As described at the outset of this paper, the period of adolescence through early adulthood, and the transition to college and living independently in many cases is a high-risk period of time for suicidal behaviors. Despite this, efforts to systematically implement and evaluate suicide prevention activities often have lagged efforts devoted to other public health priorities. The GLS suicide prevention grant programs have provided an important impetus for the initiation of youth suicide prevention activities throughout the United States in multiple settings and communities. Reducing suicide and suicidal behaviors has been identified as a national public health priority, and the GLS programs have provided important resources toward potentially reducing the burden of suicidal behaviors, and achieving the goals articulated in the National Strategy for Suicide Prevention. As of September 2009, two cohorts of GLS suicide prevention program grants will have completed their funding cycles, and these and subsequently programs are yielding important information regarding suicide prevention efforts.
There has been a strong emphasis on evaluation in the GLS programs, and these evaluation efforts have and will continue to yield very useful information in several respects. At a local level, the GLS programs have raised awareness of suicide prevention needs and the need for coordinated efforts among youth-serving agencies in suicide prevention, have provided information regarding the ease of implementation of and community readiness for different suicide prevention approaches, and have generated data regarding the perceived usefulness and preliminary indications of the effects of different approaches. Across sites, the GLS programs have contributed data regarding the extent of suicide prevention activities across the United States, and have provided important data regarding the impact of programs in terms of numbers of individuals affected (e.g., screened, trained) and proximal outcomes of efforts (e.g., increased knowledge or awareness, numbers of youth at risk referred for services). The enhanced evaluations for states and tribal groups have provided important information regarding the long-term effects of gatekeeper training, the impact of culturally tailored suicide prevention activities, the impact of different school- and community-based programs, and the impact of suicide prevention efforts focusing on youth who have made suicide attempts being seen in Emergency Departments. Specific questions of particular importance that are being addressed by GLS projects or the cross-site evaluation include (1) the degree to which referrals to services that are made because of screening or gatekeeper approaches actually result in receipt of services; (2) the degree to which gatekeepers utilize the training they receive, the extent to which differing characteristics of gatekeepers (e.g., mental health background vs. no mental health background) are associated with differences in the benefit received, and the degree to which gatekeeper training programs result in lasting changes in suicide prevention knowledge, attitudes, and behaviors such as identification, intervention, and referral of at-risk youth; and, (3) the degree to which cultural contexts for states and tribes impact the acceptability of suicide prevention efforts and the readiness to develop or implement programs.
Among the diverse set of GLS-funded college campuses, evaluations also are providing information about the cultural contexts of suicide risk and suicide prevention programs, how suicide prevention activities need to be tailored or individualized to these contexts, and how these differences in cultural environment affects the acceptability of suicide prevention efforts and the readiness to develop or implement new programs. The Campus Infrastructure Interviews being implemented as part of the GLS cross-site evaluation are providing information regarding the interface of campus culture, policy, and infrastructure that will prove useful as the next generation of campus suicide prevention activities are developed and implemented. In addition, it is clear that suicidal students, even when they are referred to and engage in mental health treatment, often drop out of treatment prematurely (Joffe, 2008). It is important to better understand barriers to seeking or staying in treatment on college campuses, and to develop methods for engaging at-risk students and motivating change or movement to better coping and adaptation. The GLS case studies have been providing information regarding barriers to help-seeking among college students that hopefully will aid in the development of new programs to overcome barriers and provide needed services to students at risk.
These efforts notwithstanding, it should be acknowledged that the GLS programs were not developed or funded as research projects. Hence, there has been little use of experimental approaches (e.g., randomization and controls) that would allow inferences to be drawn about the efficacy or effectiveness of suicide prevention programs in impacted versus non-impacted communities. For this same reason, it is inappropriate to draw definitive inferences about the comparative effectiveness of suicide prevention approaches (e.g., one method of suicide screening versus another) used in different GLS funded sites. In particular, communities that choose to implement one specific approach to suicide prevention activities may differ in systematic and uncontrolled ways from communities that implement other prevention approaches. In addition, it also may be difficult to disentangle effects of specific suicide prevention activities from co-occurring activities, especially given the fact that grantees commonly engage in multiple levels of suicide prevention activities. Lastly, it may be informative to compare data from implementation sites or communities to data (e.g., regarding rates of suicidal behavior) from national data bases or comparison sites. However, it is difficult to definitively determine whether any divergence from comparison data is actually due to the effectiveness of GLS-introduced interventions, or whether it is due to other factors. Despite these inherent limitations, the GLS programs and their accumulated data, as detailed above, are poised to make continued important contributions to the field of suicide prevention.
For the field of suicide prevention in general, however, and for the GLS funded programs in particular, there are several areas that continue to deserve additional attention. First, as evidenced with earlier school-based suicide prevention curricula (Kalafat & Elias, 1994
; Overholser, Hemstreet, Spirito, & Vyse, 1989
; Shaffer et al., 1990
), there can be deleterious effects associated with well-intended suicide prevention efforts. Some of the local suicide prevention programs developed or implemented with GLS have not been rigorously evaluated, and special attention needs to be directed towards detecting these possible unintended negative effects of intervention efforts, as well as their benefits. Second, given the problem of relatively low base rate outcomes such as suicidal behavior, and the state of the evidence base with regard to suicide prevention activities, greater collaboration across sites in the systematic evaluation of the effectiveness of suicide prevention programs would be desirable. In this way, collaborating GLS programs might not only benefit specific communities, but will be best poised to make a larger contribution to the evidence base regarding suicide prevention. Third, issues of cost-effectiveness of suicide prevention activities need attention. That is, given resources that are often limited, communities need to know how they might best invest their capital to achieve the maximum impact in terms of suicide prevention efforts. Said differently, communities need to know which suicide prevention activities “provide the biggest bang for the buck” in different circumstances. Lastly, the GLS program funding has provided an excellent opportunity for initiating activities across the country for reducing suicidal behaviors among youth. Nonetheless, the degree to which any lasting changes occur in communities or funded sites as a result of GLS funding needs to be more carefully studied, as well as the steps that might be taken to increase the sustainability of prevention efforts beyond the provision of federal resources.
In sum, the GLS Youth Suicide Prevention and Early Intervention programs and their evaluation have provided impetus for youth suicide prevention activities across the country on a scale that has not been realized previously. The knowledge gained from these GLS grantees and the evaluation of their programs can help to provide a springboard for continued efforts to implement activities designed to reduce suicide and suicidal behaviors among young people, and to help determine which suicide prevention activities result in the largest impacts, and under what circumstances. As such, the GLS programs are providing substantial contribution to the national effort to reduce suicidal behaviors and their burden.