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Mental health advocates are calling for increased efforts to support Black youth. With suicide rates rising faster among Black teens than their White peers, experts worry current public health crises may place them at even higher risk. Given the disproportionate impact of COVID-19 and police violence on Black communities, young people in these settings may be more exposed to trauma. In response, advocates are urging lawmakers to allocate funding for more mental health care in Black communities and research to understand suicide risk among Black youth. Other efforts are focused on normalizing conversations about mental health in Black families and encouraging those who are struggling to seek treatment. Young Black suicide attempt survivors, such as Victoria Waltz, are speaking out about their experience in an effort to help others. Everyone can benefit from therapy, she said.

Spark Extra! Find Black mental health resources.

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"We're Losing Our Kids": Black Youth Suicide Rate Rising Far Faster than for Whites; Coronavirus, Police Violence Deepen Trauma

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Mental health advocates are calling for increased efforts to support Black youth. With suicide rates rising faster among Black teens than their White peers, experts worry current public health crises may place them at even higher risk. Given the disproportionate impact of COVID-19 and police violence on Black communities, young people in these settings may be more exposed to trauma.

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The Pandemic Has Researchers Worried About Teen Suicide

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The Pandemic Has Researchers Worried About Teen Suicide

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Teen and youth anxiety and depression are getting worse since COVID lockdowns began in March, early studies suggest, and many experts say they fear a corresponding increase in youth suicide.

At the end of June, the Centers for Disease Control and Prevention surveyed Americans on their mental health. They found symptoms of anxiety and depression were up sharply across the board between March and June, compared with the same time the previous year. And young people seemed to be the hardest-hit of any group.

Almost 11 percent of all respondents to that survey said they had "seriously considered" suicide in the past 30 days. For those ages 18 to 24, the number was 1 in 4 - more than twice as high.

Data collection for several studies on teen mental health during the pandemic is currently underway. And experts worry those studies will show a spike in suicide, because young people are increasingly cut off from peers and caring adults, because their futures are uncertain and because they are spending more time at home, where they are most likely to have access to lethal weapons.

"Teenagers are in a developmental space where it is critically important that they have regular contact with their peers and are able to develop close and ongoing relationships with adults outside the home, such as their teachers, their coaches, their advisers," says Lisa Damour, an adolescent psychologist who is a columnist and host of the podcast Ask Lisa: The Psychology of Parenting. "And I worry very much about what it means for that to be disrupted by the pandemic."

The stressors of COVID come as youth suicide was already at a record high before the pandemic, with increases every year since 2007. Suicide is the second leading cause of death among people ages 10-24, after accidents, as it has been for many years, according to the most recent data available from the CDC.

Not having guns in the home, or keeping them safely locked away, is another overlooked factor in suicide risk. A new analysis of the latest CDC data, just released by the advocacy group Everytown for Gun Safety, found that the rate of specifically firearm suicides increased 51% for 15-24 year olds in the decade ending in 2018. Among 10- to 14-year-olds, who have a lower rate of suicide to begin with, suicide by gun increased a staggering 214% in that time frame.

Gun suicide is astonishingly lethal: Of all suicide attempts not involving guns, 94% fail, and most of those people do not try again, Everytown reports. Of all suicide attempts that do involve guns, 90% succeed. That's one reason that gun ownership correlates with the youth suicide rate, state by state. A study last year found that for each 10 percent increase in household gun ownership in a state, the suicide rate for 10- to 19-year-olds increases by more than 25 percent.

And, the presence of guns is another community risk factor that has increased during the pandemic: From March to July 2020, Everytown reports, gun sales doubled compared with the year before.

Carrson Everett, 17, says when he himself attempted suicide, the fact that his parents kept their guns safely locked away and out of reach most likely helped save his life. He says that during the pandemic, "Teenagers are already having the effect of isolation, staying at home and everything. And now there's all these new firearms in their homes and, you know, we can't tell who's safely storing their guns and who isn't. And it's very dangerous."

Everett has started his senior year of high school in Kingsport, Tenn., on a hybrid schedule. On the days that he's home, he says he wonders what he's missing out on at school. "Everyone feels isolated, and it's been very tough for everybody."

He says these past few months have been especially hard for him because he has depression and anxiety. Plus, he says he's been bullied for years for being gay, including over video chat during distance learning.

Everett is a volunteer for Students Demand Action, an anti-gun violence group that is part of Everytown. He said he's learned that gun violence isn't just a matter of crime or mass shootings, but also suicide. "I wrote an op-ed about a kid that was my age over in Cookeville, Tennessee, that had taken his own life with a firearm because he had been outed [as gay] at school. So, you know, it's very relatable for me."

Damour, the teen psychologist, explains that not having guns in the home, or keeping them safely locked away, is important especially for adolescents because "teens are impulsive."
What parents can do
She says parents need to know that suicide is preventable. A red flag is when sadness is more than a passing mood. Caregivers need to check in regularly - which can be unexpectedly complicated when the whole family is spending so much time at home.

