administrative, technical, or material support: Marrocco, Thomas, Mostkoff, Cote.

Study supervision: Gould.

Financial Disclosures: Mr Davies owns stock in Merck, Pfizer, Bristol-Myers Squibb, Wyeth, Lilly, GlaxoSmithKline, Johnson & Johnson, Amgen, Elan, and Bard. No other authors reported financial disclosures.

Funding/Support: This project was supported by National Institute of Mental Health (NIMH) grant R01-MH64632.

Role of the Sponsor: The sponsor, NIMH, was not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Acknowledgment: We thank Lia Amakawa, BA, for assistance in manuscript preparation.

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Aseltine RH, DeMartino R. An outcome evaluation of the SOS Suicide Prevention Program.  Am J Public Health. 2004;94:446-451
PubMed   |  Link to Article
Gould MS, Velting D, Kleinman M, Lucas C, Thomas JG, Chung M. Teenagers' attitudes about coping strategies and help-seeking behavior for suicidality.  J Am Acad Child Adolesc Psychiatry. 2004;43:1124-1133
PubMed   |  Link to Article
McNair D, Lorr M, Droppleman LF. POMS Manual: Profile of Mood StatesSan Diego, Calif: Educational and Industrial Testing Service; 1992
McNair DM, Lorr M. Manual for the Profile of Mood StatesSan Diego, Calif: Educational and Industrial Testing Service; 1971
Norcross JC, Guadagnoli E, Prochaska JO. Factor structure of the Profile of Mood States (POMS): two partial replications.  J Clin Psychol. 1984;40:1270-1277
PubMed   |  Link to Article
Rhoades H, Grabowski J, Elk R, Cowan K. Factor stationarity and invariance of the POMS in cocaine patients.  Psychopharmacol Bull. 1993;29:263-267
PubMed
Usala PD, Hertzog C. Measurement of affective states in adults: evaluation of an adjective rating scale instrument.  Res Aging. 1989;11:403-426
PubMed   |  Link to Article
Berger BG, Grove JR, Prapavessis H, Butki BD. Relationship of swimming distance, expectancy, and performance to mood states of competitive athletes.  Percept Mot Skills. 1997;84:1199-1210
PubMed   |  Link to Article
Fabre LF, Abuzzahab FS, Amin M.  et al.  Sertraline safety and efficacy in major depression: a double-blind fixed-dose comparison with placebo.  Biol Psychiatry. 1995;38:592-602
PubMed   |  Link to Article
Itil TM, Shrivastava RK, Mukherjee S, Coleman BS, Michael ST. A double-blind placebo-controlled study of fluvoxamine and imipramine in out-patients with primary depression.  Br J Clin Pharmacol. 1983;15:4335-4385
Link to Article
Kraemer RR, Dzewaltowski DA, Blair MS, Rinehardt KF, Castracane VD. Mood alteration from treadmill running and its relationship to beta-endorphin, corticotropin, and growth hormone.  J Sports Med Phys Fitness. 1990;30:241-246
PubMed
Lydiard RB, Stahl SM, Hertzman M, Harrison WM. A double-blind, placebo-controlled study comparing the effects of sertraline versus amitriptyline in the treatment of major depression.  J Clin Psychiatry. 1997;58:484-491
PubMed   |  Link to Article
Newcombe PA, Boyle GJ. High school students' sports personalities: variations across participation level, gender, type of sport, and success.  Int J Sport Psychol. 1995;26:277-294
Smith AM, Scott SG, O'Fallon WM, Young ML. Emotional responses of athletes to injury.  Mayo Clin Proc. 1990;65:38-50
PubMed   |  Link to Article
Steptoe A, Cox S. Acute effects of aerobic exercise on mood.  Health Psychol. 1988;7:329-340
PubMed   |  Link to Article
Terry PC, Lane AM, Lane HJ, Keohane L. Development and validation of a mood measure for adolescents.  J Sports Sci. 1999;17:861-872
PubMed   |  Link to Article
Reynolds W. SIQ Professional ManualOdessa, Fla: Psychological Assessment Resources Inc; 1988
Keane EM, Dick RW, Bechtold DW, Manson SM. Predictive and concurrent validity of the Suicidal Ideation Questionnaire among American Indian adolescents.  J Abnorm Child Psychol. 1996;24:735-747
PubMed   |  Link to Article
