67 Suicide awareness and mental health among youth in the community: Exposing dark secrets: what must be told

In this chapter, we propose a strategy for increasing the likelihood of identifying youth who are experiencing serious emotional difficulties, which would place them at risk for suicide. Admittedly, current knowledge of the multiple causes of youth suicide remains incomplete, and the scant, currently available mental health resources to address this problem are generally woefully inadequate to meet the need. The situation is even worse in under-resourced environments throughout the world, where there is an acute lack of all mental health services for youth. New efforts are called for. Raising awareness of children's mental health among important youth stakeholders, parents, teachers, and youth themselves, and increasing help and treatment-seeking behaviours, holds out the potential to help reduce unnecessary deaths by suicide in youth.

Over the past four decades, the large productive and fertile opus of work carried out by research suicidologists has significantly advanced understanding of the multifaceted underpinnings of suicide, involving predisposing proclivities and associated neurobiological and genetic factors, history of mental illness, and other commonly identified risk factors established by conducting psychological autopsies of completed suicides (Ford et al. 1984; Shafii et al. 1984; Mann and Arango 1999). Prior suicide attempt, substance use, depression, bipolar disorder, and a pervasive senseof hopelessness, have all been found to be disproportionately represented in teen suicides (Ford et al. 1984; Shaffer 1988). Culture, race/ethnicity, religion and philosophical view of life's meaning also contribute to suicide vulnerabilities (Beautrais et al. 1996; Kleinman 2004; Timmermans 2005; Patel et al. 2006; Lee et al. 2007; WHO 2007; Yang et al. 2007). Yet, tempering this air of confidence over how we might benefit from what is known about these associated precursors to prevent suicides are bold data indicating our current failure to do so: to wit, while there are approximately 150,000 suicide attempts by teenagers reported each year in New York State, and only 70 completed suicides, we have had but little success in identifying the 70 beforehand (Carpinello 2005). Bertolote et al. (2003) in a British Journal of Psychiatry editorial, asked: ‘Do we know enough about the relationship of suicide and mental disorders?’ continuing with a discussion of what we can say with confidence that we do know, and what we do not know.

Raising awareness about mental illness and related issues among youth has historically been viewed as inadvisable, even dangerous by creating a risk of improper labelling, based on misapplication of scant information by untrained individuals, thereby stigmatizing persons who only seem to fit little understood categorizations of mental disorder. Further, it has been feared that by raising issues of suicidal behaviour, it could, in consequence, spawn ‘copycat’ behaviour (Coleman 1987, 2005), and actually contribute to increased suicides (Shaffer et al. 1996). Gould et al. (2005), however, in a randomized control trial of suicide screening, which probed for suicidal ideation and behaviour, report no evidence of iatrogenic effects from suicide screening among high school students, and conclude that such screening is a safe component of youth suicide prevention efforts (Mann et al. 2005). Yet, one cannot ignore or turn a blind eye to the fact that copycat behaviour does indeed exist, especially after acts involving celebrities, or ones which gain international attention (Coleman 1987, 2005). Similarly, the popularity of committing suicide at a ‘favourite’ places such as San Francisco's Golden Gate Bridge are well-documented (Friend 2003), as well as instances of wearing black frocks in committing school shootings, copying the behaviour of the well-publicized Colorado shooting at Columbine High School (Coleman 2005).

Notwithstanding the advances that have been made in understanding precursors to suicide, we have seen that throughout the world the number of completed youth suicides, while decreasing in some countries and among select subpopulations, continues to increase in many countries (Moscicki 1999; Bertolote et al. 2003; Mittendorfer-Rutz et al. 2004). On five continents, youth suicide remains the third leading cause of mortality, following deaths from accidents and homicide (Moscicki 1999; Wasserman et al. 2005; WHO 2007). In response, efforts to stay the hand of those who would self-destruct must typically employ a spectrum of different approaches, and address this important, seemingly intractable problem in different ways and from different directions (Wasserman 2001).

In a poignant examination of the difficulty of preventing a specific suicide, in Autopsy of a Suicidal Mind, Edwin Shneidman (Shneidman 2004) convincingly demonstrates the importance of conducting a psychological autopsy to glean the perspective of a number of individuals familiar with the life of a suicidal individual, so as to best understand why an untimely death happened, and more importantly, how it might have been prevented (Fisher and Shaffer 1984). Shneidman interviews relatives and close associates of the suicide victim: mother, father, elder brother, elder sister, lifelong best friend, ex-wife, current girlfriend, childhood psychotherapist, and current attending physician. In addition, he provides transcripts of these interviews, as well as the suicide note left by the deceased, for analysis and opinion to eight eminent suicidologists (Shneidman 2004). His, which is that of examining separate accounts, is reminiscent of the famous Japanese story Rashomon, where the telling of an event (an attempted rape and murder of the helpless husband) is remembered differently by each of the persons involved. Perspectives, after all, do differ, and a true picture often requires listening to more than a single point of view. Wasserman (Wolk-Wasserman 1986; Wasserman 2001) and Leenaars (Leenaars 2004) support this multiple-informant approach to revealing aspects of an individual who might be at risk for suicide.

