Suicide Prevention Project

Youth suicide is a serious, preventable health problem affecting young people across the country. Suicide and suicide attempts result in loss of life or physical impairment, enormous medical costs, and the disruption of families and communities. Below we describe a statewide suicide prevention training project by the Virginia Department of Health and our evaluation of training outcomes.

Suicide Statistics

According to a 2001 report by the National Institute of Mental Health, suicide was the third leading cause of death among young people aged 15 to 24, following unintentional injuries and homicide. The rate was 9.9/100,000 or .01 percent.

• The suicide rate among children in the U.S. ages 10-14 was 1.3/100,000 or 272 deaths among 20,910,440 children in this age group, with a gender ratio of 3:1 (males: females).
• The suicide rate among adolescents aged 15-19 was 7.9/100,000 or 1,611 deaths among 20,271,312 adolescents in this age group, with a gender ratio of 5:1 (males: females).
• The suicide rate for young people aged 20 to 24 was 12/100,000 or 2,360 deaths among 19,711,423 people in this age group, with a gender ratio of 7:1 (males: females).

In Virginia, youth suicide is the second leading cause of death among young people aged 10-24.

• On average, one Virginia teenager dies each week from suicide.
• The rate of suicide among Virginia youth age 10-19 has increased 32% since 1975.
• Overall, the age-adjusted suicide rate in Virginia is almost 6% higher than the national rate.
• Medical costs resulting from hospitalizations in Virginia due to self-inflicted injuries total almost 30 million dollars per year.

Virginia Department of Health Training Goals

A 2001 report of the Virginia Commission on Youth suggested that "the Virginia Department of Health (VDH) and Department of Mental Health, Mental Retardation, and Substance Abuse Services (DMHMRSAS) should develop and deliver Gatekeeper Training to designated audiences throughout the Commonwealth." "Gatekeeper Training" was designed to help individuals who routinely have significant contact with youth to recognize suicide warning signs and take appropriate action. The Virginia Department of Health and the Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services have made available two such training programs: Applied Suicide Intervention Skills Training (ASIST) and Question, Persuade, Refer (QPR).

Question, Persuade, Refer (QPR)

The QPR workshop (designed to be presented in as little as an hour) is appropriate to help anyone who has regular contact with young people learn the "QPR" approach -- three simple steps that anyone can learn to help save a life from suicide. Just as people trained in CPR and the Heimlich Maneuver help save thousands of lives each year, people trained in QPR learn how to recognize the warning signs of a suicide crisis and how to question, persuade, and refer a young person for help. This training, which research has demonstrated to be effective, was created by the QPR Institute.

Applied Suicide Intervention Skills Training (ASIST)

Although available to anyone, this two-day training is most commonly attended by helping professionals and other caregivers such as counselors, social workers, nurses, crisis line workers, and others who have a strong interest in suicide prevention and intervention. Over the two days, participants learn to: Recognize opportunities from help Reach out and offer support Estimate the risk of suicide Apply a model for suicide intervention Link people with community resource

Evaluation of Suicide Training Project

The Virginia Youth Violence Project, in partnership with the Virginia Department of Health, conducted an evaluation of outcomes for participants trained in QPR and ASIST. Surveys were administered to particpants in both training programs, as well as to a comparison group of randomly sampled personnel who have not participated in either training. The survey was intended to determine whether training leads to the following outcomes:

• increased knowledge of suicide prevention and intervention methods
• improved case management of suicide referrals
• increased collaboration regarding suicide with other professionals and agencies
• improved school policies on suicide prevention
• new programs or initiatives for suicide prevention or intervention.

Executive Summary of Project

Since 2003, thousands of Virginia educators, counselors, and mental health care providers have completed training in youth suicide prevention through a program of workshops sponsored by the Division for Injury and Violence Prevention of the Virginia Department of Health. Two kinds of training were offered – Question, Persuade, Refer (QPR) and Applied Suicide Intervention Skills Training (ASIST). QPR training is an introductory program that teaches participants to question potentially suicidal students, persuade them to seek help, and refer them for further services. ASIST training is an advanced, two-day workshop intended for mental health professionals who provide services to suicidal students.

In 2004, the Virginia Department of Health asked researchers at the Youth Violence Project of the University of Virginia’s Curry School of Education to conduct an evaluation of training outcomes on school personnel, This evaluation was conducted through 1,021 surveys of school administrators, counselors, psychologists, nurses, teachers, and other staff who participated in the training, as well as a control group of personnel who did not participate in the workshops. The first phase of the study consisted of a retrospective, post-training comparison of QPR and ASIST trainees with the control group, and the second phase consisted of a prospective survey of school personnel who completed pre and post training surveys to measure changes over time.

Participants in both ASIST and QPR training reported that training was beneficial. The majority of participants said that training increased their confidence, knowledge, and expertise in working with potentially suicidal students. Consistent with these participant perceptions, pre-post analyses showed that trainees increased in knowledge of suicide risk factors and were more actively engaged with suicidal students in the months following training. Trainees also reported improvements in how their school collaborated with other agencies and responded to suicidal students.

ASIST participants received more training than QPR participants and, as would be expected, demonstrated greater training effects. ASIST trainees reported questioning more students about suicide and making more suicide contracts. Schools that sent a staff member for ASIST training were more likely to implement new policies or procedures related to suicide prevention and were more likely to assign new staff to suicide prevention efforts.

When compared with school personnel in the control group, training participants were more likely to work with suicidal students and less likely to refer them for services outside of school, yet reported fewer suicide attempts in their schools. Specifically, school personnel in the control group reported making safety contracts with suicidal students about 1.4 times per year, whereas QPR trainees made approximately 3 contracts and ASIST trainees averaged 4.4 contracts per year. Furthermore, control group participants were more than twice as likely as QPR and ASIST trainees to refer a student for services outside of school. Finally and most notably, trainees reported fewer student suicide attempts than school personnel in the control group. Control personnel reported an average of 4.4 student suicide attempts per year in their schools, whereas QPR trainees reported just 1.3 attempts and ASIST trainees just .9 attempts. These positive findings must be qualified by the caveat that this was not a randomized controlled study that would provide strong evidence that the differences between groups were caused by the training program. These findings strongly support the need for a randomized controlled study to confirm the apparent beneficial effects of QPR and ASIST training observed in this study.

Suicide Research Presentations

2006 APA Presentation on Evaluation of Statewide Training in Student Suicide Prevention
Poster from APA presentation on an Evaluation of Statewide Training, New Orleans, LA, August 12, 2006. Download File