Reynolds W, Mazza J. Assessment of suicidal ideation in inner-city children and young adolescents: reliability and validity of the Suicidal Ideation Questionnaire-JR.  School Psychol Rev. 1999;28:17-29
King CA, Hill EM, Naylor M, Evans T, Shain B. Alcohol consumption in relation to other predictors of suicidality among adolescent inpatient girls.  J Am Acad Child Adolesc Psychiatry. 1993;32:82-88
PubMed   |  Link to Article
Hovey JD. Acculturative stress, depression, and suicidal ideation among Mexican-American adolescents: implications for the development of suicide prevention programs in schools.  Psychol Rep. 1998;83:249-250
PubMed
Mazza JJ, Reynolds WM. Exposure to violence in young inner-city adolescents: relationships with suicidal ideation, depression, and PTSD symptomatology.  J Abnorm Child Psychol. 1999;27:203-213
PubMed   |  Link to Article
Mazza JJ. The relationship between posttraumatic stress symptomatology and suicidal behavior in school-based adolescents.  Suicide Life Threat Behav. 2000;30:91-103
PubMed
Rasmussen KM, Negy C, Carlson R, Mitchell Burns J. Suicide ideation and acculturation among low socioeconomic status Mexican American adolescents.  J Early Adolesc. 1997;17:390-407
Link to Article
King CA, Ghaziuddin N, McGovern L, Brand E, Hill E, Naylor M. Predictors of comorbid alcohol and substance abuse in depressed adolescents.  J Am Acad Child Adolesc Psychiatry. 1996;35:743-751
PubMed   |  Link to Article
King CA, Katz SH, Ghaziuddin N, Brand E, Hill E, McGovern L. Diagnosis and assessment of depression and suicidality using the NIMH Diagnostic Interview Schedule for Children (DISC-2.3).  J Abnorm Child Psychol. 1997;25:173-181
PubMed   |  Link to Article
Sibthorpe B, Drinkwater J, Gardner K, Bammer G. Drug use, binge drinking and attempted suicide among homeless and potentially homeless youth.  Aust N Z J Psychiatry. 1995;29:248-256
PubMed   |  Link to Article
Siemen JR, Warrington CA, Mangano EL. Comparison of the Million Adolescent Personality Inventory and the Suicide Ideation Questionnaire–Jr. with an adolescent inpatient sample.  Psychol Rep. 1994;75:947-950
Link to Article
Beck AT, Steer RA. Manual for the Beck Depression InventorySan Antonio, Tex: Psychological Corp; 1993
Roberts RE, Lewinsohn PM, Seeley JR. Screening for adolescent depression: a comparison of depression scales.  J Am Acad Child Adolesc Psychiatry. 1991;30:58-66
PubMed   |  Link to Article
Strober M, Green J, Carlson G. Utility of the Beck Depression Inventory with psychiatrically hospitalized adolescents.  J Consult Clin Psychol. 1981;49:482-483
PubMed   |  Link to Article
Teri L. The use of the Beck Depression Inventory with adolescents.  J Abnorm Child Psychol. 1982;10:277-284
PubMed   |  Link to Article
Tarter RE. Evaluation and treatment of adolescent substance abuse: a decision tree method.  Am J Drug Alcohol Abuse. 1990;16:1-46
PubMed   |  Link to Article
Tarter RE, Hegedus AM. The Drug Use Screening Inventory: its applications in the evaluation and treatment of alocohol and other drug abuse.  Alcohol Health Res World. 1991;15:65-75
Tarter RE, Laird SB, Bukstein O, Kaminer Y. Validation of the Adolescent Drug Use Screening Inventory: preliminary findings.  Psychol Addict Behav. 1992;6:233-236
Link to Article
Kirisci L, Tarter RE, Hsu TC. Fitting a two-parameter logistic item response model to clarify the psychometric properties of the Drug Use Screening Inventory for adolescent alcohol and drug abusers.  Alcohol Clin Exp Res. 1994;18:1335-1341
PubMed   |  Link to Article
Kirisci L, Mezzich A, Tarter R. Norms and sensitivity of the adolescent version of the drug use screening inventory.  Addict Behav. 1995;20:149-157
PubMed   |  Link to Article
Tarter R, Mezzich A, Kirisci L, Kaczynski N. Reliability of Drug Use Screening Inventory among adolescent alcoholics.  J Child Adolesc Subst Abuse. 1994;3:25-36
Link to Article
Tarter RE, Mezzich AC, Hsieh YC, Parks SM. Cognitive capacity in female adolescent substance abusers.  Drug Alcohol Depend. 1995;39:15-21
