Suicide Among the Young Facts, Figures, and Formulas for Prevention Karl Rosston, LCSW Suicide Prevention Coordinator (406)

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1 Suicide Among the Young Facts, Figures, and Formulas for Prevention Karl Rosston, LCSW Suicide Prevention Coordinator (406) Updated: August 2016

2 The suffering of the suicidal is private and inexpressible, leaving family members, friends, and colleagues to deal with an almost unfathomable kind of loss, as well as guilt. Suicide carries in its aftermath a level of confusion and devastation that is, for the most part, beyond description. Kay Redfield Jamison, Ph.D. Professor of Psychiatry, Johns Hopkins University Night Falls Fast: understanding suicide, pg. 24

3 Suicide Fact Sheet Center for Disease Control WISQARS website, (June, 2016) Suicide has surpassed car accidents as the No. 1 cause of injury-related death in the United States. There has been a 28% increase in the number of suicides in the United States since 2001 (CDC, 2016) In 2014 there were 42,773 suicides in the U.S. (117 suicides per day; 1 suicide every 12 minutes). This translates to an annual suicide rate of 13.4 per 100,000. Males complete suicide at a rate four times that of females. However, females attempt suicide three times more often than males. Firearms remain the most commonly used suicide method, accounting for nearly 50% of all completed suicides.

4 Suicide among Children In 2014, 428 children ages 5 to 14 completed suicide in the U.S. (up from 395 in 2013 and 311 in 2012) Suicide rates for those between the ages of 5-14 increased 60% between 1981 and 2010.

5 Suicide among the Young Suicide is the 2nd leading cause of death among young (15-24) Americans; only accidents occur more frequently. In 2014, there were 5,079 suicides by people years old. (up from 4,878 in 2013) Youth (ages 15-24) suicide rates increased more than 200% from the 1950 s to the mid 1990 s. The rates dropped in the 1990 s but went up again in the early 2000 s.

6 Research has shown that most adolescent suicides occur after school hours and in the teen s home. Within a typical high school classroom, it is likely that three students (one boy and two girls) have made a suicide attempt in the past year. Most adolescent suicide attempts are precipitated by interpersonal conflicts. The intent of the behavior appears to be to effect change in the behaviors or attitudes of others.

7 Suicide in our LGBT youth Source: The Trevor Project ( LGBT youth are 4 times more likely, and questioning youth are 3 times more likely, to attempt suicide as their straight peers. Nearly half of young transgender people have seriously thought about taking their lives, and one quarter report having made a suicide attempt. LGBT youth who come from highly rejecting families are 8.4 times as likely to have attempted suicide as LGB peers who reported no or low levels of family rejection. Each episode of LGBT victimization, such as physical or verbal harassment or abuse, increases the likelihood of self-harming behavior by 2.5 times on average.

8 Suicide in Montana Data Source: CDC-WISQARS (12/23/15), Montana Suicide Mortality Review Team (June, 2016) For all age groups, Montana has ranked in the top five for suicide rates in the nation, for the past forty years. According to the most recent numbers released by the National Vital Statistics Report for 2014, Montana has the highest rate of suicide in the United States (251 suicides for a rate of 24.52). Between January 1, 2014 and March 1, 2016, Montana had 555 suicides for a rate of 28.5

9 Updated: July, 2014

10 Just how big is Montana? Troy to Baker 746 miles Washington D.C to Chicago, Ill miles Population of 9 east coast states 50 million, Population of Montana 1 million

11 Updated: June, 2016

12 22

13 Suicide in Montana s Counties (Source: Montana Office of Epidemiology and Scientific Support, June, 2016)

14 39% Nationally

15 Youth Suicides (11-17) United States compared to Montana , United States Suicide Injury Deaths and Rates per 100,000 All Races, Both Sexes, Ages 11 to 17 ICD-10 Codes: X60-X84, Y87.0,*U03 Number of Deaths Population*** Crude Rate 10, ,866, , Montana Suicide Injury Deaths and Rates per 100,000 All Races, Both Sexes, Ages 11 to 17 ICD-10 Codes: X60-X84, Y87.0,*U03 Number of Deaths Population*** Crude Rate ,

16 Youth Suicides (11-17) United States compared to Montana for Firearm Suicides , United States Suicide Firearm Deaths and Rates per 100,000 All Races, Both Sexes, Ages 11 to 17 ICD-10 Codes: X72-X74 Number of Deaths Population*** Crude Rate 4, ,866, , Montana Suicide Firearm Deaths and Rates per 100,000 All Races, Both Sexes, Ages 11 to 17 ICD-10 Codes: X72-X74 Number of Deaths Population*** Crude Rate ,

