screening for mental health needs

Screening for Mental Health Needs

Hope M. Siler, MSW, LSW

ASPEN Project Regional Director

www.wvaspen.com

OBJECTIVES

• Participants will be introduced to SAMHSA’s “Preventing Suicide: A High School Toolkit”

• Participants will learn the significance of suicide as a public health concern

• Participants will learn to utilize tools for screening for mental health (PHQ-9, ASAP-20)

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Preventing Suicide:A Toolkit for High Schools

This tool will help schools and communities:• Assess their ability to prevent suicide among

students and respond to suicides that may occur• Understand strategies that can help students

who are at risk for suicide• Understand how to respond to the suicide of a

student or other member of the school community


Preventing Suicide:A Toolkit for High Schools

• Identify suicide prevention programs and activities that are effective for individual schools and respond to the needs and cultures of each school’s students

• Integrate suicide prevention into activities that fulfill other aspects of the school’s mission, such as preventing the abuse of alcohol and other drugs.


Why Suicide Prevention in Schools?

Many high school students reported that they had seriously considered suicide in the past year

CDC,

2010a



Suicide is the third leading cause of death among teenagers in the United States

CDC, 2009



One out of every 53 high school students (1.9 percent) reported having made a suicide attempt that was serious enough to be treated by a doctor or a nurse

CDC,

2010a



1. Maintaining a safe school environment is part of a school’s overall mission.

– Many activities designed to prevent violence, bullying, and the abuse of alcohol and other drugs can also reduce suicide risk among students (Epstein & Spirito, 2009).

– Programs that improve school climate and promote connectedness help reduce risk of suicide, violence, bullying, and substance abuse (Resnick et al., 1997; Blum, McNeely, & Rinehart, 2002).




– Efforts to promote safe schools and adult caring also help protect against suicidal ideation and suicide attempts among LGB youth (Eisenberg & Resnick, 2006).

– Some activities designed to prevent suicide and promote student mental health can reinforce the benefits of other student wellness programs.




2. Students’ mental health can affect their academic performance. – 1 out of 5 high school students receiving grades

of mostly D’s and F’s attempted




2. Students’ mental health can affect their academic performance.

3. A student suicide can significantly impact other students and the entire school community. – Knowing what to do following a suicide is critical to

helping students cope with the loss and prevent additional tragedies that may occur.

– Adolescents can be susceptible to suicide contagion


Why Suicide Prevention in Schools?1. Maintaining a safe school environment is part of a school’s overall

mission.2. Students’ mental health can affect their academic performance.3. A student suicide can significantly impact other students and the

entire school community.

4. Schools have been sued for negligence for the following reasons– Failure to notify parents if their child appears to be suicidal – Failure to get assistance for a student at risk of suicide – Failure to adequately supervise a student at risk


(Doan, Roggenbaum, & Lazear, 2003; Juhnke, Granello, & Granello, 2011; Lieberman, 2008–2009; Lieberman, Poland, & Cowan, 2006)

How Schools Can Prevent Suicides

• Protocols for helping students at risk of suicide




• Protocols for responding to suicide death





• Staff education training






• Parent education







• Student education







• Student education

• Screening


Chapter 1GETTING STARTED

The two essential components that every school should have in place are:

• Protocols for helping students at possible risk of suicide (PREVENTION)

• Protocols for responding to a suicide death (POSTVENTION)



Step 1. Engage administrators, school boards, and other key players. – Explain why it is important to address suicide

risk among students. – Highlight data and information specific to your

district, State, or tribe. – Share your plans.


SCHOOL STAFF RESPONSIBILITIES

Superintendent * Curriculum director * Principal

Assistant principal * Teachers * Technology staff Health

educator * Athletic staff * School nurse

School health coordinator * school counselor

Guidance counselor * School social worker

Student assistance program staff * pupil services

School psychologist * Special education staff

Members of the Crisis Response * school resource officer

School-based health center and/or mental health center staff



Step 2. Bring people together to start the planning process. – Engage school staff. – Engage community partners



COMMUNITY PARTNERSCommunity Youth Center * Cultural Communities Leaders Mental health providers * Community mental health agencies

Substance abuse counselors * Crisis center workers Healthcare providers * Community health department staff

Hospital, ER staff * EMT’s * Fire & Rescue personnel First responders * Coroner

Police * Clergy * County social services staff Child welfare providers * Juvenile justice professionals

Media representatives * Immigrant & Refugee organization staff LGBT youth–serving program staff * YMCA * Boys & Girls Club



Step 3. Provide key players with basic information about youth suicide and suicide prevention.