PubMed   |  Link to Article
Tarter RE, Kirisci L, Mezzich A. Multivariate typology of adolescents with alcohol use disorder.  Am J Addict. 1997;6:150-158
PubMed
Shaffer D, Fisher P, Lucas CP, Dulcan MK, Schwab-Stone ME. NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses.  J Am Acad Child Adolesc Psychiatry. 2000;39:28-38
PubMed   |  Link to Article
Gould MS, King R, Greenwald S.  et al.  Psychopathology associated with suicidal ideation and attempts among children and adolescents.  J Am Acad Child Adolesc Psychiatry. 1998;37:915-923
PubMed   |  Link to Article
Meehan PJ, Lamb JA, Saltzman LE, O'Carroll PW. Attempted suicide among young adults: progress toward a meaningful estimate of prevalence.  Am J Psychiatry. 1992;149:41-44
PubMed
Moher D, Schulz KF, Altman D. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials.  JAMA. 2001;285:1987-1991
PubMed   |  Link to Article
Altman DG. Adjustment for covariate imbalance. In: Armitage P, Colton T, eds. Encyclopedia of Biostatistics. Chichester, England: John Wiley; 1998:1000-1005
Overholser JC, Hemstreet AH, Spirito A, Vyse A. Suicide awareness programs in the schools: effects of gender and personal experience.  J Am Acad Child Adolesc Psychiatry. 1989;28:925-930
PubMed   |  Link to Article
Hazell P, King R. Arguments for and against teaching suicide prevention in schools.  Aust N Z J Psychiatry. 1996;30:633-642
PubMed   |  Link to Article
Abbey K, Madsen C, Polland R. Short term suicide awareness curriculum.  Suicide Life Threat Behav. 1989;19:216-227
PubMed
Kalafat J, Elais M. An evaluation of a school-based suicide awareness intervention.  Suicide Life Threat Behav. 1994;24:224-233
PubMed
Spirito A, Overholser J, Ashworth S, Morgan J, Bennedict-Drew C. Evaluation of a suicide awareness curriculum for high school students.  J Am Acad Child Adolesc Psychiatry. 1988;27:705-711
PubMed   |  Link to Article
Ciffone J. A classroom presentation to adolescents.  Soc Work. 1993;38:197-203
PubMed
Kalafat J, Elais M. Suicide prevention in an educational context: broad and narrow foci.  Suicide Life Threat Behav. 1995;25:123-133
PubMed
Vieland V, Whittle B, Garland A, Hicks R, Shaffer D. The impact of curriculum-based suicide prevention programs for teenagers: an 18-month follow-up.  J Am Acad Child Adolesc Psychiatry. 1991;30:811-815
PubMed
Shaffer D, Garland A, Vieland V, Underwood MM, Busner C. The impact of curriculum-based suicide prevention program for teenagers.  J Am Acad Child Adolesc Psychiatry. 1991;30:588-596
PubMed   |  Link to Article
Gould MS. Suicide and the media. In: Hendin H, Mann J, eds. Annals of the New York Academy of Sciences, Vol. 932. New York, NY: New York Academy of Sciences; 2001:200-224
Stack S. Media impacts on suicide: a quantitative review of 293 findings.  Soc Sci Q. 2000;81:957-971
Schmidtke A, Schaller S. The role of mass media in suicide prevention. In: Hawton K, van Heeringen K, eds. The International Handbook of Suicide and Attempted Suicide. New York, NY: John Wiley; 2000:675-698
Doron A, Stein D, Levine Y, Abramovitch Y, Eilat E, Neuman M. Physiological reactions to a suicide film: suicide attempters, suicide ideators, and nonsuicidal patients.  Suicide Life Threat Behav. 1998;28:309-314
PubMed
Fekete S, Schmidtke A. The impact of mass media reports on suicide and attitudes toward self-destruction: previous studies and some new data from Hungary and Germany. In: Mishara BL, ed. The Impact of Suicide. New York, NY: Springer; 1995:142-155
Costello EJ, Burns BJ, Angold A, Leaf PJ. How can epidemiology improve mental health services for children and adolescents?  J Am Acad Child Adolesc Psychiatry. 1993;32:1106-1114
PubMed   |  Link to Article
Lucas CP, Fisher P, Piacentini J.  et al.  Features of interview questions associated with attenuation of symptom reports.  J Abnorm Child Psychol. 1999;27:429-437
PubMed   |  Link to Article