Shneidman's (2004) account of a failure to prevent suicide in a carefully monitored person, who had had a history of prior attempts beginning at age 9 and a later suicide-related hospitalization, seems to augur against relying solely on professionals for information and intervention. While the victim and subject of Shneidman's book (Shneidman 2004) was himself a physician and lawyer, and presumably reasonably well-informed about suicide, there is a suggestion from those contributing information to his psychological autopsy that if their own unique and individual perspectives had been sought and shared with clinical staff, it might have been possible to prevent his specific suicide.

All too often, formal efforts designed to stem the tide of the increasing number of suicides are sorely under-funded and restricted to a one-dimensional focus, skirting the potential for a more effective, albeit more complex, comprehensive approach to suicide prevention. For example, Mann et al. (2005), suggest that a corrective approach involves better education of physicians about suicide as well as restricting access to lethal means: these are the best-known preventative methods, while public education, screening programmes, and media education are experimental and need more testing before implementation. While it is clear that more testing is good, it seems that so long as no known harm is involved, preventative methods through education are warranted. Methods of informing their youth about suicide have produced substantial evidence of efficacy (Gould et al. 2005) and should be used through expanded outreach (WHO 2007).

The greatest problem encountered in combating suicide is that it is extraordinarily difficult to successfully identify exactly which at-risk individuals who, without intervention, will be suicide completers (Beautrais et al. 1996; Pfeffer 2003; Timmermans 2005; Steele and Doey 2007). After all, only a minute fraction of youth who have experienced suicide ideation will actually become a suicide statistic (Carpinello 2005; Brezo et al. 2007). Further, while it is true that those who attempt suicide are at greater risk of dying by suicide, from an epidemiological point of view, attempted and completed suicide are considered to be quite different phenomena (Hawton and Heeringen 2000). What additional activities might be used to increase the chances that those youth who are most likely to choose to end their lives will be correctly identified, and their demise prevented?

Below, we describe a nine-country pilot study of mental health awareness campaigns, with suicide awareness issues embedded, offered in schools, simultaneously reaching out to students, teachers and parents—all key stakeholders of youth—who should also be allied in helping those they perceive to be at suicidal risk.

Based on the knowledge of worldwide deficiencies in understanding and addressing children's mental health needs, the World Psychiatric Association (WPA) developed a Presidential Program during 2002–2005 on Global Child Mental Health (initiated by WPA President at that time, under the leadership of Ahmed Okasha), a three-pronged initiative in 2002–2005 to address children's mental health, carried out in collaboration with the World Health Organization (WHO) represented by Norman Sartorius and the International Association of Child and Adolescent Psychiatry and Allied Professions (IACAPAP) represented by Myron Belfer. The Geneva Initiative in Psychiatry (GIP) supported the participation of the Azerbaijan and Georgian sites in the nine-country study at the same financial level as the seven WPA sponsored sites. This was the first major initiative by the WPA to specifically address mental health needs of children. Three multinational task forces were established to carry out the agenda: awareness (Sam Tyano, Israel, Chair), services (Peter Jensen, USA, Chair), and prevention (Helmut Renschmidt, Germany, Chair), with each task force functioning essentially independently. The mission of the awareness task force was to test ways of increasing knowledge of children's mental illness in general, while building on what had previously been learned from WHO's International Stigma Campaign (Sartorius and Schulze 2005).

The awareness task force took the position that, ethically, child mental health information should not be withheld, but shared with the public, especially key stakeholders, parents, teachers and the youth themselves. Further, it was agreed by the task force that it would challenge the approach of turning solely to child psychiatrists as the only reliable and acceptable professionals to be entrusted to advance child mental health. In under-resourced environments, this approach severely constricts public knowledge about child mental health, so that instead of helping to ameliorate mental health-related stigma, actually perpetuates it. With relying on so scarce a body of professionals, the worldwide shortage of child psychiatrists, an approach perpetuates failure to address the feelings of isolation and despair prevalent among youth, which, all too often, increases risk for suicide. Consequently, the awareness task force mandate was to develop child and adolescent mental health awareness campaigns, in order to increase the public's knowledge and understanding of child and adolescent mental illness and suicide. It was felt that this knowledge would open pathways of communication among essential stakeholders, so as to reach those at risk for self-destructive or suicidal behaviour. Clearly, this approach is consistent with the need to prepare the next generation with the appropriate understanding and knowledge they will need to confront the significant burden of mental illness in the future (WHO 2007). Enlisting key stakeholders: parents, teachers, as well as the youth themselves, is emblematic of the task force approach.