RISK FACTORS

• Behavioral Health Issues/Disorders

• Personal Characteristics

• Adverse/Stressful Life Circumstances

• Risky Behaviors

• Family Characteristics

• Environmental Factors


RISK FACTORS

• Behavioral Health Issues/Disorders– Depressive disorders– Substance abuse or dependence– Conduct/disruptive behavior disorders– Other disorders (anxiety, personality, etc.)– Previous suicide attempts– Self-injury (without intent to die)– Genetic/biological vulnerability


RISK FACTORS

• Personal Characteristics– Hopelessness– Low self-esteem– Loneliness– Social alienation and isolation, lack of belonging– Low stress and frustration tolerance– Impulsivity– Risk-taking, recklessness– Poor problem-solving or coping skills– Perception of self as very underweight or very overweight– Capacity to self-injure– Perception of being a burden


RISK FACTORS

• Adverse/Stressful Life Circumstances– Interpersonal difficulties or losses– Disciplinary or legal problems– Bullying, either as victim or perpetrator– School problems– Physical, sexual, and/or psychological abuse– Chronic physical illness or disability– Exposure to suicide of peer


RISK FACTORS

• Risky Behaviors – Alcohol or drug use– Delinquency– Aggressive/violent behavior– Risky sexual behavior


RISK FACTORS

• Family Characteristics– Family history of suicide or suicidal behavior– Parental mental health problems– Parental divorce– Death of parent or other relative– Problems in parent-child relationship


RISK FACTORS• Environmental Factors

– Negative social and emotional environment– Lack of acceptance of differences– Expression and acts of hostility– Lack of respect for the cultures of all students– Limitations in school physical environment– Weapons on campus– Poorly lit areas conducive to bullying and violence– Limited access to mental health care– Access to lethal means, particularly at home– Exposure to other suicides, leading to suicide

contagion– Exposure to stigma and discrimination


PROTECTIVE FACTORS

• Individual Characteristics and Behaviors

• Family and Other Social Support

• School

• Mental Health and Healthcare Providers and Caregivers

• Access to Means


WALL OF RESISTANCEWALL OF RESISTANCE

www.wvaspen.com There is HOPE. Ask for HELP. Choose LIFE. Suicide Prevention Lifeline 1-800-273-TALK (8255)

WARNING SIGNS“IS PATH WARM”

• I…ideation• S…substance abuse• P…purposelessness• A…anxiety• T…trapped• H…hopelessness• W…withdrawal• A…anger• R…recklessness• M…mood changes (sudden, positive or negative)


Suicide Crisis Episode

Years Days Hours Days Years

Ris

k Le

vel

Stable Stable

Hazard Encountered

Crisis Begins

Crisis Peaks

Risk Imminent

Crisis Diminishes

Plus or minus three weeks www.wvaspen.com There is HOPE. Ask for HELP. Choose LIFE. Suicide Prevention Lifeline 1-800-273-TALK (8255)

The Many Paths to Suicide

WA

LL OF

RE

SIS

TA

NC

E

Fundamental Risk Acute Risk Cause of Death

Biological

Personal/Psychological

Environmental

Increased hopelessness serious contemplation

Poison

Firearm

Hanging

Jumping

Autocide


Stopping the chain reaction anywhere = PREVENTION

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NATIONAL DATAAges 13-19

• 2009, 1,852 young people died by suicide

• Suicide is the 3rd leading cause of death

• For every completed suicide death, there is 100-200 attempts (1 every 60 seconds)

• For every suicide death, there is at least 6 survivors left behind


NATIONAL DATAYRBS Report

• 1/53 high school students reported having made a suicide attempt that was serious enough to be treated by a doctor or nurse

• 1/16 high school students reported having attempted suicide at lease once.

• 1/9 had made a plan about how to attempt suicide

• 1/7 reported having seriously considered attempting suicide during the preceding 12 months


West Virginia Data15-24 Years

2000-2009

www.wvaspen.com Suicide Prevention Lifeline 1-800-273-TALK (8255)

Ask for HELP.

Choose LIFE.

There is HOPE.

