States with Higher Mental Healthcare Capacity Have Lower Youth Suicide Rates

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Journal of Adolescent Health 70 (2022) 83e90
www.jahonline.org
Original article
Preventing Adolescent and Young Adult Suicide: Do States
With
Greater Mental Health Treatment Capacity Have Lower Suicide
Rates?
Evan V. Goldstein, Ph.D., M.P.P. a, Laura C. Prater, Ph.D.,
M.P.H., M.H.A. b, and
Thomas M. Wickizer, Ph.D., M.P.H. c,*
a Division of Health System Innovation & Research,
Department of Population Health Sciences, University of Utah
School of Medicine, Salt Lake City, Utah
b Firearm Injury Prevention & Research Program, Harborview
Medical Center, The University of Washington, Seattle,
Washington
c Division of Health Services Management & Policy, The Ohio
State University College of Public Health, Columbus, Ohio
Article history: Received December 30, 2020; Accepted June
17, 2021
Keywords: Gun violence; Suicide prevention; Adolescent
suicide; Firearm suicide; Mental health
A B S T R A C T
IMPLICATIONS AND
Purpose: Youth suicide is increasing at a significant rate and is
the second leading cause of death
for adolescents. There is an urgent public health need to address

the youth suicide. The objective of
this study is to determine whether adolescents and young adults
residing in states with greater
mental health treatment capacity exhibited lower suicide rates
than states with less treatment
capacity.
Methods: We conducted a state-level analysis of mental health
treatment capacity and suicide
outcomes for adolescents and young adults aged 10e24 spanning
2002e2017 using data from
Centers for Disease Control and Prevention, U.S. Bureau of
Labor Statistics, Federal Bureau of
Investigation, and other sources. Multivariable linear fixed-
effects regression models tested the
relationships among mental health treatment capacity and the
total suicide, firearm suicide, and
nonfirearm suicide rates per 100,000 persons aged 10e24.
Results: We found a statistically significant inverse relationship
between nonfirearm suicide and
mental health treatment capacity (p ¼ .015). On average, a 10%
increase in a state’s mental health
workforce capacity was associated with a 1.35% relative
reduction in the nonfirearm suicide rate
for persons aged 10e24. There was no significant relationship
between mental health treatment
capacity and firearm suicide.
Conclusions: Greater mental health treatment appears to have a
protective effect of modest
magnitude against nonfirearm suicide among adolescents and
young adults. Our findings under-
score the importance of state-level efforts to improve mental
health interventions and promote
mental health awareness. However, firearm regulations may
provide greater protective effects
against this most lethal method of firearm suicide.

� 2021 Society for Adolescent Health and Medicine. All rights
reserved.
Conflicts of interest: The authors have no conflicts of interest to
disclose.
* Address correspondence to: Thomas M. Wickizer, Ph.D.,
M.P.H., Division of
Health Services Management & Policy, 1841 Neil Avenue,
Columbus, Ohio 43210.
E-mail address: [email protected] (T.M. Wickizer).
1054-139X/� 2021 Society for Adolescent Health and
Medicine. All rights reserved.
https://doi.org/10.1016/j.jadohealth.2021.06.020
CONTRIBUTION
The increase in youth sui-
cide requires the develop-
ment of more effective
interventions. This study
elucidates differences be-
tween nonfirearm and
firearm suicide to under-
stand different prevention
pathways. Mental health
treatment capacity is
important for nonfirearm
suicide prevention, while
firearm suicide prevention
may be best addressed
through firearm safety and
storage policies.
The U.S. is in the midst of a suicide epidemic taking the lives
of
almost 50,000 Americans each year, with rates increasing in
every state from 1999 to 2016 [1]. Although suicide is the 10th

leading cause of death in the U.S. overall, it is the second
leading
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E.V. Goldstein et al. / Journal of Adolescent Health 70 (2022)
83e9084
cause of death among adolescents and young adults aged 10e24
[1,2]. Adolescent and young adult suicides are increasing at a
faster rate among young females compared to young males [3];
the firearm suicide rate among persons aged 14e24 increased by
54% since 2004 [4]. Among young adults aged 15e24, firearms,
suffocation/hanging, and poisoning are the most frequently used
suicide methods, respectively [5,6]. For persons younger than
15,
suffocation is the most frequently used method, followed by
firearms and poisoning [5]. For females aged 15%e24%, 45% of
suicides were attributed to a firearm injury, 28% to suffocation,
and 17% to poisoning [4]. Among males in the same age range,
53% of suicides were attributed to a firearm injury, 34% to suf-
focation, and 8% to poisoning [4]. Beyond individual mortality,
adolescent and young adult suicides have devastating social
consequences. Among high-income countries in 2014, adoles-
cent and young adult suicides accounted for an estimated loss of
406,730 years of potential life, 77% of which was attributable
to
the U.S., the country with the most significant adolescent and
young adult suicide problem [7].
Researchers have found individual and household factors
associated with the risk of suicide among adolescents and

young adults. At the household level, family discord and
parental divorce are associated with increased risk of adoles -
cent suicide [3]. Access to firearms in the home is associated
with higher suicide rates [8], while greater social support and
public welfare expenditures appear to have a protective effect
[9]. Suicide rates are higher among male youth compared to
female youth, but suicidal ideation is more common among
female youth [10]. Male adolescents are also more likely than
females to use firearms in lethal suicide attempts [3]. White
adolescents have experienced higher suicide rates than
nonwhite adolescents [10], despite recent rising rates among
black youth [11]. Those who report same-sex sexual orientation
are also at greater risk for suicide [12]. Mental illness,
especially
depression, has been associated with increased risk of adoles -
cent suicide [13]. Unfortunately, many suicides occur prior to
uncovering mental illness [14], making the suicide attempt the
first sign of distress.
With firearms accounting for so many U.S. suicide deaths,
many public policy efforts have focused on limiting access to
firearms through state-level regulatory restrictions. In general,
the academic literature demonstrates that stricter firearm laws,
such as policies aimed at regulating the supply of firearms
through background checks and mandatory waiting periods
before firearm issue, are associated with lower firearm fatality
rates [15,16]. Evidence predating the recent spike in adolescent
suicides demonstrated that child access prevention laws
reduced the rate of youth firearm suicide, and offered some
protective effect on firearm suicide for older members within
the household by limiting access to firearms [17]. Meaningful
firearm safety and control policies remain controversial and
difficult to enact even at the state level, despite states’ authority
to do so [18].
Beyond firearm regulation, much public attention has focused

on mental health treatment interventions to reduce youth sui -
cide. However, studies examining the effectiveness of these in-
terventions have been limited by power issues and small sample
sizes [19]. Substance abuse, interpersonal trauma, and mental
illness are known risk factors strongly linked to suicide
attempts
among younger persons [13,20], but studies have shown promise
that primary care-based interventions, adequate outpatient care,
and access to ongoing mental healthcare may reduce youth
suicide [21,22]. Prior research also suggests the assessmen-
t/restriction of lethal means (i.e., firearms, medications) and
counseling by clinicians can reduce lethal suicide attempts
among adults and may improve opportunities to detect and treat
mental health conditions [23e26], but knowledge is more
limited for youth.
Mental healthcare shortages are well-documented across the
U.S., and many families find it difficult to access child or
adolescent mental health clinicians. Prior research [27] has
demonstrated an association between access to mental health-
care and reduced risk of suicide among persons of all ages,
including one recent study suggesting that living in a federally
designated mental health professional shortage area was corre-
lated with suicide death [28]. But less is known about the pro-
tective effects of mental health services for suicide among
adolescents and young adults. To our knowledge, there has not
been a comprehensive state-level analysis of mental health
treatment capacity and suicide rates among adolescents and
young adults.
The severity of youth suicide in the U.S., and the fact that
states have significant power to fund and design their mental
healthcare systems and enact firearm safety and control pol-
icies, prompted this state-level analysis examining the rela-
tionship between mental health treatment capacity and suicide.
Using data from 2002 to 2017, we examined whether states

with greater mental health treatment capacity have lower sui -
cide rates among adolescents (aged 10e19) and young adults
(aged 20e24), including both firearm and nonfirearm
suicide rates, compared with states having less treatment
capacity.
Methods
Data and study design
Our analysis merged data from multiple sources. The pri-
mary data sources were the Centers for Disease Control and
Prevention (CDC) Web-based Injury Statistics Query and
Reporting System (WISQARS) [4], an interactive database that
compiles information on fatal and nonfatal injury and violent
death in the U.S., and the Bureau of Labor Statistics (BLS)
Occupational Employment Statistics program, which produces
state-level, longitudinal employment data for nearly 800 occu-
pations. Additional data sources included the American Com-
munity Survey and Current Population Survey from IPUMS,
Kaiser Family Foundation State Health Facts database, Federal
Bureau of Investigation National Instant Criminal Background
Check System, U.S. Census Bureau Historical Poverty Tables,
and
the Urban Institute State and Local Finance initiative.
We performed a state-level, time-series cross-sectional
analysis that took advantage of natural variation between
states and over time in our variables of interest. The state-year
was the unit of analysis, which is appropriate because states
have authority over the funding, design, and regulation of their
mental healthcare systems, as well as firearm safety and control
regulation. The final analytic file contained 186 observations
spanning four time periods: t ¼ 2002, 2007, 2012, and 2017.
Dependent variables