Figures

Figure. Flow of Participants Through the Study
Graphic Jump Location

Tables

Table Graphic Jump LocationTable 2. Attrition Rates as a Function of Randomization Group and Risk Status
Table Graphic Jump LocationTable 3. Distress and Suicidal Ideation by Randomization Group
Table Graphic Jump LocationTable 4. Distress and Suicidal Ideation by Randomization Group and Depression Symptoms
Table Graphic Jump LocationTable 5. Distress and Suicidal Ideation by Randomization Group and Substance Use Problems
Table Graphic Jump LocationTable 6. Distress and Suicidal Ideation by Randomization Group (Experimental or Control) and Suicide Attempt History

References

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Screening for Mental Health Inc.  Signs of suicide. Available at: http://www.mentalhealthscreening.org. Accessed February 9, 2005
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Groholt B, Ekberg O, Wichstrom L, Haldorsen T. Suicide among children and younger and older adolescents in Norway: a comparative study.  J Am Acad Child Adolesc Psychiatry. 1998;37:473-481
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Shaffer D, Gould MS, Fisher P.  et al.  Psychiatric diagnosis in child and adolescent suicide.  Arch Gen Psychiatry. 1996;53:339-348
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Reynolds W. A school-based procedure for the identification of adolescents at risk for suicidal behaviors.  Fam Community Health. 1991;14:64-75
Thompson EA, Eggert LL. Using the Suicide Risk Screen to identify suicidal adolescents among potential high school dropouts.  J Am Acad Child Adolesc Psychiatry. 1999;38:1506-1514
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Shaffer D, Scott M, Wilcox H.  et al.  The Columbia Suicide Screen: validity and reliability of a screen for youth suicide and depression.  J Am Acad Child Adolesc Psychiatry. 2004;43:71-79
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Reynolds W. Development of a semi-structured clinical interview for suicidal behaviors in adolescents.  Psychol Assess J Consult Clin Psychol. 1990;2:382-390
Aseltine RH. Evaluation of a school based suicide prevention program.  Adolesc Family Health. 2003;3:81-88
Aseltine RH, DeMartino R. An outcome evaluation of the SOS Suicide Prevention Program.  Am J Public Health. 2004;94:446-451
PubMed   |  Link to Article
Gould MS, Velting D, Kleinman M, Lucas C, Thomas JG, Chung M. Teenagers' attitudes about coping strategies and help-seeking behavior for suicidality.  J Am Acad Child Adolesc Psychiatry. 2004;43:1124-1133
PubMed   |  Link to Article
McNair D, Lorr M, Droppleman LF. POMS Manual: Profile of Mood StatesSan Diego, Calif: Educational and Industrial Testing Service; 1992
McNair DM, Lorr M. Manual for the Profile of Mood StatesSan Diego, Calif: Educational and Industrial Testing Service; 1971
Norcross JC, Guadagnoli E, Prochaska JO. Factor structure of the Profile of Mood States (POMS): two partial replications.  J Clin Psychol. 1984;40:1270-1277
PubMed   |  Link to Article
Rhoades H, Grabowski J, Elk R, Cowan K. Factor stationarity and invariance of the POMS in cocaine patients.  Psychopharmacol Bull. 1993;29:263-267
PubMed
Usala PD, Hertzog C. Measurement of affective states in adults: evaluation of an adjective rating scale instrument.  Res Aging. 1989;11:403-426
PubMed   |  Link to Article
Berger BG, Grove JR, Prapavessis H, Butki BD. Relationship of swimming distance, expectancy, and performance to mood states of competitive athletes.  Percept Mot Skills. 1997;84:1199-1210
PubMed   |  Link to Article
Fabre LF, Abuzzahab FS, Amin M.  et al.  Sertraline safety and efficacy in major depression: a double-blind fixed-dose comparison with placebo.  Biol Psychiatry. 1995;38:592-602
