To our knowledge, Promoting CARE is the only systematically evaluated comprehensive suicide prevention program for youth identified as at risk for suicide. Findings demonstrate the efficacy of suicide prevention efforts that include parent and school involvement and expand previous findings demonstrating the success of the C-CARE intervention.24,30
All study groups reported significant declines from their baseline risk levels for suicide ideation, suicide threats, depression, hopelessness, anxiety, and family dysfunction. In addition, there were significant gains for all groups in personal control, problem-solving coping, and family support, and these changes were maintained up to the 15-month assessment, with no evidence of relapse. These findings speak to the power of brief school-based intervention and, specifically, to the importance of the screening, identification of risk, and linkage to support resources, both at home and at school, that was central to all components of the intervention, including IAU. Furthermore, they confirm an approach to suicide prevention that involves increasing the readiness and willingness to receive support on the part of youth at the same time that it activates the availability of support both at home and at school.
Prevention effects were examined for 2 phases of the intervention. Period 1 corresponds to the immediate postintervention effects and thus the effects can be attributed to the youth intervention (eg, C-CARE or SYSR), connections to school counselor (in person) and parent (via telephone), and the first of the 2 P-CARE visits. This is the period immediately following the identification of youth risk and, perhaps, the most critical intervention period. It is during this period that the intervention focuses specifically on awareness of suicide risk behaviors, establishing sources of support and planning for future stressors. Period 2 captures additional effects attributable to the second P-CARE visit, the parent booster phone call, and the follow-up C-CARE interview, which are focused on maintaining gains and expanding the repertoire of mood management and problem-solving skills.
As hypothesized, the majority of the short-term effects observed are related to the C + P-CARE intervention. C + P-CARE demonstrated important reductions in suicide risk variables and increases in coping and family support. C + P-CARE and, secondarily, C-CARE, showed reductions in emotional distress and increases in personal control. A pattern of results emerges where initial reductions in risk from the C-CARE intervention become either increasingly significant, or only significant, with the addition of the P-CARE intervention. Importantly, C-CARE is the only intervention that showed results on its own, that is, reductions in depression, anxiety, and anger and an increase in personal control during the first month postintervention. Since the parent intervention, P-CARE, on its own, did not produce significantly different results compared with IAU for any outcome, it seems that it is C-CARE that provides a foundation upon which the parent intervention boosts effects. These outcomes are consistent with observations that suicide-vulnerable youth often have difficulty assessing their situation, realizing their risk, and asking for or receiving help, but benefit when their risk is identified by others and appropriate help and support are offered.
The supplementary effects achieved by adding P-CARE to C-CARE are notable. The same effects were not observed for the P-CARE–only condition where youth participate in the brief SYSR interview instead of C-CARE. P-CARE is founded on the basis of the social support principle of optimizing naturally occurring support resources as a method of creating durable support34
and on the basis of teens’ preference for seeking help from a parent if the parent is seen as competent and knowledgeable.35
P-CARE, which focuses on increasing communication related to suicide risk and mood management, and activating parent support, seems to complement the strategies of the C-CARE intervention and to be responsive to the reciprocal nature of support relationships—in other words, both interventions are more effective in the presence of the other. Finally, we posit that C + P-CARE represents a developmentally appropriate approach to parent involvement for the older adolescent,8
responsive to a developmental period when the parent role is important but less central than in earlier years. Results for the C + P-CARE intervention suggest that individual youth intervention in conjunction with parent intervention is effective for the high school–age adolescent, with the parent intervention supporting and amplifying the effects of youth intervention. Accordingly, planning for how parent and youth interventions interact can be a way to maximize the potential effects of the 2 interventions together.
While the C + P-CARE intervention demonstrated the majority of intervention effects, the advantage of C + P-CARE in terms of rate of decline over the other interventions and IAU had dissipated by 15 months. However, additional analysis-of-covariance comparisons of the intervention components indicate that as far as 9 months postintervention, C + P-CARE maintains a lower rate of suicide ideation and threats, as well as lower anxiety, than IAU. Thus, the combined intervention is distinguished from the briefer IAU intervention over a period of at least 9 months, conferring greater protection from escalation of suicide risk. This is not a trivial advantage considering the compressed nature of time during adolescence (9 months represents a school year), the impulsivity common during this period, and the serious consequences of escalating suicide risk. Finally, it is important to remember that results for C-CARE and C + P-CARE are being tested against results for a comparison group that was treated with a minimal intervention that also had powerful effects on risk—an assessment that was founded upon similar prevention principles as the tested interventions (increased awareness of risk behavior and connection to support).
This study is limited to reliance on self-report data. However, when attempting to understand internal experiences such as suicide ideation and depression, reliance on self-report data is appropriate and typical. In addition, the study does not address the question of which aspects of intervention predict the successful outcomes, nor the question “for whom these brief interventions work best”—for example, across gender and ethnicity, by degree of severity of suicide risk behaviors, or based on specific parent characteristics/responses.
The findings for the Promoting CARE program are an important contribution to the search for acceptable, feasible, and efficacious suicide prevention for high-risk populations. Study results demonstrate the advantage of a comprehensive approach to suicide prevention that involves risk screening and the implementation of a brief, school-based, preventive intervention that includes both adolescents and their parents.