Our first dependent variable measured total intentional suicide
among adolescents (aged 10e19) and young adults (aged 20e24).
83e90 85
Our second and third dependent variables measured intentional
firearm and nonfirearm suicide, respectively, among adolescents
and young adults. Because the CDC recognizes suicide as a
leading
cause of death among persons up to age 24 [1], we extracted
crude
rates of annual suicides per 100,000 persons aged 10e24 from
the
WISQARS Fatal Injury database for the three dependent
variables
[4]. CDC data restrictions prevent the analysis of state-level
suicide
rates involving less than 10 decedents. For this reason, for each
dependent variable, we combined the annual suicide rates for
each time period and its preceding year to develop an average
rate
for the 2-year period. Following this process, we excluded state-
years from the analysis if the 2-year average suicide rate for any
dependent variable was still constructed from less than 10 de-
cedents. Excluded state-years were Connecticut (2012),
Delaware
(2002, 2007), Hawaii (2002, 2007, 2017), Massachusetts (2012),
New Hampshire (2012), Rhode Island (all years), Vermont
(2002,
2007), and Washington, DC (all years), representing 8.8% of all
possible state-years.
Independent variables

We had one independent variable: mental health treatment
capacity, measured as the annual mental health workforce size
for
each state-year. To construct this measure, we extracted occupa-
tional (OCC) codes gathered from the Occupational
Employment
Statistics database [29]. OCC codes 19-3031 (clinical,
counseling,
and school psychologists), 21-1011 (substance abuse and
Table 1
Characteristics of the analytic sample: 2002e2017
2002 2007
Total suicide rate per 100,000
(2-year averages)
8.5 (3.2) 8.6
Firearm suicide rate per
100,000 (2-year averages)
4.8 (2.4) 4.3
Nonfirearm suicide rate per
100,000 (2-year averages)
3.7 (1.3) 4.4
Mental health practitioners per
state, in 1,000s
10.6 (10.5) 12.4
Annual FBI firearm background
checks per state, in 100,000s

1.8 (1.5) 2.4
State population, in 100,000s 61.6 (64.6) 64.5
Race (% of population)
White 80.6% (10.1) 79.3%
Black 10.3% (9.7) 10.4%
Male (% of population) 49.0% (.8) 49.4%
Adult population with high
school diploma (%)
83.9% (4.1) 86.0%
Population reporting divorced
marital status (%)
7.9% (1.2) 8.0%
Per capita public expenditure
on parks, recreation, and
libraries
$175.3 (63.7) $185.2
State unemployment rate 5.2% (1.0) 4.6%
Population living below
poverty (%)
11.8% (3.2) 11.9%
Affordable Care Act Medicaid
expansion
Expansion not yet adopted 46 0% 46
State adopted expansion 0 100% 0
Observations 46 46

Authors’ analysis of data from the Web-based Injury Statistics
Query and Reporting S
Population Survey from IPUMS CPS, Federal Bureau of
Investigation (FBI) National Insta
initiative, U.S. Census Bureau, and Kaiser Family Foundation,
2002e2017. For each var
included in the analytic. Standard deviations are shown in
parentheses for continuou
States could enact the Affordable Care Act Medicaid expansion
beginning in 2014.
behavioral disorder counselors), 21-1014 (mental health coun-
selors), 21-1022 (medical and public health social workers), 29-
1066 (psychiatrists), 31-1013 (psychiatric aides), and 21-1023
(mental health and substance abuse social workers) were used to
construct the variable for each state-year in the analytic sample.
Covariates
We included covariates in our statistical models to adjust for
potential confounding factors. We used data from the Bureau of
Labor Statistics, U.S. Census Bureau, and American Community
Survey to adjust for state-level, temporal differences in unem-
ployment rate, poverty rate, and educational attainment, race,
and gender compositions. Our models adjusted for the total
population of each state across time to account for population-to
size-related variation in mental health workforce capacity. We
included data from the Current Population Survey to adjust for
the percentage of people in each state-year who reported
“divorced” for their marital status. To adjust for state-level dif-
ferences in the availability of social support resources, we used
data from the Urban Institute to construct a proxy measure of
the
per capita public expenditure on parks, recreation, and libraries.
Because the Affordable Care Act Medicaid expansion may have
been associated with reductions in suicide by improving access
to healthcare [30], we included data from Kaiser Family Foun-

dation to adjust for whether states enacted the Affordable Care
Act Medicaid expansion. Finally, we included dummy variables
2012 2017
(3.8) 10.1 (3.6) 12.5 (5.1)
(2.3) 5.0 (2.6) 6.3 (3.4)
(1.8) 5.1 (1.9) 6.2 (2.3)
(13.1) 12.9 (14.5) 14.8 (15.8)
(2.6) 4.1 (4.5) 5.1 (7.3)
(67.6) 65.3 (72.0) 67.1 (73.9)
(10.4) 77.2% (13.0) 77.4% (10.7)
(9.6) 10.8% (9.9) 10.8% (9.7)
(.8) 49.4% (.8) 49.4% (.8)
(3.7) 87.9% (3.2) 89.5% (2.7)
(1.1) 8.5% (1.3) 8.6% (1.4)
(73.2) $175.4 (61.6) $179.4 (76.4)
(.9) 7.7% (1.6) 4.4% (.9)
(2.9) 14.5% (3.3) 12.1% (2.9)
0% 46 0% 19 39.6%
100% 0 100% 29 60.4%
46 48
ystem (WISQARS) Fatal Injury system, American Community
Survey and Current
nt Criminal Background Check System, the Urban Institute

State and Local Finance
iable, unadjusted average percentages or counts per year are
shown for the states
s variables, and percentages are shown in parentheses for
categorical variables.
Table 2
National suicide and crude death rates by year and age group:
2002e2017
Panel A: ages 10e19
Year Total suicide rate
per 100,000, ages 10e19
Firearm suicide rate
per 100,000, ages 10e19
Nonfirearm suicide rate
per 100,000, ages 10e19
Crude death rate per 100,000,
ages 10e19 (all causes)
2002 4.23 1.98 2.25 42.85
2007 3.87 1.59 2.28 39.00
2012 4.97 2.05 2.92 30.79
2017 7.18 3.09 4.09 33.65
Panel B: ages 20e24
Year Total suicide rate
per 100,000, ages 20e24

Firearm suicide rate
per 100,000, ages 20e24
Nonfirearm suicide rate
per 100,000, ages 20e24
Crude death rate per 100,000,
ages 20e24 (all causes)
2002 12.33 6.65 5.68 95.01
2007 12.62 6.03 6.59 98.13
2012 13.68 6.47 7.21 84.61
2017 17.04 8.38 8.66 95.57
National suicide rates were obtained from the CDC Web-based
Injury Statistics Query and Reporting System (WISQARS) Fatal
Injury Reports and crude death data were
obtained from the CDC WONDER database. Crude rates per
100,000 shown.
CDC ¼ Centers for Disease Control and Prevention.
83e9086
for each time period and each state to adjust for secular time
trends and unmeasured, time-invariant state-level policies and
characteristics.
Firearm availability is associated with suicide [31], but we
were unable to directly control for it. Consistent measures of
firearm availability are not available at the state level for all
states. As recommended elsewhere [32], we included the mea-
sure of annual federal firearm background checks from the
Federal Bureau of Investigation National Instant Criminal Back-
ground Check System as a proxy for gun ownership rates in the
Table 3
Highest and lowest total suicide rates per 100,000, by state and