17 Youth Suicides (11-17) Montana by Ethnicity , Montana Suicide Injury Deaths and Rates per 100,000 White, Both Sexes, Ages 11 to 17 ICD-10 Codes: X60-X84, Y87.0,*U03 Number of Deaths Population*** Crude Rate , , Montana Suicide Injury Deaths and Rates per 100,000 Am Indian/AK Native, Both Sexes, Ages 11 to 17 ICD-10 Codes: X60-X84, Y87.0,*U03 Number of Deaths Population*** Crude Rate 24 91,

18 2015 YRBS Data - Suicide 11.6% of 7th-8th graders have attempted suicide in the past 12 months

19 2015 YRBS Data - Suicide Montana high school students who had attempted suicide are more likely than those students who had not attempted suicide to have: Drove when drinking alcohol during the past 30 days (27% of students who attempted suicide compared to 9% of students who had not attempted suicide). Ever been physically forced to have sexual intercourse when they did not want to (32% of students who attempted suicide compared to 6% of students who had not attempted suicide). Been bullied on school property during the past 12 months (55% of students who attempted suicide compared to 23% of students who had not attempted suicide).

20 2015 YRBS Data - Suicide Montana high school students who had attempted suicide are more likely than those students who had not attempted suicide to have: Been electronically bullied during the past 12 months (49% of students who attempted suicide compared to 16% of students who had not attempted suicide). Smoked a cigarette during the past 30 days (35% of students who attempted suicide compared to 11% of students who had not attempted suicide). Used marijuana during the past 30 days (42% of students who attempted suicide compared to 17% of students who had not attempted suicide).

21 Cutting or Self-Injurious Behavior Habitual self-mutilation may be best thought of as a purposeful, if morbid, act of self-help which enables the subject to re-establish contact with the world Armando Favazza, M.D. (1996) Bodies Under Siege. 2nd Ed Baltimore: John Hopkins Press

22 Non-Suicidal Self Injury (NSSI) (Identified as a condition for further study in the DSM-5) In the last year, the individual has, on 5 or more days, engaged in intentional self-inflicted damage to the surface of his or her body, of a sort likely to induce bleeding or bruising or pain (e.g., cutting, burning, stabbing, hitting, excessive rubbing), for purposes not socially sanctioned (e.g., body piercing, tattooing, etc.), but performed with the expectation that the injury will lead to only minor or moderate physical harm.

23 Non-Suicidal Self Injury (Identified as a condition for further study in the DSM-5) The absence of suicidal intent is either reported by the patient or can be inferred by frequent use of methods that the patient knows, by experience, not to have lethal potential. The behavior is not of a common and trivial nature, such as picking at a wound or nail biting.

24 Non-Suicidal Self Injury (Identified as a condition for further study in the DSM-5) The intentional injury is associated with at least 2 of the following: 1. Negative feelings or thoughts, such as depression, anxiety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act. 2. Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to resist.

25 Non-Suicidal Self Injury (Identified as a condition for further study in the DSM-5) 3. The urge to engage in self-injury occurs frequently, although it might not be acted upon. 4. The activity is engaged in with a purpose; this might be relief from a negative feeling/cognitive state or interpersonal difficulty or induction of a positive feeling state. The patient anticipates these will occur either during or immediately following the self-injury.

26 Facts about Self-Injurious Behavior Self-injury is a maladaptive mechanism by which troubled teens cope with extreme and painful emotions. Self-injurers are typically not attempting suicide. By expressing their inner pain through injury, they are keeping themselves from suicide (Only about 0.2% of suicide related deaths were due to cutting ). Self-injurers can become suicidal or accidentally kill themselves.

27 Facts about Self-Injurious Behavior Self-injury is an Impulse Disorder, similar to eating disorders, shoplifting, and substance abuse. Approximately 4% (12.2 million) of the general population and 15%-20% (2-3 million) of middle and high school students have reported a history of deliberate self-harm. * More than 70% of self-mutilators are girls, many of whom were abused (this was based on clinical studies, however, community studies have show less difference in gender) *Source: Am J Psychiatry 2003; 160: *Source: SPRC Research-to-Practice Webinar: Understanding Non-suicidal Self-Injury in Suicide Prevention, July 27, 2010

28 Facts about Self-Injury Self-injurers have low-self esteem and difficulty regulating their emotions. Self-injurers can have underlying personality or mood disorders and depression. Self-injury appears to have a contagious affect among peer groups. Source: Lieberman, R. (March, 2004)Understanding and Responding to Students who Self-Mutilate, Principal Leadership, pp Source: Beyond the Pain: Hope and Healing from Self-Injury and Self-Mutilation, Mark Hirschfeld, LCSW. October 10, 2006 conference in Missoula, MT.