Barbour

Berkeley

Boone

Braxton

Brooke

CabellClay

Fayette

Gilmer

Grant

Greenbrier

Hampshire

Hancock

Hardy

Harrison

Jackson

Kanawha

Lewis

Lincoln

Logan

McDowell

Marion

Mason

Mercer

Mineral

Mingo

Monongalia

Monroe

Morgan

Nicholas

Ohio

Pendleton

Pocahontas

Preston

Putnam

Raleigh

Randolph

Ritchie

Roane

Summers

Taylor

Tucker

Tyler

Upshur

Wayne

Webster

Wetzel

Wirt

Wood

Wyoming

JeffersonPleasantsDodd-ridge

Cal-houn

4 (12.26)

4 (12.56)

7 (10.81))

12 (29.79)

Marshall

10 (3.97)

5 (26.13)

4 (19.02)

2 (10.22)

3 (15.30)

4 (34.13))

2 (12.97)

2 (16.07)

3 (20.28)

7 (20.00))2 (7.78)

3 (18.15)

11 (9.89)

2 (20.60)

3 (26.51)

18 (10.32)4 (30.34)

47 (20.96))

9 (20.92)

2 (6.79)

10 (10.55)

2 (13.69)3 (8.81)

8 (20.23))

6 (9.75)

West Virginia Suicides by countyAges 15-242000-2009

Rate per 100,000 Population

WV Average Rate 13.2/100,000320 Deaths by Suicide

18.15 – 46.92

12.26 – 16.39

10.07 – 11.34

0.00 – 9.89

Suicide:

A PREVENTABLE DEATH IN OUR STATE

5 (46.92)

12 (160.5)

4 (14.53)

2 (22.25)

2 (6.68)

1 (13.19)

5 (15.89)

6 (16.39)

1 (9.88)

3 (9.01)

1 (5.34)0 (0.00)

16 (27.19)

13 (15.36)

1 (3.47)

3 (8.30)

3 (10.07)

4 (10.52)

10 (16.14)

11 (12.38)

0 (0.00)

1 (13.66)

10 (9.68)

5 (9.63)

0 (0.00)

2 (11.34)


Chapter 1 GETTING STARTED

Step 4: Develop your overall strategy.– Assess your current policies, programs and

school culture


No one is safe from the risk of suicide – wealth,

education,

intact family, or

popularity

cannot protect us from this risk


Chapter 2PROTOCOLS FOR HELPING STUDENTS

AT RISK FOR SUICIDE

WHY IS IT IMPORTANT TO BE PREPARED TO HELP STUDENTS AT RISK OF SUICIDE?



AT RISK FOR SUICIDE

Why is it important to be prepared…?• Maintain a safe and secure school environment

• Promote the behavioral health of students, which enhances their academic performance

• Avoid liability related to suicides or suicide attempts by students



AT RISK FOR SUICIDE

• Suicide risk resources• Self-injury and suicide risk information• Guidelines for notifying parents• Parent contact acknowledgement form• Guidelines for student referrals• Student suicide risk documentation form• Protocol for responding to a student suicide attempt• Guidelines for facilitating a student’s return to school


Chapter 3AFTER A SUICIDE

• Immediate response protocol• Sample script for office staff• Sources of postvention consultation• Guidelines for working with the family• Guidelines for notifying staff• Sample announcements• Sample letter to families• Talking points for students and staff after a suicide• Guidelines for Memorialization• Guidelines for working with the media• Long-term response protocol• Guidelines for anniversaries of a death


Chapter 3AFTER A SUCIDE

• Key Terms:– Survivor: a person who has experienced the suicide

of a family member, friend, or colleague– Attempt survivor: a person who attempts suicide but

does not die – Postvention: refers to programs and interventions for

survivors following a death by suicide– Suicide contagion: is “a process by which the

suicide or suicidal behavior of one or more persons influences others to commit or attempt suicide” (Davidson and Gould, 1989)


Chapter 4STAFF EDUCATION & TRAINING

• All staff should be…– Aware of risk of suicide– Aware that the school is taking steps to

reduce suicide risks– Trained to recognize the warning signs– Able to take action if they become aware of a

student who displays suicide warning signs


Chapter 4STAFF EDUCATION & TRAINING

• NREPP (National Registry for Evidenced-Based Prevention Practices) Gatekeeper Trainings:– Lifelines

• BPR (Best Practice Registry) Gatekeeper Trainings:– QPR (Question, Persuade, Refer)– More Thank Sad– safeTALK– ASIST


Chapter 5PARENT/GUARDIAN EDUCATION & OUTREACH

• Education and outreach programs– NREPP (National Registry for Evidenced-Based Prevention Practices)

• Lifelines

– BPR (Best Practice Registry)

• Not My Kid (17-minute video online)

• Facts For Parents (handout)– Designed to educate and gain support for

implementation of initiatives


Chapter 5PARENT/GUARDIAN EDUCATION & OUTREACH

• Effective programs should include…– Identifying students at possible risk and referring them

to appropriate services– Responding appropriately to a suicide death– Providing training and suicide awareness education

for staff– Educating parents regarding suicide risk and mental

health promotion– Educating and involving students in mental health

promotion and suicide prevention efforts– Screening students for suicide risk


Chapter 6STUDENT PROGRAMS

• Types of programs (3):– Curricula for all students

• Provide information about suicide prevention• Promote positive attitudes• Increase student’ ability to recognize if they or their

peers are at risk for suicide• Encourage students to seek help for themselves

and their peers



• Types of programs:– Skill-building programs for at-risk students

• Help protect at-risk students from suicide by – Building their coping, problem-solving, and cognitive

skills– Addressing related problems such as depression and

other mental health issues, anger, and substance abuse



• Types of programs:– Peer leader programs

• Teach selected students skills to identify and help peers who may be at risk.