The awareness task force study was designed for and carried out in Armenia (Yerevan), Azerbaijan (Baku), Brazil (Porto Alegre), China (Shanghai), Egypt (Alexandria), Georgia (Tbilisi and Rustavi), Israel (North), Russia (Chernoprudsky), and Uganda (Kampala), each under the direction of a local psychiatrist, based on a pre- and post-assessment design. A baseline assessment of students, parents and teachers, based on self-report questionnaires, was to be conducted first. This was to be followed by a locally designed awareness campaign, developed from the Awareness Manual (Hoven et. al 2008)and conducted for two weeks to one month. One month after the end of the campaign, a post-assessment questionnaire of students, parents and teachers was to be administered. The Study Procedures Manual, developed specifically for this study, was distributed to and guided the research activities at each site (Hoven et al. 2004b).

Questionnaires were developed to assess the effect of the campaigns on the mental health awareness of students, parents and teachers. Each of the questionnaires, as well as the Awareness Manual, Procedures Manual (Hoven et al. 2004a) and the Data Entry Manual (Musa et al. 2004), were translated and back-translated for use in the eight local languages of the study: Armenian, Arabic, Azeri, Chinese, Georgian, Hebrew, Portuguese and Russian.

Prior to launching the study, staff at each site were trained in the facets of study methodology using the Procedures Manual. Training was assisted by Columbia University staff, either in person or via telephone-conference calls. Each site deliberated how to best conduct the pre-awareness campaign to fit their particular milieu. The child assessment was based on the self-report questionnaires, which were initially distributed to students in randomly selected classrooms in schools enrolling youth ages 10–11-years old, and students 16–17 years of age. To standardize these efforts, the procedures manual detailed the methodology for selecting a stratified sample of schools according to size and location (urban or rural), as well as providing detailed instructions for selecting classrooms in each school to capture samples for both youth age groups of interest. Instructions for random sampling included training on the use of provided tables of random numbers.

The target sample for youth was 400 per site, 200 per age group or N = 3600. Student questionnaires were to be completed during one classroom session; parent questionnaires were to be completed at the school, if possible, or sent home and brought back to school by the students. Teacher questionnaires were to be distributed and collected by study personnel. Study participants were assured that all information would be kept confidential. Institutional Review Board approvals were obtained at the study coordinating site (Columbia University) and at each of the nine country sites.

The Web was used for dissemination of information, data entry programmes and the transmission of study manuals. A Web-based email link facilitated exchange of information and questions. All data were was double entered and transmitted to the study coordinating centre (Columbia University) for analysis.

The WPA-WHO Awareness Manual (Hoven et al. 2004b) was developed for use in child mental health awareness campaigns, and was designed so that it could be adapted locally and administered by either a psychiatrist or other well-trained mental health providers. The manual was designed to inform and guide the campaigns by providing five critical elements: purpose and contextual issues for planning a campaign; mental health content areas; selection of target populations; campaign implementation methodologies, and an annotated reference of websites and other resources. The informational content explores a range of important issues, including healthy child development, mental retardation and epilepsy, as well as common childhood psychiatricdisorders, e.g. depression, anxiety, conduct disorders, PTSD, substance abuse and schizophrenia. Suicide was intentionally folded in as an area to focus on in an awareness campaign. Similarly, stigma, service use and treatment issues were also included. The awareness manual elaborates upon and stresses the need for employing local contexts appropriate for utilizing different campaign methods at the least cost. The annotated references of worldwide authoritative sources are divided into potential user groups, e.g children, parents and families; policy-makers and NGOs, and health care professionals. Recognizing the influence of racial, ethnic and cultural differences (Moscicki 1999), creativity and local resources were taken into account in fashioning site-specific campaigns, rather than proposing a fixed standard model.