29 Most Common Methods in Adolescents Cutting and Scratching 75% Burning 35% Picking at scabs 25% Self-inflicted tattoos/piercing15% Biting oneself 10% Hair pulling 5% Hitting oneself 2% Bone breaking 2% Beyond the Pain: Hope and Healing from Self-Injury and Self-Mutilation, Mark Hirschfeld, LCSW. October 10, 2006 conference in Missoula, MT.

30 Cutting/Self-Injury Demographics of the young cutter 70% are females 3 Average educational level is one year of college. 1 Average age of first incident of self-injury was 13.5 years 1 Average number of times they have engaged in self-injury is fifty (50) % of those studied report having been sexually abused as children Cutting and Self-Mutilation: When Teens Injure Themselves (2003). Kathleen Winkler, Enslow Publishing, Berkeley Heights, NJ. Beyond the Pain: Hope and Healing from Self-Injury and SelfMutilation, Mark Hirschfeld, LCSW. October 10, 2006 conference in Missoula, MT. Lieberman, R. (March, 2004)Understanding and Responding to Students who Self- Mutilate, Principal Leadership, pp

31 Detecting students who Self-Injury Frequent or unexplained scars, cuts, bruises, and burns, (often on the arms, thighs, abdomen) and broken bones (fingers, hands, wrists, toes) Consistent, inappropriate use of clothing designed to cover scars Secretive behavior, spending unusual amounts of time in the bath room or other isolated areas

32 Refuse to be involved in activities that involve revealing skin or to change for Physical Education Show evidence of self-injury in their creative writing, journals, or art projects. General signs of depression Social and emotional isolation and disconnectedness Substance abuse Possession of sharp implements (razor blades, thumb tacks) Source: Toste & Heath, School Response to Non-Suicidal Self-Injury. The Prevention Researcher, Vol. 17, No. 1, Feb. 2010

33 Cutting/Self-Injury Why Do Young People Do This? It is a coping skill to manage intense emotions Make selves feel real instead of numb. Feel rush of pleasure, like a runner s high. To physically express emotional pain Communicate their pain in the absence of words. To re-enact physical or sexual abuse. To take control over something in their lives. It is a pain they can control (statement by patient). Source: Cutting and Self-Mutilation: When Teens Injure Themselves (2003). Kathleen Winkler, Enslow Publishing, Berkeley Heights, NJ.

34 Cutting/Self-Injury But, does it work? Feelings about self-injury immediately after 70% feel better 21% feel worse 9% no change a few hours later 30% feel better 47% feel worse 23% no change a few days later 18% feel better 50% feel worse 32% no change Beyond the Pain: Hope and Healing from Self-Injury and Self-Mutilation, Mark Hirschfeld, LCSW. October 10, 2006 conference in Missoula, MT.

35 Initial Response to Students Engaging in NSSI Do Approach the student in a calm & caring way Accept the person even though you may not accept the behavior Let the student know that people care Understand that this is a way of coping Use the students language for NSSI Show respectful willingness to listen Show non-judgmental compassion for their experience

36 Initial Response to Students Engaging in NSSI Don t Over-react. It will alienate the student Respond with panic or shock Try to stop the behavior with ultimatums Show interest in the actual behavior Permit the student to relive the experience Talk about it in front of the class or peers Tell the student that you won t tell anyone Source: Toste & Heath, School Response to Non-Suicidal Self-Injury. The Prevention Researcher, Vol. 17, No. 1, Feb. 2010

37 Cutting/Self-Mutilation Treatment of Self-Injury Unfortunately, no single definitive approach has been identified to treat NSSI. The most promising treatments involve a combination of cognitive behavioral therapy with medications (SSRIs, Atypical Antipsychotics) for underlying disorders.