year: 2002e2017
2002
States with highest ratesa Total suicide rate per 100,000
Alaska 19.78
Wyoming 17.84
South Dakota 14.19
Idaho 12.56
Montana 12.33
New Mexico 11.64
Colorado 11.37
Arizona 10.96
Kansas 10.41
New Hampshire 10.39
2017
States with highest ratesa Total suicide rate per 100,000
Alaska 32.81
Montana 23.48
South Dakota 23.12
Wyoming 19.72
North Dakota 18.81
New Mexico 18.63
Colorado 16.99
Oklahoma 16.60
Utah 16.37
Idaho 15.99
Authors’ analysis of data from the CDC Web-based Injury
Statistics Query and Reportin
average of crude firearm suicide rates for individuals aged
10e24 for each study time

observations were available in this analysis. For 2002 and 2017,
we compared the av
highest and lowest suicide rates using bivariate t-tests and
Mann-Whitney U-tests. p
a The states with the highest suicide rates had significantly
greater federal firearm
statistical models for total and firearm suicide rates, but not in
the nonfirearm suicide rate model.
Analysis
We tested multivariable linear fixed-effects regression
models to examine the relationships between mental health
treatment capacity and suicide rates. Robust standard errors
were clustered at the state level to correct for problems poten-
tially caused by heteroscedasticity or serial correlation. To
States with lowest rates Total suicide rate per 100,000
New Jersey 3.58
Massachusetts 4.41
California 4.42
New York 4.71
Connecticut 4.84
South Carolina 6.1
Illinois 6.31
Florida 6.54
Maryland 6.69
Virginia 6.71
States with lowest rates Total suicide rate per 100,000
New Jersey 5.54
New York 5.90
Connecticut 6.50
Massachusetts 6.56

California 6.83
Maryland 6.87
Delaware 7.58
Florida 8.17
Illinois 8.23
North Carolina 9.56
g System (WISQARS) Fatal Injury Reports. The total suicide
variable is the 2-year
period (and its preceding year), as described in the manuscript.
Not all state-year
erage federal firearm background checks per capita between the
states with the
< .01 using both tests.
background checks per capita than the states with the lowest
suicide rates.
Table 4
Estimating the effects of greater mental health treatment
capacity on suicides per 100,000 persons aged 10e24
1 2 3
Outcome: total
suicides/100,000 persons
Outcome: firearm
Outcome: nonfirearm
Mental health practitioners per state, in 1,000s �.073 �.021
�.052*

.106 .521 .015
Annual FBI firearm background checks, in 100,000s .025 .022
.430 .221
State population, in 100,000s �.009 �.007 �.003
.746 .706 .984
Race (%)
White �.032 �.12 .083
.734 .136 .112
Black �.643* �.518þ �.131
.035 .077 .307
Male population (%) 1.192 .324 .866þ
.162 .541 .069
Adult population with high school diploma (%) �.453** �.14
�.299**
.005 .222 <.001
Population reporting divorced marital status (%) �.294 .047
�.335*
.127 .693 .018
Per capita public expenditure on parks, recreation, and libraries
.005 .003 .002
.361 .432 .432
Unemployment rate (state) .086 .062 .01
.653 .546 .931
Population living below poverty (%) .074 .026 .043
.544 .786 .376

Affordable Care Act Medicaid expansion
Expansion not yet adopted Reference Reference Reference
State adopted the expansion �.459 �.432 �.066
.448 .342 .849
Year
2002 Reference Reference Reference
2007 .843 �.339 1.138**
.177 .348 <.001
2012 3.450** .583 2.847**
<.001 .268 <.001
2017 7.272** 2.505** 4.666**
<.001 .004 <.001
Constant .322 15.327 �15.783
.933 .543 .503
Observations 186 186 186
Adjusted R2 .69 .52 .69
p values are shown in italics below each coefficient. State
fixed-effects (FE) coefficients not shown. Authors’ analysis of
data from the Web-based Injury Statistics Query
and Reporting System (WISQARS) Fatal Injury system,
American Community Survey from IPUMS USA, Current
Population Survey from IPUMS CPS, Federal Bureau of
Investigation (FBI) National Instant Criminal Background
Check System, U.S. Census Bureau, Kaiser Family Foundation,
and the Urban Institute State and Local Finance
initiative, 2002e2017.
FBI ¼ Federal Bureau of Investigation.
þp < .10; *p < .05; **p < .01.

83e90 87
facilitate the interpretation of our findings, we generated
regression-adjusted annual probabilities of suicide for each
study
year, while keeping other covariates at their observed values
(i.e.,
estimating average marginal effects). We established an a priori
two-sided statistical significance level of .05. Analyses were
conducted using Stata version 15.1 (College Station, TX). Insti-
tutional Review Board approval was not necessary for this state-
level study.
Results
On average, the total suicide rate among individuals aged 10e
24 in the states included in this analysis increased 47.1% from
2002 to 2017 (Table 1). The average firearm and nonfirearm
suicide rates grew by 31.3% and 67.6%, respectively, over the
same
time period. Mental health treatment capacity, as measured by
our mental health workforce variable, grew by 28.6% on a per
capita basis. Table 2 shows that the total suicide rate from 2002
to 2017 grew more among adolescents aged 10e19 (69.8% in-
crease) than young adults aged 20e24 (38.2% increase). From
2002 to 2017, the firearm and nonfirearm suicide rates
increased
by 56.1% and 81.8%, respectively, among 10- to 19-year olds
and
by 26.2% and 52.5%, respectively, among 20- to 24-year olds.
In
2002, 9.9% of all deaths among individuals aged 10e19 were
suicides. By 2017, approximately 21.3% of all deaths among
per-
sons aged 10e19 and 17.8% of all deaths among persons aged
20e
24 were suicides.

Table 3 demonstrates the between-state variation in total
suicide rates over the study period, listing states with the
highest
and lowest total suicide rates at the beginning and end of our
study. Among the states included in our analysis, Alaska,
Wyoming, Montana, and South Dakota experienced the highest
adolescent and young adult suicide rates, on average, from 2002
to 2017, and the rates increased in all four states from 2002 to
0.0000%
0.0020%
0.0040%
0.0060%
0.0080%
0.0100%
0.0120%
0.0140%
0.0160%
2002 2007 2012 2017
P
ro
b

a
b
il
it
y
o
f
su
ic
id
e
Any suicide Firearm suicide Non-firearm suicide
Figure 1. Adjusted probability of suicide, by method of suicide:
2002e2017. This figure shows the regression-adjusted
probability of any suicide, firearm suicide, and
nonfirearm suicide for the years 2002, 2007, 2012, and 2017.
These probabilities were calculated for the entire estimation
sample for each year, keeping all other
covariates at their observed values (i.e., using average marginal
effects).
83e9088
2017. In contrast, New Jersey, New York, Massachusetts,
Califor-
nia, and Connecticut were consistently ranked among the states
experiencing the lowest suicide rates from 2002 to 2017,
although the suicide rates also increased in these states from
2002 to 2017. Bivariate analyses comparing the states with the
lowest and highest suicide rates in 2017 also showed that the 10

states with the highest suicide rates likely had significantly
greater firearm availability, as measured by the annual federal
firearm background checks per capita. In 2017, the states with
the
highest suicide rates had an average of .096 federal firearm
background checks per capita, compared to an average of .047
federal firearm background checks per capita in the states with
the lowest suicide rates (p < .001).
Table 4 shows the results of our multivariable analysis. We
found an inverse relationship between the state-level mental
health workforce capacity and the total suicide rate (b ¼ �.073,
p ¼ .106). Although the finding was not statistically significant
at the .05 significance level, the result implies that, on average,
a 10% relative increase in the mental health workforce capacity
in a state would be independently associated with a
.923% relative reduction in the total suicide rate for persons
aged 10e24 (p ¼ .106). We found a statistically significant,
inverse relationship between the mental health workforce
capacity and the nonfirearm suicide rate (b¼ �.052, p ¼ .015).
This result implies that, on average, a 10% relative increase in
the mental health workforce capacity in a state would be
independently associated with a 1.35% relative reduction in the
nonfirearm suicide rate for persons aged 10e24 (p ¼ .015).
There was no statistically significant relationship between
state-level mental health workforce capacity and the firearm
suicide rate.
Figure 1 shows the adjusted probability of suicide in a given
year for persons aged 10e24 over the study period, as
observed in our estimation sample. The adjusted probability of
a person aged 10e24 dying by any method of suicide in a year
increased from .0071% in 2002% to .0143% in 2017da 101.4%
relative increase. Although the adjusted probability of firearm
suicide increased only modestly over time, the adjusted
probability of a persons aged 10e24 dying by nonfirearm