The Mental Health Awareness Questionnaire for students assessed demographics, including but not limited to, age, gender and school grade. In an effort to determine general level of impairment in the student population, as well as comparability of samples across sites, the Strengths and Difficulties Questionnaire (SDQ) (Goodman 1999), an instrument to assess behaviours, thoughts and feelings was utilized. Additional questions designed to gather information about the students' opinions concerning child mental health problems were included. These questions addressed different issues, including the students' knowledge of and attitudes about mental health. Questions also assessed the students' views about mental health treatment for children. Finally, there were a number of baseline-specific and follow-up-specific questions, including those about the child's desire for more knowledge about child mental health. The follow-up questions concerned other aspects of the campaign and its effectiveness in increasing knowledge about child mental health, and sought to ascertain whether the campaign altered attitudes, especially the students'.

The Mental Health Awareness Questionnaire for parents and teachers, except for the SDQ, paralleled the content of the student questionnaire. These questionnaires aimed to determine the knowledge and attitudes of parents and teachers about child mental health treatment issues. Baseline questions addressed parent and teacher knowledge of child mental health and their own attitudes about the recent awareness campaign. The follow-up questions were designed to assess changes from baseline responses, as well as views of the effectiveness of the campaign, and whether it played a role in increasing the respondent's knowledge of or change in attitudes about child mental health.

The nine-country study explored and tested the suitability and appropriateness of different media approaches, selected in each country by locals who best knew which of the available modalities among the many suggested in the Awareness Manual had the greatest possibility for effective transmission of mental health information for youth in their specific culture. Baseline assessment included N = 3574 participants: 2471, 607 parents, and 495 teachers. Participation at follow-up (N = 2450) included 1954 students, 260 parents, and 236 teachers.

Some general results, true for all sites:

In sum, the awareness campaigns seemed to have ‘loosened tongues’, that is, increased willingness to ‘expose dark secrets’ and to tell ‘what must be told’.

Given the wide variation and extraordinary differences in cultures, languages, race/ethnicity, religion, population size, level of economic development, and nature of the workforce (Maris et al. 2000; De Leo and Evans 2004; Didiot 2004; Kleinman 2004; Lee et al. 2007), the fact that the nine selected countries participating in the WPA Study were able to partially or completely successfully comply with most of the very tight parameters for the conduct of the study, as well as with the rigorous data entry procedures, was an achievement per se. This is especially laudable inasmuch as the near draconian budgetary restrictions of this study pilot sorely hampered anything approaching an expensive publicity programme for bolstering ‘awareness’. Six of the nine countries were able to finish both pre-campaign and post-campaign requirements, while all nine demonstrated adherence to training, learning basic field methods for epidemiological research, including sample selection procedures, interviewing techniques, data entry and data reporting, all the while conforming to all confidentiality procedures, thereby protecting the privacy of study participants.

The awareness programme has, thus, been shown to have great potential for opening communication pathways, thereby providing broader avenues of intervention (Hoven et al. 2008). Moreover, this simultaneous, cross-stakeholder approach (parents, teachers and students) can be effective in changing attitudes about mental health and fostering a willingness of troubled youth to speak openly with parents and teachers (and they in turn with the students) about their emotional problems, empowers each stakeholder to be appropriately responsive. Expanding knowledge and understanding of mental illness among the most universal youth stakeholders, parents, teachers as well as among the youth themselves, potentially enhances early detection by multiplying the number of eyes and ears attuned to any individual youth who may be suffering, often silently (Steele and Doey 2007). Evidence shows that awareness programmes increase mental health literacy, but that it must be strengthened with more focused suicide preventive interventions in order to help suicidal pupils (Goldney and Fisher 2008). The awareness programme is designed to be offered in addition to, and not to replace, any other interventions which have proven to be affective in reaching youth who are at known elevated risk (Burns et al. 2007). The programme is, thus, intended to expand the scope and reach of existing suicide prevention programmes, as well as to be a free-standing programme in places where children's mental health services are essentially non-existent.

These results are heartening, but do such efforts as these seem likely to help to stem the tide of youthful suicide? While recognizing that some researchers originally warned of potential problems associated with use of such education methods with children and adolescents (Shaffer et al. 1996), we, nonetheless, believe that campaigns such as those conducted in this pilot can be very important for suicide prevention, provided that:

It also seems useful to develop a sense of connectedness among stakeholders in resolving child mental health problems, so that all who are involved have an investment in positive results: higher degree of mental health, lesser amount of mental illness, and fewer suicides.

Epidemiological studies over the past several decades have identified problems of mental illness and suicide throughout the world (De Leo and Evans 2004). They demonstrate annual rise in suicide rates during the quarter century from the mid-1950s to the late 1970s, among youth (ages 15–24) (Moscicki 1999; Gould et al. 2003; De Leo and Evans 2004; Wasserman et al. 2005); where, for example, during this period in the United States, the rate more than tripled for boys, and more than doubled for girls. In the 1990s, these rates largely declined. We simply do not know what accounts for such fluctuations (Gould et al. 2003). Also, we are unsure as to how generalizable throughout the world such rates may be, as there is much imprecision in rates gathered from different WHO Regions (Cantor 2000; Timmermans 2005).

