Suicidal ideation, plans, and attempts among adolescents are far more common than many realize, and these suicide antecedents are likely to be exacerbated in the wake of COVID-19. Pre-pandemic, nearly 1 in 5 youth have seriously considered suicide, 1 in 6 have made a suicide plan, and nearly 1 in 10 have made an attempt. Thus, in a typical 30-student classroom, 5 have made a suicide plan and 2-3 have attempted; those numbers are staggering. And while post-pandemic estimates are just becoming available, higher rates of reported anxiety, depression, loneliness, and suicidal thinking among youth as a result of upended schools, activities, and social connections, and greater use of crisis services (inpatient treatment and crisis phone/text lines) and emergency room visits for suicide attempts portend a mental health pandemic following this public health one.
The prevailing suicide prevention paradigm entails identification and treatment within the formal mental health system, largely disconnected from the places and people where youth spend most of their time (e.g., schools, trusted extended family, peers, social media). While clinical research has led to greater availability of effective psychotropic medications and promising treatments, the difficulty of identifying youth at risk for suicidal behaviors, barriers to care access and quality (especially for marginalized youth), and the high cost of mental health services as compared to preventive ones, argues for a new approach. As it currently exists, the mental health system will only reach a small portion of youth who need services and often years after suicidal thinking emerges. Promising models involve a) peers and trusted others who are often the “first lines of defense” for learning about youth’s suicidal thinking and sending help-seeking messages, and b) schools and other non-health settings as universally-accessible entrees and supports for mental health services; in short, a “no wrong door” approach. But to date, we have paid less attention to school-based prevention programs, supporting youth in norm-setting for help seeking, and involving non-mental-health personnel in referring youth for mental health services and supporting their engagement in treatment.
ARCADIA for Suicide Prevention takes a developmentally-informed, population-health approach to adolescent suicide. With the prediction of adolescent suicide barely better than chance, we focus on the places where adolescents already are (schools, primary care, emergency rooms) and leverage trusted sources of support (peers, parents, trusted adults). With attention to the unique developmental needs of adolescent autonomy and identity, and guided by the ideas of youth themselves and those with lived experience, we draw on innovations from diverse disciplines (e.g., neuroscience, behavioral economics, implementation science, public health, communications) for our Center. Our focus is to strengthen bridges, integrating prevention and intervention, within and across the places where youth are situated, drawing from the “Swiss cheese model” for industrial accidents (recognizing that each place has gaps but their layering can support more kids at risk than when each exists on its own). We approach our work as a partnership between academia and public agencies, for seamless integration into practice, and to reach all youth, at population-scale.
Our team is well positioned to address the urgent need to advance youth suicide prevention research and practice with expertise in school- and primary-care based prevention and policy research with low-income and marginalized populations; research-practice partnerships with city agencies; collaborations with experts in mental health/suicide prevention and the experiences of marginalized youth (e.g., Michael Lindsey, Cheryl King, Stephen Russell, Kiara Alvarez); and partnerships with program developers (e.g., Directing Change co-founders Jana Sczersputowski and Stan Collins) and policy leaders (e.g., New York City Department of Education, New York State Office of Mental Health). Through this transdisciplinary, cross-sector work, we aim to generate actionable solutions for youth suicide, while simultaneously addressing disparities facing marginalized BIPOC and LGBTQI+ youth, and meet National Action Alliance goals to reduce youth suicide, nationwide.
Examples of our current work, for which we are seeking funding, include:
1. Evaluation of a novel school-based mental health/suicide prevention program, “Directing Change,” that can be a catalyst for changing norms for suicide prevention school- and community-wide. In Directing Change, a program “disguised as a film contest” with a nearly 10-year history serving diverse youth across California (CA), students create 30- or 60-second films in mental health/suicide prevention and disseminate them to the school community. By following film submission guidelines, students learn about suicide prevention and mental health, discuss and apply that knowledge, and communicate youth-oriented, positive, action-oriented messages to peers. The hands-on process of filmmaking is designed to facilitate learning of suicidal signs and concrete prevention actions, and program features allow students to infuse prevention messages with youth-oriented, culturally-specific perspectives, motivating helping (and help-seeking) behaviors. As students share films in schools, Directing Change is expected to reduce stigma and change norms, with the intention of connecting marginalized and other high-risk youth to trusted adults more quickly than they would otherwise, thus reducing disparities. Impacts of Directing Change will be evaluated via a mixed-method randomized trial of 40 high schools in CA in a research-practice partnership. Funding is also being sought for an implementation study of this same program in New York State.
2. Addressing rising rates of suicide attempts of Black youth through a system-level strategy to recognize and connect high risk Black youth who present to emergency departments (EDs). Our strategy, WeCare, combines two evidence-based strategies implemented in the general ED -- universal screening using the Computerized Adaptive Screen for Suicidal Youth and an adapted version of the SAFETY-ACUTE that incorporates work with Black youth, their families, and community stakeholders to develop culturally tailored strategies for addressing treatment barriers, with a technological adaptation for increased feasibility (i.e., follow-up text messaging). Our goal is to increase risk identification, treatment referral and engagement, and, in turn, reduce suicidal ideation and behavior among Black youth, addressing National Action Alliance goals for youth suicide. Understanding the effectiveness of WeCare for Black youth who seek emergency medical services has the potential to provide definitive support for implementation and scaling, resulting in transformative changes in practice to prevent Black youth suicide at the population-level.
3. Examining trends in adolescent suicidal behaviors by place, cohort, and policy. To date, research on youth suicide trends has primarily focused on individual-level characteristics with less attention to the contexts and policies in which youth develop. Imagine a world in which we could identify places (easily and in real-time) where progress has been made in suicide antecedents. Imagine a world in which state suicide prevention centers could find communities that “looked like theirs” in terms of the demographics of their populations, to try out new ideas locally. Imagine if we could understand not only how suicide behavior rates differ across different demographic groups, but whether they differ because of the conditions, services, and policies in which youth of different demographic groups live? We aim to bring together publicly-available administrative data at national, state, and district levels to better identify trends in suicidal behaviors, the place-based factors that contribute to these trends, and policy levers for altering them, to offer new solutions for youth suicide prevention.
Why the name ARCADIA?
Arcadia, the name of a Tom Stoppard play, is the story of a girl named Thomasina who explores the relationship between math and nature, more than a century ahead of her time. The mystery of her mathematical discoveries (that form the roots of Chaos Theory) and of her fate are told through the juxtaposition of past and present.
The name of the play comes from a painting of a country scene, entitled “Et in Arcadia ego” which means “In Arcadia, I am” referring to the presence of death (the “I”) in the midst of beauty (the country). The notion is that even in the most tranquil of spaces, there is still tragedy.
Four themes from Arcadia are highlighted in this Center’s work:
- This Center is aimed at uncovering the mystery of suicide prevention that has long eluded prevention scientists and mental health professionals just as the play presents a historical mystery of Thomasina’s life and contributions.
- In Chaos Theory (also known as the “butterfly effect”), order is found in disorder, and small initial differences can have large impacts. With our Center, we seek order within the complexity that is suicide research.
- Thomasina brings together math with nature - enlightenment with romanticism - in much the same way that progress on suicide likely requires the integration of multiple disciplines.
- The story (and its title) alludes to the acknowledgement of tragedy as part of the human experience. We need to speak of suicide – and recognize its presence among us – in order to address it.