38 Cutting/Self-Mutilation Cognitive behavioral therapy focuses on: not telling them to stop cutting unless you have a replacement behavior. Remember, cutting is a coping skill, a way they are surviving. not condemning their anger, teach them healthier ways of expressing their anger. teaching the child how to label and articulate a broader range of emotions. encouraging journal writing to enhance awareness and insight. helping child identify triggers that start cycle preparing the child to stop (a list of 10 things you could do instead of cutting)

39 Approximately 90% of those who complete suicide suffer from at least one major psychiatric disorder Mood disorders are consistently the most prevalent disorder (49-64%) The 2nd most frequent diagnosis is a Substance abuse disorder. (however, it is important to note that not all mentally ill people attempt suicide)

40 Depression is Treatable Depression is one of the most treatable of all psychiatric disorders in young people 86% treatment rate with a combination of antidepressants and therapy* Only 40-70% with either by themselves. * Source: The TADS Team. The Treatment for Adolescents with Depression Study (TADS): Long-term Effectiveness and Safety Outcomes. Archives of General Psychiatry. Oct 2007; VOL 64(10).

41 Rebound Effect People do not recover overnight. People come out of wanting to commit suicide slowly. Their affect may appear brighter because they have finally made up their minds and see an end to their pain and anguish.

42 Rebound Effect The greatest suicidal risk is not when the people are in the depths of depression, but during the first 90 days after the depression begins to lift. 1 Suicidal thoughts or attempts were four times more likely during the first 10 days of treatment than after three months. 2 The highest rate of suicide is not while a person is in inpatient treatment, it is the first 30 days after discharge. 3 Source: 1 The Center for Information on Suicide, Marv Miller, Ph.D. Suicidologist, Sand Diego, CA. 2 Journal of the American Medical Association. 2004;292: American Association of Suicidology National Convention, San Francisco, CA, April 16-18,2009

43 Factors involved in adolescent suicidal ideations Lack of parental connectedness 86% of parents whose child completed suicide did not know their child was suicidal. Correlated with all school violence Depression by the youth Suicidal behavior by the parent Domestic violence

44 Traits that are highly associated with suicide are: Immaturity Egocentricity Dependency Hostility Anxiety Low Tolerance for Frustration Impulsivity

45 A few things to remember concerning the method of attempted suicide 70-90% of attempted suicides involve drug overdose, but only 2-11% succeed while over 90% of suicides attempts using guns succeed (CDC, 7/1/08). The role of ambivalence. Both sexes prefer overdose, but males tend toward violent means (guns, autos) In recent years, there has been an increase in wrist cutting. However, this is rarely the sole cause of death in completed suicides.

46 Demographics associated with the youth who attempt suicide Females make more attempts(3:1) Males succeed more often (5:1) Average age is 16 History of previous out of home placement Committed criminal offenses, including violence. Previous suicide attempts

47 Warning Signs of Adolescent Suicide Abrupt change in personality Expressing thoughts of death or suicide Giving away prized possessions Previous suicide attempt Increase in drug/alcohol use Eating disturbance Sleep disturbance Inability to tolerate frustration

48 Warning Signs of Adolescent Suicide Withdrawal and rebelliousness Isolating from friends and family Decrease in communication Sexual promiscuity Decrease in personal hygiene Uncharacteristic theft or vandalism

49 Warning Signs of Adolescent Suicide Flat affect or depressed mood. Exaggerated apathy Complaints of being bored Carelessness or increase in accidents Unusually long grief reaction Overall sense of sadness or hopelessness

50 Warning Signs of Adolescent Suicide Increase in hostility Decrease in academic performance Difficulty concentrating Recent family disruption Recent history of running away Abrupt end to a romance The key is that the youth is acting out of character

51 Keys things to remember in assessing the degree of risk Don t hesitate to bring up the subject of suicide for fear of planting the idea in the mind of the youth. This is a serious mistake! Being direct validates their pain and feelings. Ask the youth directly, Are you having thoughts of killing yourself? If they answer yes, ask them, How would you do it? (suicide plan)

52 If the youth does have a suicide plan, how to determine the seriousness of risk. Specificity How specific are the details of the plan of attack? Have they rehearsed? Lethality What is the level of lethality of the proposed method of self attack. Availability What is the availability of the proposed method? Proximity What is the proximity of helping resources?

53 Factors to use to access current level of risk (given an attempt) The strongest behavioral warning is an attempted suicide Dangerousness The greater the dangerousness of the attempt, the higher the current level of risk. e.g. Did the youth take five pills or twenty pills? Intent of degree of risk e.g. Did the youth believe taking five pills would kill them?

54 Factors to use to access current level of risk (given an attempt) Timing The more recent the attempt, the higher the current level of risk.- e.g. was it three months ago or three years ago? Rescue Did the youth tell anyone they made an attempt? Any notes left? -In over 70% of successful suicides, the person gave some type of warning.