As noted, the WPA/WHO/IACAPAP Awareness task force successfully conducted studies of child mental health awareness in nine countries on different continents simultaneously. The goal was to test the feasibility and separate requirements of waging awareness campaigns in different cultures, using different languages, and in countries at varying levels of economic development. These efforts ultimately led to important insights relevant for conducting larger-scale child mental health awareness campaigns, which appear to have potential to augment existing youth suicide prevention efforts, especially in under-resourced environments.

Of utmost importance, however, is to be very fastidious about the correctness of information that is transmitted in awareness campaigns, to avoid untoward effects from the passing on of false facts. A brief synoptic treatment of mental disorders is clearly insufficient for making diagnoses, and doing so could wrongly identify people. Not only could those who are not at great risk come to think that they are, but also those who are at high risk might feel falsely safe, when they are not. For example, first identified cases of HIV-AIDS in the mid-1980s (Centers for Disease Control and Prevention 2001) suggested that people at risk for acquiring HIV were: gay white men, Haitians, intravenous drug abusers, and haemophiliacs. The information was ‘correct’ based on the first cases that had turned up; however, the CDC's publication of these findings had the unfortunate effect of inducing a false feeling of security and safety for persons not on the CDC at-risk list. The AIDS epidemic, at the time, had already been shown to involve heterosexual transmission in Africa, and soon began showing up in other populations not identified at first as being at high risk. What may have ensued is the kind of carelessness that would produce avoidable and unnecessary infections, had there been better information available.

The limited information obtained in this study certainly appears promising for bostering suicide prevention efforts. It should be noted, however, that the questions asked, about mental health–mental illness were general. No specific assessment of suicide risk was made. However, as the WPA-WHO-IAPACAP Awareness Task Force determined, withholding child mental health information is unethical, so that the challenge before us was to find a way to make such information available and useful to as many persons, especially youth, as possible, so as to contribute to their taking steps to reduce rates of suicide. We believe mental health awareness campaigns, which succeed in opening pathways of communication about these issues, can make a significant contribution to this effort. They can help to reduce stigma, shame and distress of families with mentally ill and suicidal children, and improve awareness that mental health problems are treatable and suicide is preventable. However, in-depth studies about how information is perceived by students, parents and teachers and how to motivate and ensure referral of vulnerable young persons for care and treatment, are required to further promote suicide prevention.

Finally, it would be overly optimistic to expect that such a brief exposure, as an awareness campaign without follow-up activity, can sustain a lasting effect. ‘Lighting a candle’ is by no means sufficient to illuminate the darkness surrounding mental illness and suicide; in fact, we feel that such a brief exposure is soon extinguished, and even worse raises false hopes of relief when it is not followed by making resources available, or at the very least, directing those who feel that there may be need for ameliorative action that there are places to consult for help. The Awareness Manual does introduce such sources, but even that manual, up to date at time of publication, soon requires updating. And projects aiming to change attitudes and behaviour require consistent action into the future.

What is desperately needed to realize such change is a dramatic increase of effort, extended over a long period of time. Let us give an example: In November 1981, a 31-year-old surgical resident, returning to the hospital after a brief dinner break, was accosted by two muggers who attempted to rob him. Although he was carrying only five dollars, he ran and/or offered resistance and was fatally shot. The incident occurred just outside below our own present offices at Columbia University-New York State Psychiatric Institute.

The accounts among others in New York Times that followed revealed that the area had long been considered unsafe, and lacking in proper lighting and police protection. There had been a number of similar incidents occurring when nurses finishing their work shifts were walking home. Nothing of consequence, however, was done until the time of this incident involving a male surgeon from a prominent medical family. The earlier incidents did not bring about any response involving increasing safety and security. However, after Dr John Chase Wood Jr's demise, sodium vapour lamps were installed all around the area; the dark shadows were no more. Security personnel were assigned to patrol duty and electronic surveillance was installed. The chances for a repeat of this kind of attack were now much more remote.

We understand, of course, that this account is only a metaphor, but we feel that in like manner, only when the mystery and dark shadows which continue to surround topics like mental illness and suicide are exposed, brought into full view, and discussed openly, will there result a sufficient call for change, enabling the provision of help for the troubled and a stronger safety net for those on the verge of suicide.