PubMed   |  Link to Article
Itil TM, Shrivastava RK, Mukherjee S, Coleman BS, Michael ST. A double-blind placebo-controlled study of fluvoxamine and imipramine in out-patients with primary depression.  Br J Clin Pharmacol. 1983;15:4335-4385
Link to Article
Kraemer RR, Dzewaltowski DA, Blair MS, Rinehardt KF, Castracane VD. Mood alteration from treadmill running and its relationship to beta-endorphin, corticotropin, and growth hormone.  J Sports Med Phys Fitness. 1990;30:241-246
PubMed
Lydiard RB, Stahl SM, Hertzman M, Harrison WM. A double-blind, placebo-controlled study comparing the effects of sertraline versus amitriptyline in the treatment of major depression.  J Clin Psychiatry. 1997;58:484-491
PubMed   |  Link to Article
Newcombe PA, Boyle GJ. High school students' sports personalities: variations across participation level, gender, type of sport, and success.  Int J Sport Psychol. 1995;26:277-294
Smith AM, Scott SG, O'Fallon WM, Young ML. Emotional responses of athletes to injury.  Mayo Clin Proc. 1990;65:38-50
PubMed   |  Link to Article
Steptoe A, Cox S. Acute effects of aerobic exercise on mood.  Health Psychol. 1988;7:329-340
PubMed   |  Link to Article
Terry PC, Lane AM, Lane HJ, Keohane L. Development and validation of a mood measure for adolescents.  J Sports Sci. 1999;17:861-872
PubMed   |  Link to Article
Reynolds W. SIQ Professional ManualOdessa, Fla: Psychological Assessment Resources Inc; 1988
Keane EM, Dick RW, Bechtold DW, Manson SM. Predictive and concurrent validity of the Suicidal Ideation Questionnaire among American Indian adolescents.  J Abnorm Child Psychol. 1996;24:735-747
PubMed   |  Link to Article
Reynolds W, Mazza J. Assessment of suicidal ideation in inner-city children and young adolescents: reliability and validity of the Suicidal Ideation Questionnaire-JR.  School Psychol Rev. 1999;28:17-29
King CA, Hill EM, Naylor M, Evans T, Shain B. Alcohol consumption in relation to other predictors of suicidality among adolescent inpatient girls.  J Am Acad Child Adolesc Psychiatry. 1993;32:82-88
PubMed   |  Link to Article
Hovey JD. Acculturative stress, depression, and suicidal ideation among Mexican-American adolescents: implications for the development of suicide prevention programs in schools.  Psychol Rep. 1998;83:249-250
PubMed
Mazza JJ, Reynolds WM. Exposure to violence in young inner-city adolescents: relationships with suicidal ideation, depression, and PTSD symptomatology.  J Abnorm Child Psychol. 1999;27:203-213
PubMed   |  Link to Article
Mazza JJ. The relationship between posttraumatic stress symptomatology and suicidal behavior in school-based adolescents.  Suicide Life Threat Behav. 2000;30:91-103
PubMed
Rasmussen KM, Negy C, Carlson R, Mitchell Burns J. Suicide ideation and acculturation among low socioeconomic status Mexican American adolescents.  J Early Adolesc. 1997;17:390-407
Link to Article
King CA, Ghaziuddin N, McGovern L, Brand E, Hill E, Naylor M. Predictors of comorbid alcohol and substance abuse in depressed adolescents.  J Am Acad Child Adolesc Psychiatry. 1996;35:743-751
PubMed   |  Link to Article
King CA, Katz SH, Ghaziuddin N, Brand E, Hill E, McGovern L. Diagnosis and assessment of depression and suicidality using the NIMH Diagnostic Interview Schedule for Children (DISC-2.3).  J Abnorm Child Psychol. 1997;25:173-181
PubMed   |  Link to Article
Sibthorpe B, Drinkwater J, Gardner K, Bammer G. Drug use, binge drinking and attempted suicide among homeless and potentially homeless youth.  Aust N Z J Psychiatry. 1995;29:248-256
PubMed   |  Link to Article