55

56 Suicide Risk Factors Previous suicide attempts Mental disorders particularly mood disorders such as depression and bipolar disorder Co-occurring mental and alcohol and substance abuse disorders Family history of suicide Hopelessness

57 More Risk Factors Impulsive and/or aggressive tendencies Barriers to accessing mental health and/or substance abuse treatment Relational, social, work, or financial loss Physical illness Easy access to lethal methods, especially guns

58 More Risk Factors Unwillingness to seek help because of stigma attached to mental and substance abuse disorders and/or suicidal thoughts Influence of significant people family members, celebrities, peers who have died by suicide both through direct personal contact or inappropriate media representations Cultural and religious beliefs for instance, the belief that suicide is a noble resolution of a personal dilemma Local epidemics of suicide that have a contagious influence Isolation, a feeling of being cut off from other people

59 Suicide Protective Factors Effective and appropriate clinical care for mental, physical, and substance abuse disorders (depression is the one of the most treatable of all psychiatric disorders) Easy access to a variety of clinical interventions and support for help seeking Restricted access to highly lethal methods of suicide Family and community support

60 More Protective Factors Support from ongoing medical, mental health and substance abuse care relationships Learned skills in problem solving, conflict resolution, and nonviolent handling of disputes Cultural and religious beliefs that discourage suicide and support self-preservation instincts

61 QPR Ask A Question, Save A Life

62 QPR Question, Persuade, Refer

63 QPR QPR is not intended to be a form of counseling or treatment. QPR is intended to offer hope through positive action.

64 QPR Suicide Myths and Facts Myth No one can stop a suicide, it is inevitable. Fact If people in a crisis get the help they need, they will probably never be suicidal again. Myth Confronting a person about suicide will only make them angry and increase the risk of suicide. Fact Asking someone directly about suicidal intent lowers anxiety, opens up communication and lowers the risk of an impulsive act.

65 QPR Suicide Myths and Facts Myth Only experts can prevent suicide. Fact Suicide prevention is everybody s business, and anyone can help prevent the tragedy of suicide Myth Suicidal people keep their plans to themselves. Fact Most suicidal people communicate their intent sometime during the week preceding their attempt.

66 QPR Myths And Facts Myth Those who talk about suicide don t do it. Fact People who talk about suicide may try, or even complete, an act of self-destruction. Myth Once a person decides to complete suicide, there is nothing anyone can do to stop them. Fact Suicide is the most preventable kind of death, and almost any positive action may save a life. How can I help? Ask the

67 QPR Suicide Clues And Warning Signs The more clues and signs observed, the greater the risk. Take all signs seriously!

68 QPR Direct Verbal Clues: I ve decided to kill myself. I wish I were dead. I m going to commit suicide. I m going to end it all. If (such and such) doesn t happen, I ll kill myself.

69 QPR Indirect Verbal Clues: I m tired of life, I just can t go on. My family would be better off without me. Who cares if I m dead anyway. I just want out. I won t be around much longer. Pretty soon you won t have to worry about me.

70 QPR Behavioral Clues: Any previous suicide attempt Acquiring a gun or stockpiling pills Co-occurring depression, moodiness, hopelessness Putting personal affairs in order Giving away prized possessions Sudden interest or disinterest in religion Drug or alcohol abuse, or relapse after a period of recovery Unexplained anger, aggression and

71 QPR Situational Clues: Being fired or being expelled from school A recent unwanted move Loss of any major relationship Death of a spouse, child, or best friend, especially if by suicide Diagnosis of a serious or terminal illness Sudden unexpected loss of freedom/fear of punishment Anticipated loss of financial security Loss of a cherished therapist, counselor, teacher, or pet Fear of becoming a burden to others

72 QPR Tips for Asking the Suicide Question If in doubt, don t wait, ask the question If the person is reluctant, be persistent Talk to the person alone in a private setting Allow the person to talk freely Give yourself plenty of time Have your resources handy; QPR Card, phone numbers, counselor s name and any other information that might help Remember: How you ask the question is less important than that you ask it

73 Q QUESTION Less Direct Approach: Have you been unhappy lately? Have you been very unhappy lately? Have you been so very unhappy lately that you ve been thinking about ending your life? Do you ever wish you could go to sleep and never wake up?