suicide in a year increased considerably from .0027% in 2002 to
.0074% in 2017.
There was a negative relationship between the percentage of
a state’s population reporting divorced marital status and the
nonfirearm suicide rate (Table 4; p ¼ .018). The percentage of a
state’s adult population with a high school diploma was also
inversely related with the total (p ¼ .005) and nonfirearm
suicide
rates (p < .001).
Discussion
Our findings suggest that greater mental health treatment
capacity at the state level has a statistically significant
protective
effect of modest magnitude against nonfirearm suicide among
adolescents and young adults aged 10e24, though no protective
effect against firearm suicide. Our findings have relevance for
policy considerations and for the development of interventions
aimed at reducing youth suicide incidence.
Substance abuse, interpersonal trauma, and mental illness are
strongly linked to suicide attempts among younger persons
[13,20,33,34]. The high case-fatality rate of firearm suicide [35]
may dampen the ability of mental health practitioners to diag-
nosis a mental illness or successfully intervene when necessary,
yet only 7% of those who make a nonfatal suicide attempt go on
to die from a future attempt [36]. For younger persons who will
attemptdor have attempteddsuicide using less lethal means,
risk factors for suicide may be more sensitive to greater mental
illness detection efforts, and improving access to mental health
treatment when needed may help prevent nonfirearm suicide
attempts.
Previous studies have shown promise that adequate outpa-

tient care, primary care-based interventions such as improved
screening for suicide risk factors and access to cognitive behav-
ioral therapy, and access to mental healthcare after presenting
in
an emergency department following a suicide attempt may
reduce youth suicide [21,22,34,37,38]. Lethal means
assessment/
restriction has also shown promise among youth with programs
such as SafetyCheck [39]. As index suicide attempts (IA) have
been shown to be more lethal for youth and young adults across
83e90 89
all methods [3,40], prevention efforts should start prior to an IA
and consider an approach that addresses both identifying serious
suicidal ideation and restricting access to lethal means.
Our findings may therefore support state-level efforts to
improve mental health treatment capacity and promote mental
health awareness. For example, states can enhance school -based
mental health services capacity, which has been shown to help
reduce depressive episodes and suicide risk among adolescents
[41]. Schools often access funds for school-based mental health
and substance abuse services through state sources, including
Medicaid benefits (e.g., Early and Periodic Screening,
Diagnostic
and Treatment) and Medicaid waiver programs; through the
state-level allocation of funds from the Every Student Succeeds
Act (2015); and through state applications to the federal School -
Based Mental Health Services Grant Program.
States can also raise awareness about youth mental health
issues by promoting mental health literacy programs like
Mental Health First Aid (MHFA), which provides training on

common mental health conditions and how to refer youth for
care. Since 2015, 20 states have prioritized MHFA by enacting
policies to fund training, require certification for public sector
employees, and establish state-wide mental health training
requirements. California and Pennsylvania led the U.S. in
funding MHFA trainings in 2014, and Texas allocated $5
million
to train youth educators in MHFA [42]. Prior evaluations have
shown that the MHFA program may help reduce unmet need
for behavioral healthcare in rural areas [43]. The Youth MHFA
program has also helped participants (e.g., neighbors and
teachers) become more aware of mental health resources,
accepting of young persons with mental health conditions, and
willing to help in times of need [44]. States can also fund
mental health awareness campaigns using social media, such
as California’s Each Mind Matters Campaign, which have
improved positive beliefs about the possibility of recovery
from mental illness [45].
Our findings do not suggest that greater mental health
treatment capacity will systematically reduce firearm suicide
among adolescents and young adults. The risk of firearm suicide
may be less about diagnosing a mental illness and more about
the potential impulsivity of those who attempt suicide with
firearms [46,47] and the lethality of firearm suicide [48], which
together often prevent intervention from health professionals.
Prior research suggests that the adoption of stricter firearm
safety and control policies will likely yield greater protective
effects against firearm suicide [27]. Measures often discussed
by
policymakers include mandatory waiting periods before firearm
issue and child access prevention laws, which are shown to
reduce youth firearm suicide [49,50]. However, policy interven-
tion to improve firearm control is often overwhelmed by pre-
vailing political forces, even though large majorities of
Americansdincluding both firearm owners and nonfirearm

ownersdsupport a range of regulatory measures to strengthen
firearm safety laws [51]. As described in Table 3, states with
the
highest suicide rates had significantly greater federal firearm
background checks per capita, a proxy for gun ownership. Yet
evidence-based policies shown to reduce firearm suicide appear
to be absent in states with the highest suicide rates [17].
Our findings also suggest that higher rates of high school
completion were significantly associated with lower suicide
rates, consistent with other studies [52]. These findings may
support the idea that investments in education are important for
preventing suicide among adolescents and young adults. At the
individual level, suicide risk tends to increase with poor school
performance and dropout [53,54], though the link between
educational attainment and suicide is less certain. However,
when considering education as a measure of aggregate human
capital in the context of other related socioeconomic factors,
education may have a protective effect [55]. Improving funding
for K-12 public education in states with high suicide rates,
encouraging other investments in human capital development,
and providing opportunities for family counseling as part of
schooling [56] should be explored as population-level suicide
prevention strategies.
Limitations
This study has several limitations. First, we used a non-
randomized, retrospective study design, which imposes limits
on
causal inference. Second, because we conducted a state-level
analysis, readers should refrain from making inferences about
individual behavior. Third, without more granular data (e.g., in-
dividual or county level), we could not perform a multivariable
analysis within each state longitudinally. Fourth, as described
earlier, CDC data restrictions prevented us from constructing
our

dependent variables for all state-years. For this reason, the
generalizability of our results is potentially limited to the states
included in our analytic sample. Fifth, for the same reasons of
insufficient data and data restrictions, we could not conduct
subgroup analyses by sex or age (e.g., only persons <18 years).
It
would be important to explore how sex may have moderated our
findings in future studies using different data. Sixth, due to Bu-
reau of Labor Statistics data limitations, we could not identify
and
include other types of providersdsuch as mental health nurse
practitioners or adolescent behavioral health physiciansdin our
measure of mental health treatment capacity. Nonmental health
practitioners may provide mental health screening or other
services to adolescents and young adults. This limitation also
prevented us from identifying and constructing a measure of
only school-based mental healthcare providers. Finally, we
could
not directly control for firearm availability, an important pre-
dictor of youth suicide. Consistent with other studies we
included a proxy measure of the annual number of federal
firearm background checks performed in each state [32]. How -
ever, federal background checks do not capture private firearm
purchases, hence this variable is an incomplete proxy measure
for firearm availability.
Conclusions
Increasing the mental health workforce and the availability
of mental health services at the state level appears to be
important for nonfirearm suicide prevention. In contrast,
mental health treatment capacity appears to have little effect on
the more lethal method of firearm suicide. Mental health dis-
orders may go undiagnosed among youth who die by all
methods of suicide. However, given that suicide can be an
impulsive act [46] and suicide attempts using a firearm are
nearly always fatal, preventing firearm suicide directly may be

best addressed through the enactment of evidence-based
firearm safety and storage regulations by state-level policy-
makers. Population-level investments in human capital devel-
opment may also promote future well-being and protect young
persons from suicide.
83e9090
Funding Sources
Dr. Prater receives research funding support from the State of
Washington.
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k_v6.pdf?daf=375ateTbd56

http://refhub.elsevier.com/S1054-139X(21)00333-
5/sref56Preventing Adolescent and Young Adult Suicide: Do
States With Greater Mental Health Treatment Capacity Have
Lower Suicide R ...MethodsData and study designDependent
variablesIndependent
variablesCovariatesAnalysisResultsDiscussionLimitationsConcl
usionsFunding SourcesReferences
Aggression and Violent Behavior xxx (xxxx) xxx
Please cite this article as: Scott Poland, Sara Ferguson,
Aggression and Violent Behavior,
https://doi.org/10.1016/j.avb.2021.101579
Available online 15 February 2021
1359-1789/© 2021 Elsevier Ltd. All rights reserved.

