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LETTER |
Correspondence: Requests for reprints should be sent to Mary Jane Rotheram-Borus, PhD, Center for Community Health, UCLA, 10920 Wilshire Blvd, Suite 350, Los Angeles, CA 90024 (e-mail: rotheram{at}ucla.edu).
I read with great interest the article on screening high-school students for suicide risk by Hallfors et al.1 The suicide prevention program described by Hallfors et al. appeared to be one of the best implemented and managed programs possible. When it failed, the authors looked at organizational factors at the school level to suggest how the program could be better implemented on a more consistent basis. A more likely hypothesis is that this suicide prevention program was not feasible in a real-world school setting and a different approach should be adopted.
More than 10 years ago, our research team faced a similar problem when studying homeless youths.2,3 Screening on statistically based risk factors (e.g., past attempts, depression, ideation) would yield statistically based rates of suicide risk of more than 80% among homeless youths. It would not be feasible to base any suicide prevention program on the results of such screening; to do so would require one full-time shelter staff member just to take youths designated as at risk to the emergency room for psychiatric intervention. Screening is feasible only for imminent danger of suicide, not for risk. Screening for risk is likely to identify all adolescents demonstrating multiple problem behaviors, not only those who are likely to attempt suicide.
We proposed a screening strategy based on behavioral characteristics incompatible with suicidal behavior: being able to identify positive events and personal attributes, being able to specify situations that would elicit suicidal acts, having a plan for dealing with suicidal feelings, being able to verbalize one’s current mood, being able to identify 3 persons to seek social support from if suicidal feelings arose, and contracting not to engage in suicidal behavior. Screening based on these criteria yielded a much smaller group—only 1.2% of the youths screened were considered at risk and referred for further screening by a backup professional.3 This was a feasible screening strategy.
When elegant research programs do not work, it is incumbent on us to consider that our approach may be wrong, not the organization in which we try to mount our programs. Hallfors et al. are a great research team and could address suicide risk with a different strategy.
References
1. Hallfors D, Brodish PH, Khatapoush S, Sanchez V, Cho H, Steckler A. Feasibility of screening adolescents for suicide risk in "real-world" high school settings. Am J Public Health. 2006;96:282–287.
2. Rotheram-Borus MJ. Evaluation of imminent danger for suicide among youth. Am J Orthopsych. 1987; 57:102–110.
3. Rotheram-Borus MJ. Evaluation of suicide risk among youths in community settings. Suicide Life Threat Behav. 1989;19:108–119.[ISI][Medline]
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