74 Q QUESTION Direct Approach: You know, when people are as upset as you seem to be, they sometimes wish they were dead. I m wondering if you re feeling that way, too? You look pretty miserable, I wonder if you re thinking about suicide? Are you thinking about killing yourself? NOTE: If you cannot ask the question, find someone who can.

75 How Not to Ask the Suicide Question You re not suicidal, are you?

76 P PERSUADE HOW TO PERSUADE SOMEONE TO STAY ALIVE Listen to the problem and give them your full attention Remember, suicide is not the problem, only the solution to a perceived insoluble problem Do not rush to judgment Offer hope in any form

77 P PERSUADE Then Ask: Will you go with me to get help? Will you let me help you get help? Will you promise me not to kill yourself until we ve found some help? YOUR WILLINGNESS TO LISTEN AND TO HELP CAN REKINDLE HOPE, AND MAKE ALL THE DIFFERENCE.

78 R REFER Suicidal people often believe they cannot be helped, so you may have to do more. The best referral involves taking the person directly to someone who can help. The next best referral is getting a commitment from them to accept help, then making the arrangements to get that help. The third best referral is to give referral information and try to get a good faith commitment not to complete or attempt suicide. Any willingness to accept help at some time, even if in the future, is a good outcome.

79 REMEMBER Since almost all efforts to persuade someone to live instead of attempt suicide will be met with agreement and relief, don t hesitate to get involved or take the lead.

80 For Effective QPR Say: I want you to live, or I m on your side...we ll get through this. Get Others Involved. Ask the person who else might help. Family? Friends? Brothers? Sisters? Pastors? Priest? Rabbi? Bishop? Physician?

81 For Effective QPR Join a Team. Offer to work with clergy, therapists, psychiatrists or whomever is going to provide the counseling or treatment. Follow up with a visit, a phone call or a card, and in whatever way feels comfortable to you, let the person know you care about what happens to them. Caring may save a life.

82 REMEMBER WHEN YOU APPLY QPR, YOU PLANT THE SEEDS OF HOPE. HOPE HELPS PREVENT SUICIDE.

83 Evidenced-Based Suicide Prevention Programs QPR A two hour training that provides anybody the basic tools on how to intervene with a suicidal person

84 Other Evidenced-Based Suicide Prevention Programs ASIST A two-day workshop designed to provide participants with gatekeeping knowledge and skills. Gatekeepers are taught to recognize the warning signs and to intervene with appropriate assistance.

85 Other Evidenced-Based Suicide Prevention Programs SOS: Signs of Suicide School-based program which aims to raise awareness of suicide and reduce stigma of depression There is also a brief screening for depression and other factors associated with suicidal behavior.

86 Other Evidenced-Based Prevention Programs Mental Health First Aid Mental Health First Aid is a groundbreaking public education program that helps the public identify, understand, and respond to signs of mental illnesses and substance use disorders.

87 Other Evidenced-Based Prevention Programs Crisis Intervention Training CIT came out of the Memphis Police Dept. and is a training for law enforcement officers to help them manage mental health issues when they respond to a call.

88 Other Evidenced-Based Prevention Programs Good Behavior Game The classroom management strategy is designed to improve aggressive/disruptive classroom behavior. It is implemented when children are in 1st or 2nd grade in order to provide students with the skills they need to respond to later, possibly negative, life experiences and societal influences. Studies have suggested that implementing the Good Behavior Game may delay or prevent onset of suicidal ideations and attempts in early adulthood.

89 Other Suicide Prevention Resources for Schools Assists high schools and school districts in designing and implementing strategies to prevent suicide and promote behavioral health. Includes tools to implement a multi-faceted suicide prevention program that responds to the needs and cultures of students. Available free at

90 Other Resources Suicide Prevention Toolkit for Rural Primary Care Physicians Suicide assessment and intervention kit designed for physicians practicing in rural communities.

91 Other Resources Parents as Partners: A Suicide Prevetnion Guide for Parents A 9 page guide that helps parents recognize the signs of depression and suicide in their kids.

92 Other Resources The Trevor Project the leading national organization providing crisis intervention and suicide prevention services to lesbian, gay, bisexual, transgender and questioning (LGBTQ) young people ages

93 Other Resources Firearm Safety Program Increase suicide awareness while protecting firearms from inappropriate use. 90% of the people who attempt suicide and survive will not go on to die by suicide at a later date. Means Matter

94 Depression is Treatable Suicide is Preventable If you are in crisis and want help, call the Montana Suicide Prevention Lifeline, 24/7, at TALK ( ) Or text mt to