Youth suicide in the school context
Scott Poland, Sara Ferguson *
Nova Southeastern University, 3301 College Ave, Fort
Lauderdale, FL 33314, United States of America
A R T I C L E I N F O
Keywords:
School mental health professionals
Postvention
Intervention
School
Prevention
Youth suicide
A B S T R A C T
Across the domains of youth risk behavior, suicidality is a
significant concern for parents and professionals alike,
requiring ongoing efforts to better understand and prevent rising
trends. Recent examinations of suicidal be-
haviors in the United States over the last decade revealed an
increase in emergency and inpatient hospital set-
tings. Of importance, seasonal variations were demonstrated,
finding the lowest frequency of suicidality
encounters in summer months, and observed peaks in the fall
and spring, during the school year. Given these
findings and the fact that youth spend nearly half of their time
at school, consideration of youth suicide in the
school environment is critical. This paper will review the trends
of youth suicide within the school context,
exploring factors such as at-risk youth, bullying, relevant legal
issues, and the current state of crisis response in
school settings. Recommendations for prevention, intervention,

and postvention will be provided. The authors
propose that school professionals play a vital role in addressing
youth suicide and will aim to provide guidance
on effective crisis response within the school context.
1. Introduction
Suicide is a leading cause of death in the United States (CDC,
2018)
and a prominent concern in the mental health and medical fields
given
the high rates of suicidal ideation and attempts. While death by
suicide
is an incredibly difficult and often unfathomable tragedy, its
occurrence
in the youth population can bring even more confusion and
intense grief
for loved ones. In 2016, suicide became the second leading
cause of
death for ages 10–34 (CDC, 2017b). Furthermore, a 2018 review
of
injury mortality among youth during 1999–2016 identified
suicide as
the second leading injury intent among 10–19 years (in which a
56%
increase was observed between 2007 and 2016 [Curtin et al.,
2016]).
The Youth Risk Behavior Surveillance Survey ([YRBSS], CDC,
2017a), the Centers for Disease Control and Prevention’s (CDC)
biennial
survey of adolescent health risk and health protective behaviors,
revealed upward trends in their survey of suicidality and related
be-
haviors of high school students (see Fig. 1.1). Specifically,
students re-

ported an increase over the last decade in seriously considering
attempting suicide and making a suicide plan. Of concern,
among the
few states that queried middle school students, trends were
observed at
an even higher rate.
Given the high rates of suicidal behavior among young people,
ample
research has been dedicated to this topic, resulting in pertinent
knowl-
edge necessary to better understand the matter. A variety of risk
factors
have been consistently identified across the literature, many of
which
inform prevention and intervention practices for clinicians.
There is,
however, an area in which additional attention should be
awarded: the
school context.
Young people spend a significant portion of their time in school
settings in which they are actively engaged with their peers and
subject
to the potential stressors of academic achievement and future
success. In
light of this, consideration of youth suicide in the school
context is of
utmost importance. Evidence reports that school influences the
behavior
and health of young people (Evans & Hurrell, 2016). This is
additionally
supported by recent research that has demonstrated significant
seasonal
variations in youth suicide patterns (Plemmons’ et al., 2018),

suggesting
that involvement in school should be further examined as a
critical
factor in youth suicidality.
This paper aims to contribute to this suggestion, in which we
will
review relevant literature related to youth suicide in the school
context,
including associated risk factors, existing prevention,
intervention, and
postvention programming, and related legal implications.
Recommen-
dations for best practices will be offered, specific to both
school and
mental health professionals. The authors propose that school
pro-
fessionals play an essential role in addressing youth suicide and
will aim
to offer guidance on effective crisis response within the school
context.
* Corresponding author.
E-mail addresses: [email protected] (S. Poland),
[email protected] (S. Ferguson).
Contents lists available at ScienceDirect
Aggression and Violent Behavior
journal homepage: www.elsevier.com/locate/aggviobeh
Received 1 December 2019; Received in revised form 19 July
2020; Accepted 5 February 2021

www.sciencedirect.com/science/journal/13591789
https://www.elsevier.com/locate/aggviobeh
2
2. Youth suicide & seasonal variations
As discussed, it has been well established that there are rising
trends
in youth suicidal behavior. Recent research in related domains
supports
these findings, such as observed increases in hospitalizations
(Burstein
et al., 2019), attempts by females (CDC, 2017b), use of
suffocation as
preferred method (Curtin et al., 2018), and serious
considerations of
suicide, along with the creation of a plan (CDC, 2017a).
Plemmons’ et al.
(2018) recent large-scale study examining youth suicidal
encounters in
pediatric emergency and inpatient hospital settings further
supported
the observed increases, demonstrating consistent upward trends
of sui-
cidal ideation and attempts across age groups and genders. Of
interest, a
pattern of seasonal variation was observed, in which a higher

percentage
of cases was found during the fall and spring and conversely, a
lower
number of cases during the summer months.
Such findings are of significance, as they shed light on a critical
factor of youth suicide that has not been historically explored.
Research
related to this matter is limited and recent (see Hansen & Lang,
2011;
Lueck et al., 2015), suggesting a gap in the conceptualization of
youth
suicide. Plemmons’ et al. (2018) findings of seasonal patterns
lead one to
consider the variables associated with the months in which
increased
and decreased rates were observed. Most glaringly, is the
consideration
of youth participation in school during the fall and winter
months and
the subsequent break during the summer months.
Lueck et al. (2015) set out to investigate this aspect of youth
suicide,
in which they analyzed the relationship between weeks in
school vs.
weeks out of school (i.e., vacation) with concern for danger to
self or
others. Of note, the researcher’s review of 3223 subjects (mean
age,
13.8 years) who presented to a local pediatric emergency unit
included
youth with both suicidal and homicidal ideation, creating
challenges in
isolating the results solely to the examination of suicidal
behavior.

However, their findings of higher rates of such ideation during
weeks in
which the subjects were in school vs. the reduced rates observe d
during
vacation weeks certainly contributes to the growing
understanding that
the school context has a significant impact on risk behaviors
such as
suicidality.
Similarly, Hansen and Lang (2011) hypothesized that youth in
school
served as a crucial factor in the seasonal patterns of youth
suicide. Their
investigation established a distinct alignment of youth suicide
with the
school calendar, including a significant decrease during the
summer
breaks; one that commenced upon entering adulthood. Further,
unlike
many youth suicide studies, the researchers examined the data
for each
gender separately, finding that the suicide rate, on average, was
95%
higher for boys in school months when compared to girls (33%).
Addi-
tionally, the authors proposed theories regarding school specific
factors
that likely influenced these trends, including negative peer
interactions,
along with academic stressors and the related mental health
impact.
These findings create a scientific foundation for youth suicide
in the

school context that warrant a deeper investigation. Additionally,
the
authors would be remiss not to highlight the fact that youth
spend nearly
half of the total days of the year in school settings, thereby
making it the
most logical place to intervene. Access to the youth, along with
potential
resources within the school and community create an ideal
environment
for prevention and intervention. These factors create a cogent
argument
for continued exploration of youth suicide in the context of the
school
environment.
3. Risk factors in the school context
In light of the reviewed findings of seasonal patterns of youth
suicide
rates and their association to school participation, along with
the sheer
amount of time spent in the school setting, consideration of the
school
related factors that may contribute to youth suicidal behaviors
is
essential. Risk factors associated with youth suicide have been
broadly
identified, including specific individual and psychosocial
variables.
Such factors include youth that have little social supports, many
of
whom often present with pathologies such as mood and
substance use
disorders, bullies and victims, individuals who identify as
LGBTQ, and

youth exposed to adverse early childhood experiences such as
trauma,
family system disturbances, and most notably, suicide (Gould et
al.,
2003; Lieberman et al., 2008). Moreover, across the risk factors
reviewed, of greatest significance is a prior suicide attempt.
Research
reveals that a prior attempt is the strongest predictor of a future
death by
suicide (Harris & Barraclough, 1997).
Fig. 1.1. YRBSS suicide related behavioral trends.
S. Poland and S. Ferguson
3
3.1. Social connectedness
Specific to the context of school, a variety of risk factors are
pertinent
to review in detail. As mentioned, level of social support has
been
determined as a risk factor for youth suicide, in which a child or
ado-
lescent’s connectedness to his or her peers can play a
significant role in
his or her vulnerability to suicidal behavior (Lieberman et al.,
2008). It is
broadly accepted that the development of positive and close
relation-
ships with others can serve as a protective and preventive buffer

against
suicidal ideation and behaviors. Connectedness typically results
in high
rates of social contact and lower rates of feelings of loneliness
and
isolation (CDC, 2011).
While social connectedness has been established as a prominent
factor in the conceptualization of suicidal behaviors (Joiner,
2005), it is
important to consider this variable specifically in the context of
youth
suicide, given the easy access to potential social relationships
(both
negative and positive). Furthermore, it has been well
documented that
young people who are at higher risk for suicidal behaviors often
face
adversity such as familial disturbances and related neglect,
homeless-
ness, or involvement in social services (i.e., foster care), all of
which
negatively impact an individual’s level of connectedness. Lack
of social
connectedness in youth is a broad risk factor to consider and the
related
vulnerabilities that arise as a result are certainly contributing
factors to
suicidal behavior. Increased isolation, for example, can
negatively
impact self-esteem and potentially lead to depression, another
identified
risk factor of youth suicide (Lieberman et al., 2008).
The milieu of school provides an ideal setting to enhance social
connectedness for children and adolescents. Moreover, it gives