• Some teach connectedness among students and also between students and staff


Chapter 7SCREENING

• Ideas for maximizing parental response rate

• Screening programs– NREPP (National Registry of Evidenced-Based Prevention Practices)

• www.sprc.org/bpr/section-i-evidence-based-programs

• SOS Signs of Suicide

– BPR (Best Practice Registry)

• www.sprc.org/bpr/section-iii-adherence-standards • More Than Sad


http://www.sprc.org/bpr/section-i-evidence-based-programs

http://www.sprc.org/bpr/section-i-evidence-based-programs

http://www.sprc.org/bpr/section-iii-adherence-standards

Chapter 7SCREENING

• Identifying Students at Risk, Alternatives:– Academic achievement– Effort– Conduct– Attendance– Negative report card comments– Code of student violations– Involvement with school police


Chapter 7SCREENING

• Active Parental Consent– Definition: a student can participate only if the parent

gives explicit permission, in writing– Pros: ensures parents are informed and their

approval is obtained. This engagement increases the likelihood that parents will help their child obtain treatment, if it is needed.

– Cons: often difficult to get responses from parents and takes more staff time; fewer students likely to be screened.


PHQ-9 Screening Questionnaire


•The Patient Health Questionnaire Modified for Teens (PHQ-9 Modified) can be used with patients between the ages of 12 and 18 and takes less than five minutes to complete and score.

•Patients should be informed of their confidentiality rights before the PHQ-9 Modified is administered.

PHQ-9 Screening QuestionnaireSCORING…

• For every “X”– Not at all = 0– Several days = 1– More than half the days = 2– Nearly every day = 3

• Add up all the “X”ed boxes = total score

• Total score > 11 are POSITIVE



• Regardless of the PHQ-9 Modified total score, endorsement of serious suicidal ideation OR past suicide attempt (questions 12 and 13 on the screen) should be considered a positive screen.



INTERPRETATION…

• The questionnaire indicates only the likelihood that a youth is at risk for depression or suicide; its results are not a diagnosis or a substitute for a clinical evaluation.



DEPRESSION…

• The overall score on the PHQ-9 Modified provides information about the severity of depression, from minimal depression to severe depression.



• Total Score: Depression Severity• 1–4: Minimal depression• 5–9: Mild depression• 10–14: Moderate depression (≥ 11 = Positive

Score)• 15–19: Moderately severe depression• 20–27: Severe depression


ASAP-20Adolescent Suicide Assessment Protocol

• 20 items divided into 5 subgroups– Historical items (#1-4)– Clinical items (#5-9)– Specific suicidality items (#10-12)– Context items (#13-18)– Protective factor items (#19-20)

• Other considerations



Actions Taken1. Continue monitoring risk factors 2. Notify family 3. Notify/consult with supervisor 4. Recommend/refer to outpatient treatment 5. Recommend/refer to psychiatric consult/med evaluation6. Contract for NO SUICIDAL behaviors 7. Recommend elimination of access to firearms/poisons 8. Notify legal authorities &/or CPS of risk to self/or others 9. Recommend/refer to day treatment 10. Recommend/refer to crisis unit/voluntary hospitalization 11. Initiate involuntary hospitalization 12. Other:



• SCORING…– No = 0– Mild = 1– Moderate = 2– Severe = 3

– Risk level (total score of all 20 items)• Low = 0-15• Medium = 16-19• High = 20+


QUESTIONS or THOUGHTS

wvsuicidecouncil.orgwvaspen.com

sprc.orgafsp.org

spanusa.orgsuicidology.org

jasonfoundation.orgthetrevorproject.orgjedfoundation.org

Suicide Prevention Lifeline1-800-273-TALK (8255)

RESOURCES

www.wvaspen.com

Your willingness to listen and to help can rekindle hope.

HOPE MAKES ALL THE DIFFERENCE.

screening for mental health needs

Documents

student suicide

suicide risk

risk of suicide

suicide attempts

significance of suicide

safe schools

schools mission

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