Siemen JR, Warrington CA, Mangano EL. Comparison of the Million Adolescent Personality Inventory and the Suicide Ideation Questionnaire–Jr. with an adolescent inpatient sample.  Psychol Rep. 1994;75:947-950
Link to Article
Beck AT, Steer RA. Manual for the Beck Depression InventorySan Antonio, Tex: Psychological Corp; 1993
Roberts RE, Lewinsohn PM, Seeley JR. Screening for adolescent depression: a comparison of depression scales.  J Am Acad Child Adolesc Psychiatry. 1991;30:58-66
PubMed   |  Link to Article
Strober M, Green J, Carlson G. Utility of the Beck Depression Inventory with psychiatrically hospitalized adolescents.  J Consult Clin Psychol. 1981;49:482-483
PubMed   |  Link to Article
Teri L. The use of the Beck Depression Inventory with adolescents.  J Abnorm Child Psychol. 1982;10:277-284
PubMed   |  Link to Article
Tarter RE. Evaluation and treatment of adolescent substance abuse: a decision tree method.  Am J Drug Alcohol Abuse. 1990;16:1-46
PubMed   |  Link to Article
Tarter RE, Hegedus AM. The Drug Use Screening Inventory: its applications in the evaluation and treatment of alocohol and other drug abuse.  Alcohol Health Res World. 1991;15:65-75
Tarter RE, Laird SB, Bukstein O, Kaminer Y. Validation of the Adolescent Drug Use Screening Inventory: preliminary findings.  Psychol Addict Behav. 1992;6:233-236
Link to Article
Kirisci L, Tarter RE, Hsu TC. Fitting a two-parameter logistic item response model to clarify the psychometric properties of the Drug Use Screening Inventory for adolescent alcohol and drug abusers.  Alcohol Clin Exp Res. 1994;18:1335-1341
PubMed   |  Link to Article
Kirisci L, Mezzich A, Tarter R. Norms and sensitivity of the adolescent version of the drug use screening inventory.  Addict Behav. 1995;20:149-157
PubMed   |  Link to Article
Tarter R, Mezzich A, Kirisci L, Kaczynski N. Reliability of Drug Use Screening Inventory among adolescent alcoholics.  J Child Adolesc Subst Abuse. 1994;3:25-36
Link to Article
Tarter RE, Mezzich AC, Hsieh YC, Parks SM. Cognitive capacity in female adolescent substance abusers.  Drug Alcohol Depend. 1995;39:15-21
PubMed   |  Link to Article
Tarter RE, Kirisci L, Mezzich A. Multivariate typology of adolescents with alcohol use disorder.  Am J Addict. 1997;6:150-158
PubMed
Shaffer D, Fisher P, Lucas CP, Dulcan MK, Schwab-Stone ME. NIMH Diagnostic Interview Schedule for Children Version IV (NIMH DISC-IV): description, differences from previous versions, and reliability of some common diagnoses.  J Am Acad Child Adolesc Psychiatry. 2000;39:28-38
PubMed   |  Link to Article
Gould MS, King R, Greenwald S.  et al.  Psychopathology associated with suicidal ideation and attempts among children and adolescents.  J Am Acad Child Adolesc Psychiatry. 1998;37:915-923
PubMed   |  Link to Article
Meehan PJ, Lamb JA, Saltzman LE, O'Carroll PW. Attempted suicide among young adults: progress toward a meaningful estimate of prevalence.  Am J Psychiatry. 1992;149:41-44
PubMed
Moher D, Schulz KF, Altman D. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials.  JAMA. 2001;285:1987-1991
PubMed   |  Link to Article
Altman DG. Adjustment for covariate imbalance. In: Armitage P, Colton T, eds. Encyclopedia of Biostatistics. Chichester, England: John Wiley; 1998:1000-1005
Overholser JC, Hemstreet AH, Spirito A, Vyse A. Suicide awareness programs in the schools: effects of gender and personal experience.  J Am Acad Child Adolesc Psychiatry. 1989;28:925-930
PubMed   |  Link to Article
Hazell P, King R. Arguments for and against teaching suicide prevention in schools.  Aust N Z J Psychiatry. 1996;30:633-642
PubMed   |  Link to Article
Abbey K, Madsen C, Polland R. Short term suicide awareness curriculum.  Suicide Life Threat Behav. 1989;19:216-227
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