the op-
portunity for school staff to act as warm and accepting social
role models
that can aid in providing a formal support system of
connectedness.
Recommendations for enhancing social support and
connectedness as
means to buffer suicide risk have been discussed across the
literature,
including the development of prevention programs that are
founded
upon this concept (e.g., Gatekeeping Training (Burnette et al.,
2015;
CDC, 2011)). While such programs (which will be reviewed in
further
detail) have been demonstrated as being an effective
intervention for
reducing suicide attempts in youth (see Aseltine et al., 2007;
Aseltine &
DeMartino, 2004), there are a variety of factors in school
settings that
not only create challenges in enhancing social connectedness
across
diverse student bodies, but also contribute to higher rates of
suicidal
behavior in young people.
3.2. Bullying
Relatedly, engagement in bullying (whether as the bully or the
victim), has been identified as a risk factor for youth suicide
(Holt et al.,
2015; Lieberman et al., 2008). The Suicide Prevention Resource
Center’s
(SPRC) (2011) Issue Brief on Suicide and Bullying revealed a
strong

association between bullying and suicide, reporting that
children who
are bullied are at highest risk for suicide due to the
commonality of risk
factors. Dan Olweus, creator of the Olweus Bullying Prevention
Program
(1993), defines bullying as occurring “when a person is exposed
repeatedly, and over time, to negative actions on the part of one
or more
persons, and he or she has difficulty defending himself or
herself” (p. 9,
Olweus, 1993). Lierberman and Cowan (2006) reported that
interper-
sonal problems are frequently cited by adolescents as the
antecedent of
suicidal behavior, in which loss of dignity and humanity is
conceptu-
alized as a triggering event. Moreover, Gould and Kramer
(2001) pro-
vided insight regarding bully behavior, suggesting that the more
frequently an adolescent engages in bullying, the more likely
that she or
he is experiencing feelings of hopelessness and depression, has
serious
suicidal ideation, or has attempted suicide in the past.
The 2017 School Crime Supplement (National Center for
Education
Statistics and Bureau of Justice, 2018) found that in the United
States,
approximately 20% of students ages 12–18 experienced
bullying. It is
important to note that bullying can occur both in and out of the
school
environment, especially given the rapidly evolving state of

technology
and social media. Cyberbullying is a growing concern (YBRSS
data es-
timates that 14.9% of high school students were electronically
bullied in
the 12 months prior to the survey [CDC, 2017a]). It is defined
as any
type of bullying (i.e., mean/hurtful comments, spreading
rumors,
physical threats, pretending to be someone else, and
mean/hurtful pic-
tures) through a cell phone text, e-mail, or any social media
outlet or
online source (Hinduja & Patchin, 2012).
Cyberbullying presents significant concerns related to its
aspects of
anonymity and ease of access. Moreover, it is pervasive and can
occur in
both the home and school setting, creating an environment of
contin-
uous bullying. The high frequency of cyberbullying is
significant in the
conceptualization of youth suicide in the school context, as
students
often have access to social media platforms where bullying
frequently
occurs during school hours. This likely contributes to the
finding that
reports of bullying continue to be highest within the school
setting (U.S.
Department of Health and Human Services, 2019). This is
further sup-
ported by the YRBSS data (CDC, 2017a), which revealed that
nationally,
19% of students in grades 9–12 report being bullied on school

property
in the 12 months preceding the survey. While bullying has
received
increased public attention over time and actions have been taken
to
target the issue, it clearly persists in the school settings. More
so, the
findings certainly demonstrate the tragic and very permanent
implica-
tions that bullying can lead to in the context of youth suicide.
3.3. LGBTQ population
Given the significant findings related to bullying and suicidal
behavior in children and adolescents, it is important to consider
special
populations that may be at higher risk of being bullied, as this
may serve
as an indirect route to suicidal behaviors. Children and
adolescents who
are questioning their sexual orientation or gender identity have
been
found to have high rates of negative outcomes in a number of
areas
including harassment, victimization, and bullying, along with
violence,
drug abuse, sexually transmitted diseases, and mental health
problems,
such as depression (Birkett et al., 2015; CDC, 2017a).
Strikingly, this
population has been found to be more likely to consider and
attempt
suicide (Almeida et al., 2009; Hatzenbuehler, 2011; Kosciw,
Greytak,
Bartkiewicz, Boesen, & Palmer, 2012; Lieberman et al., 2014).
In fact,

YRBSS (CDC, 2017a) data revealed significantly higher
percentages of
attempted suicides of lesbian, gay, or bisexual students (23.0%)
and
students not sure of their sexual identity (14.3%) when
compared to
their heterosexual students (5.4%).
Family acceptance appears to be a major factor in the
experience of
suicidal ideation, as those who experience a high level of
acceptance are
found to have lower rates (18.5%) when compared to those with
low
acceptance from their families (38.3% (Ryan, Russell, Huebner,
Diaz, &
Sanchez, 2010)). Furthermore, acceptance in other areas of a
LGBTQ
identifying youth’s life, such as the school and broader
community, has
been suggested as a significant protective factor to the many
risks they
face (Birkett et al., 2015), thereby promoting self-acceptance
and resil-
ience (Dahl & Galliher, 2012).
Consideration of the LGBTQ population in the school context is
critical, as it can serve as an environment of safety, acceptance,
and
connectedness. There are a number of recommendations for
school and
mental health professionals to best support LGBTQ youth;
however,
despite the availability of specific recommendations (e.g.,
creation of
safe-spaces and student-led advocacy groups), LGBTQ youth

continue to
widely report feeling unsafe at school (10%, CDC, 2017a),
presenting
serious ongoing concerns for this population. These findings,
paired
with the previously mentioned associated negative outcomes,
including
high rates of suicidal behavior, certainly justify the need for
special
attention and consideration in the school context.
4
3.4. Ethnicity and culture
Consideration of high-risk populations must include the
examination
of suicide rates and related risk factors of young people across
diverse
ethnic and cultural backgrounds. While the prevalence rates of
SI and SA
vary among differing identifications of race and ethnicity, there
are
specific populations who have been identified as high risk for
suicidal
behavior (Lieberman et al., 2008). In 2017, The CDC (2017b)
reported
that the age-adjusted rate of suicide among American
Indians/Alaska
Natives was 22.15 per 100,000 and among non-Hispanic whites

it was
17.83. In contrast, lower and more similar rates were found
among
Asian/Pacific Islanders (6.75%), Blacks (6.85%), and Hispanics
(6.89%). YRBSS’ data reveals that Black or African American
students
reported the highest rate of suicide attempts (9.8%), followed
by white
students at 6.1% (CDC, 2017a). Of note, YRBSS did not include
Amer-
ican Indians/Alaska Natives as an option of ethnic
identification; how-
ever, the CDC (2017b) reported that suicide rates peak during
adolescence and young adulthood among this population and
then
decline. This pattern greatly differs from the general United
States
population, where rates of suicide peak in mid-life.
The disproportionate level of risk for suicide in youth who
identify as
American Indian and Alaska Native has been well researched, in
which a
variety of contributing factors have been identified, e.g., high
rates of
substance use, exposure to adverse early childhood experiences,
limited
access to resources due to rural settings, and increased potential
for
contagion effects of suicide (Leavitt et al., 2018). In light of
these
complex vulnerabilities, researchers often recommend school
involve-
ment in prevention and intervention to target the varied risk
factors
present, especially as they relate to suicidal behavior. School

program-
ming can typically reach larger populations, a dire need in rural
areas in
which many of these young people reside (Leavitt et al., 2018;
Lieber-
man et al., 2008). Specific recommendations within the school
context
are offered across the relevant literature, which will be
integrated into
clinical recommendations in later reading.
4. Legal implications of suicide in the school context
Suicide in the school context is a complex issue that can create
sig-
nificant legal implications regarding the liability of the school
district
and staff, especially administrators, support staff, and school
psycholo-
gists. In the United States, there have been numerous legal
battles in
which schools are sued in the aftermath of a death by suicide of
a young
person. While this presents major concerns for school
personnel, very
rarely do the parents of suicidal students succeed in court
proceedings.
With the exception of the school’s failure to notify parents
when there is
reason to suspect a student’s risk for suicide, courts have been
reluctant
to find schools culpable (Stone, 2017).
Friedlander (2013) reported that parents as the plaintiffs face
slim
chances when they file a lawsuit against the school or its

officials after
the suicide of their child. Many factors contribute to this,
including the
lack of resources, i.e., financial means, the lengthy trial
periods, and
limited evidentiary documentation. Cases that cite bullying as a
critical
factor in the youth’s suicide, for example, often lack the
necessary
documentation of the parents’ concerns that are often reportedly
shared
with school officials prior to their child’s death by suicide.
Moreover, Poland (Erbacher, Singer, & Poland, in press)
reported
that only a small number of these cases make it to a jury trial.
More
often, the school districts’ insurance companies decide to settle
the cases
outside of court, as it can be a less costly and public matter,
when
compared to the potential of a lengthy defense of the district in
litiga-
tion. Moreover, public legal battles can generate a negative
stigma
around the school and its district. However, MacIver (2011)
suggested
that the number of court cases against schools may continue to
rise in the
future, as courts are becoming more receptive to finding the
defendants
liable for causing another person’s suicide. Further, suicide
experts are
reported as having increased success in either proving or
disproving a

specific cause of suicide.
In review of cases that have gone to trial, rulings are varied,
muddying the legal guidelines for school suicide prevention and
related
liability. Dr. Scott Poland, one of the present authors and a
leading
expert in youth suicide, discussed the complexity of these cases
in his
chapter on Legal Issues for Schools (Erbacher et al., in press).
In sum,
courts must primarily consider whether a student’s death by
suicide was
a direct result of an inadequate response from the school
personnel;
however, given the varied psychosocial risk factors associated
with
youth suicide (e.g., mental health, and adverse childhood
experiences),
it is highly difficult to prove that a school’s breach of duty is
the sole
causal factor of the suicide, thereby making the personnel
liable.
4.1. School liability: relevant legal cases
What then is the school’s liability in cases of student suicides?
His-
torically, courts ruled that schools did not have a legal
obligation to
prevent suicide (Stone & Zirkel, 2012). A 1991 appellate case,
Eisel v.
Board of Education of Montgomery County, set new precedent
on this
matter. The father of 13-year-old Nicole Eisel sued the school
district

and two of its school counselors after they failed to report their
learning
of an apparent murder-suicide pact with another peer. The
father argued
that the special relationship the personnel maintained with his
daughter
placed a duty upon them to share her reported suicidal ideation
with her
parents. The Maryland Supreme Court held that the state’s
Suicide
Prevention School Programs Act, the school’s own suicide
prevention
policy, and the relationship between school, counselor, and
youth gave
rise to a duty on the counselors’ part to use “reasonable means
to
attempt to prevent a suicide when they are on notice of a child
or
adolescent student’s suicidal intent” (Eisel v. Board of
Education of
Montgomery County, 1991), including, at a minimum, a report
to the
student’s parents. The Court listed “foreseeability of harm,”
i.e., a
reasonable person would have been able to recognize that a
student was
in an acute emotional state of distress and in danger of suicide,
as the
prominent factor in determining whether school employees had
a duty
to warn student’s parents (Eisel v. Board of Education of
Montgomery
County, 1991; Friedlander, 2013).
While this was significant regarding the role of school
professionals,

it did not create an absolute precedent of liability for schools.
In fact, the
very same school district cited in the 1991 case was sued just a
few years
later after another student’s suicide in Scott v. Montgomery
County
Board of Education (1997), in which the court did not adhere to
the
precedent of liability for school mental health professionals
(SMHPs). A
federal appellate court upheld the dismissal of the lawsuit
initiated by
the mother of a middle school student who had hanged himself.
The
school psychologist met with the student approximately two
months
prior to the student’s suicide and did not assess him as posing
an im-
mediate danger of self-harm; furthermore, did not report the
informa-
tion to the student’s parents. The court dismissed the mother’s
claims of
negligence as educational malpractice, concluding that the
alleged
causal linkage to the school psychologist was not sufficient
(Scott vs.
Montgomery County Board of Education, 1997; Stone & Zirkel,
2012).
Court cases post Eisel (1991) in many states have continued to
consider school districts or personnel liability for student
suicides.
Friedlander (2013) relayed that among these cases, claims of
negligence
that are grounded in “statutory, regulatory, or district policy for
suicidal

threats and suicide prevention” (Friedlander, 2013) are most
promising
to plaintiffs. Negligence is a breach of duty owed to an
individual
involving injury or damage (suicide) that finds a causal
connection be-
tween a lack of or absence of duty to care for the student and
his/her
subsequent suicide (Stone, 2017).
In Wyke v. Polk County School Board (1997), for example, the
Eleventh Circuit Court of Appeals concluded that the school
board was
liable for the death of 13-year-old Shawn Wyke. Wyke hanged
himself at
his home two days after two failed attempts were completed at
school.
His mother, Carol Wyke utilized the “failure to train theory”
arguing that
5
the lack of suicide prevention/intervention training for the
school
personnel demonstrated a direct indifference to their duty to
care and
protect (Erbacher et al., in press). While the school board
argued that
suicide is an intervening force, the jury found that the school
was

“somewhat aware” of the attempts on campus and made no
efforts to
intervene, i.e., hold the child in protective custody, recommend,
pro-
vide, or obtain protective counseling for the student, or report
the in-
cidents to his parents. Further, the Court concluded that given
the
known attempts, the school personnel had strong reason to
anticipate
the suicide which was thus, foreseeable (Erbacher et al., in
press;
Friedlander, 2013; Wyke v. Polk County School Board, 1997).
Negligence and foreseeability are not the only factors that have
been
identified in determining school liability in student suicides.
Sovereign
immunity, for example, has been used in school related suicide
cases.
Government entities are granted immunity if their conduct does
not
clearly violate constitutional rights of which a reasonable
person would
have known. There is a constitutional right of a duty to protect
students
and state laws require compulsory attendance for students;
however,
legal cases have failed to find that a child’s required attendance
at school
creates a relationship that would mandate a school’s duty to
protect
students. Immunity is based on state law; if the state deems
schools an
arm of the state government, then schools within that state are
granted

sovereign immunity (Erbacher et al., in press).
Additionally, a school can be found in violation of legal re-
sponsibility based on the constitutional rights of the victims,
i.e., state
created danger. The school may be liable if it does not enact or
follow
through with specific policies and procedures, thereby causing
danger to
the student who died by suicide (Erbacher et al., in press;
Sanford v.
Stiles, 2006). Lastly, many school attorneys use the
“intervening force”
argument to defend the school and its personnel, stating that
suicide is a
superseding and intervening force that breaks the direct
connection
between the defendants’ actions, i.e., failure to notify parents,
and the
suicide. In sum, the intervening force is the real reason for the
suicide
that resulted and the longer the timeframe between the possible
negli-
gence of the school and the suicide of a student, the more
logical the
intervening force argument (Erbacher et al., in press).
4.2. Legislation
The major legal implications of youth suicide in the school
context
certainly justify the need for state laws and mandates targeted at
suicide
prevention and intervention in the school setting. In the past,
district-
wide suicide prevention efforts oftentimes only occurred after

the
occurrence of a tragic student death. Currently, a majority of
states
require some type of suicide prevention training for their school
personnel. However, the programming, efforts, and quality vary
state by
state (Kreuze et al., 2017; Singer et al., 2018).
The American Foundation of Prevention for Suicide (AFPS,
2019)
reviewed current state laws in the United States, finding varied
policies
and procedures related to prevention programming. To date, 11
states
require mandated annual training; moreover, 20 states (40%)
also
require mandated training, but without the yearly contingency.
Many
states without mandated training are making efforts to
encourage
training throughout school districts; further, many require the
provision
of suicide prevention and intervention policies and procedures
(AFPS,
2019).
The Garrett Lee Smith Memorial Act (2004) was the first bill
signed
into law pertaining to suicide prevention among young people in
the
United States. It affirmed suicide as national public health
problem and
intended to provide funding to states, tribes, campuses, and
behavioral
mental health services for grants that support prevention and
inter-

vention efforts. In 2007, a hallmark piece of legislation, the
Jason Flatt
Act, was passed in the state of Tennessee, requiring all
educators in the
state to complete 2 h of youth suicide awareness and prevention
training
each year in order to be able to be licensed to teach. The
Tennessee
legislation now serves as the model to introduce the Jason Flatt
Act
(2007) in other states. It’s founders, Jason Foundation Inc. (a
non-profit
agency dedicated to bringing suicide prevention awareness and
educa-
tion to schools), report that to date, 20 states have adopted the
act
(although each state’s requirements vary [AFPS, 2019]) and
have been
supported by the state’s Department of Education and the state’s
Teacher’s Association, highlighting the value observed in such
preven-
tative training (Erbacher et al., in press; JasonFoundation,
2019).
AFPS (2019) is dedicating major advocacy efforts toward the
adop-
tion of the Jason Flatt Act (2007) in states that are still lacking
in legal
mandates for suicide prevention. For these states, AFPS has
created a
model legislation that can be used as a guide for individuals
who would
like to lobby for the passage of this type of training. Lobbyists
and ad-
vocates report frustrations in their continued efforts,

particularly
regarding the language used in the adoption of policies and
procedures.
One critique, for example, is the state’s use of the word
“recommended”
instead of “required” in suicide training for schools (Lieberman
&
Poland, 2017). Nevertheless, ongoing pursuits for mandated
prevention
programming and training for school personnel are imperative,
as they
have been demonstrated as significant lifesaving and life
changing
legislation.
5. Addressing youth suicide in the school context
The content reviewed thus far has set forth a solid foundation
for the
argument that increased attention must be dedicated to youth
suicide in
the school context. Comprehensive research on broad suicidal ity
has
acted as a crucial guide to informing professionals and the
general
public, creating more awareness and understanding surrounding
the
topic. It has generated helpful statistics that shed light upon
specific
factors that are associated with suicidal behaviors in children
and ado-
lescents. The identified risk factors discussed are key findings
that
inform suicide response practices in the school setting; best
practices to
target youth suicide include health promotion, prevention,

intervention,
and postvention (Gould et al., 2003; Katz et al., 2013).
5.1. Prevention
The World Health Organization (WHO, 2019) emphasizes the
fact
that while suicide is a significant public health concern, it is
one that is
preventable, with timely, evidence-based and at times,
affordable in-
terventions. The conceptualization of youth suicide as a public
health
problem prompted the United State to adopt a public health
model of its
prevention. “The public-health approach focuses on identifying
patterns
of suicide and suicidal behaviors in a group or population. It
aims at
changing the environment to protect people against diseases and
changing the behaviors that put people at risk of getting them”
(p. 118,
Yip, 2011). While suicide is not considered a “disease” in the
traditional
sense, it is a significant public health concern. Moreover, given
the legal
implications discussed and the very real preventability of such
tragic
deaths, school personnel, specifically SMHPs, must understand
the
importance implementing suicide prevention programs via the
lens of
public health in order to reduce suicide risk and suicide rates
among the
adolescent population (Lieberman et al., 2014).

Prevention strategies for this population are traditionally
completed
in three domains, including community, healthcare systems, and
school.
The primary goal of prevention programs is to reduce the
prevalence of
suicidal behavior in the youth population (Katz et al., 2013).
Ancillary
goals include identification of at-risk individuals and the
completion of
appropriate referrals and treatment targeting risk factor
reductions
(Gould & Kramer, 2001; Gould et al., 2003). Given the sheer
amount of
time that youth spend in the school setting, school-based
programs have
been suggested as being perhaps the most effective way to reach
this
population (Calear et al., 2016; Miller et al., 2009).
5.1.1. School suicide prevention programs
A variety of school-based suicide prevention programs exist;
6
however, systematic reviews reveal that the field has yet to find
a
definitive, evidence-based, best practice guideline (Calear et
al., 2016;
Gould et al., 2003; Katz et al., 2013). While prevention

programming
varies across design, methods, and implementation, common
recom-
mendations are observed across the literature. AFPS (2019) has
devel-
oped four evidence-based frameworks for youth in the U.S. for
ensuring
success of suicide prevention strategies, including gatekeeping
(i.e.,
training those considered to be natural helpers to recognize
signs and
symptoms of suicide [Katz et al., 2013]), psychoeducation,
restriction to
access of lethal means, and provision of mental health treatment
to
students with depression and/or anxiety disorders, or those at
risk for
such disorders (Lieberman et al., 2014). Additionally, the U.S.
Depart-
ment of Health and Human Services Substance Abuse and
Mental Health
Services Administration (SAMHSA, 2012), has developed
“Preventing
Suicide: A Toolkit for High Schools” that outlines a plan on
how to
educate school personnel, students, and parents on youth suicide
and
related behaviors. Lieberman et al. (2014) relayed that
SAMHSA’s
guidelines are highly regarded methods that target the
identification of
at-risk youth and the use of appropriate protocols for these
students.
Additionally, the toolkit offers suggestions for evidence-based
suicide
prevention programs that are well matched for the school setting

(SAMHSA, 2012).
Katz et al. (2013) comprehensive systematic literature review
examined a number of school-based suicide prevention
programs,
including, but not limited to suicide awareness curricula,
general skills
training, and peer leadership. Ultimately, the investigators
concluded
that while there are numerous available programs, few are
evidence
based; importantly, the research lacks randomized controlled
trial (RCT)
studies that evaluate their effectiveness on the outcome of
suicide.
Suggestions for best practices include the combined use of
multiple
programs in order to address the varied and complex needs of
youth
suicide in the school context.
Cooper et al. (2011) drew similar conclusions in their
systematic
review of high school-based suicide prevention programs in the
United
States, in which they recommended a hybrid approach that
includes
elements from the various programs reviewed. Of note, the
authors re-
ported that across the most commonly used programs, four types
were
isolated, including enhancement of protective factors, screening
tools,
gatekeeper trainings, and curriculum based. Programs that
enhance
protective factors were described as those that aim to identify

problem
solving skills, means to adaptively cope, and the promotion of
devel-
opmentally appropriate mental health. As mentioned previously,
gate-
keeping utilizes a training approach in which school personnel
and
sometimes peers work to increase their skills related to the
identification
of and response to suicidal behavior in the school environment.
Addi-
tionally, screening methods, such as depression screening tools,
are used
to gain objective measures of student self-report of suicidality
and
related risk factors. Lastly, curriculum-based programs
emphasize the
importance of addressing mental health factors, including the
use of
training materials that educate school personnel on suicidality
and at
risk-youth (Condron et al., 2015; Cooper et al., 2011). Kalafat
(2006)
highlighted that while aspects of these programs are critical
components
of effective suicide prevention planning, there is little evidence
to prove
they are effective as stand-alone programs; however, these four
cate-
gories warrant deeper review, including a brief discussion of
existing
programs that fall within respective types of prevention
programming.
5.1.2. Enhancement of protective factors
Common protective factors for at risk youth have been

identified,
including family cohesion and stability, strong coping and
problem-
solving skills, positive self-worth, connections to school and
extracur-
ricular participation, academic success, and enhanced impulse
control
(WHO, 2014). Self-esteem and social support are two critical
protective
factors that buffer the risk of suicide. When the availability of
peer and
family support is present, suicide risk decreases, as self-esteem
increases
(Eisenberg & Resnick, 2006; Kleiman & Riskind, 2013; Sharaf
et al.,
2009). Further, stronger levels of resiliency have been found in
in-
dividuals with higher self-esteem (Sharaf et al., 2009). These
factors are
significant in the conceptualization of youth suicide prevention
plan-
ning and can be enhanced in programs that emphasize protective
fac-
tors. Kalafat (2006) reported that research findings (Jessor et
al., 1995)
have demonstrated that prevention strategies targeting the
enhance-
ment of protective factors may be more effective than those that
address
risk factors. Despite this, such programs are not recommended
as lone
practices, as they do not fully account for the complex needs
present in
youth suicidality.

Promoting CARE, for example, is a school and home-based
program
that primarily targets the enhancement of protective factors
(i.e., per-
sonal and social resources) in suicide-vulnerable high school
youth. It
incorporates principles of behavior change maintenance as
means to
increase skills acquisition, motivation, social support, and self-
efficacy.
The program implements strategies aimed to decrease negative
behav-
iors via the improvement of emotional management,
interconnected-
ness, and coping skills. Its design is based on the empirical
findings that
have demonstrated that interventions that emphasize motivation
to
change, social support access, and self-efficacy (i.e., the
confidence that
an individual is equipped with the ability to face life challenge
and ac-
cess learned skills), increase the likelihood of skill acquisition,
behav-
ioral change, and continued maintenance of change (Cooper et
al., 2011;
Hooven et al., 2010; Hooven et al., 2012).
Hooven et al. (2010) analyzed the longitudinal data of the long-
term
maintenance of achieved short-term changes of 615 high school
youth
and their parents, all of whom had participated in the Promoting
CARE
program in the United States. A review of the identified at-risk

States with Higher Mental Healthcare Capacity Have Lower Youth Suicide Rates

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