A common pattern, she notes, is parents trying to work during the day, and teenagers staying up late at night to have time to themselves. This isn't inherently a problem, Damour says, but "there's a difference between allowing privacy and allowing a teenager to hole up in their room for days at a time."

If a teen talks about harming themselves or wanting to disappear, a parent should ask directly, "Is that something you think you might really do or you think about doing? Or are you just letting me know that you're very upset right now?" And, she adds, hear them out without dismissing what they're saying.

She also says parents should look out for anger: "In teenagers, uniquely, depression can take the form of irritability. That depression in teenagers sometimes looks like a prickly porcupine. Everybody rubs them the wrong way. And that is easy to miss because sometimes we'll just dismiss that as being a snarky teenager."

If school is all-virtual, she says, parents should look for safe sports, work or volunteer opportunities that allow teens to have social time and contact with other caring adults.

Finally, Damour says she sees one bright spot: During the pandemic, she and other clinicians are finding that telemedicine - therapy over video chat - is working surprisingly well with adolescents.

"The teenagers that I see are often talking to me from their bedrooms, sometimes flopped over in their beds," she says. "There's something unguarded about it that's very different than having them sit in my office."

And, virtual therapy can lower barriers to access for families who might have had to travel to get accessible mental health care.
If you or someone you know is having suicidal thoughts, reach out for help. The National Suicide Prevention Lifeline is open 24 hours a day at 800-273-8255.

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The Pandemic Has Researchers Worried About Teen Suicide

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Teen and youth anxiety and depression are getting worse since COVID lockdowns began in March, early studies suggest, and many experts say they fear a corresponding increase in youth suicide. At the end of June, the Centers for Disease Control and Prevention surveyed Americans on their mental health.

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America is Facing a Teen Suicide Pandemic 

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America is Facing a Teen Suicide Pandemic 

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Six months ago, we could not have imagined that our daily vocabulary would be filled with the p-word. And while perhaps we are getting tired of hearing the word pandemic, I can't help but ask why we haven't used it to bring urgency to confronting teen suicide. The race to find a cure to the COVID-19 pandemic certainly is front and center, but that same sense of urgency does not seem to be evident for the unsettling rise in teen suicide.

In the United States, suicide is the 10th leading cause of death-with more than 2,000 14- to 18-year-olds dying every year by suicide, and accounting for about one of every three injury-related deaths. That's the equivalent of losing a large high school's worth of teenagers to suicide, year after year. These numbers demand our attention.

New CDC data reveal that almost one in five teens across the nation have seriously considered attempting suicide. Picture a typical high school classroom of 25 students. About five of those students could be thinking about suicide.

Data come from the Youth Risk Behavior Surveillance System, which has monitored trends in youth health behaviors since 1990. According to the new report, the numbers of students who have considered attempting suicide are even higher for students identifying as female, Black, or non-heterosexual. In addition, about one in six students have made a suicide plan and slightly more than one in 10 have attempted suicide.

These numbers are scary-and become even more alarming when we look at the data over time; trends suggest that we are facing a teen suicide pandemic. Over the past 20 years, suicide rates have skyrocketed by over 60 percent, with almost every suicide indicator and student population showing increasing trends.

Similar findings can be found as our teens continue to young adulthood. The Healthy Minds Study tracks student mental health in participating colleges and universities across the United States. Results from the most recent winter/spring survey administration of over 55,000 students indicate that slightly more than one in 10 (14 percent) experienced suicidal ideation over the past year. More than half say they somewhat to strongly needed help for emotional or mental problems, yet 9 percent said they would not talk to anyone if they were experiencing serious emotional distress. In a lecture hall of 50 college students, this means that about seven of them may have considered suicide this past year, and five of them would not talk to anyone about their distress.

In his New York Times piece, " Why Are Young Americans Killing Themselves?", Dr. Richard Friedman questions how the high rates of teen depression and suicide are even possible given that proven solutions are readily available. We aren't entirely clear on why this is the case, but all of us must take part in a comprehensive approach to prevent, recognize, and respond to this crisis:

Prevent. Create a physically and emotionally safe environment for your teens so that thoughts and behaviors about suicide are less likely to happen in the first place. When teens and those around them have the necessary skills to regulate their emotions, and have opportunities to practice these skills and connect with others through positive relationships, we create a safer environment. Through suicide prevention efforts, we can reduce risk and promote resilience and coping.

Recognize. Be aware of the warning signs of youth suicide. Learning the signs and taking part in mental health awareness campaigns is important, as is ensuring that teens have open channels for talking about their emotions. Actions such as these will help us recognize when something is off, while reducing any stigma around seeking help for mental health issues. Every young person needs someone to confide in about their thoughts and feelings.

Respond. Learn to be comfortable supporting those who appear emotionally distressed. #BeThe1To offers five action steps for communicating with someone who may be considering suicide: (1) ask in a non-judgmental and supportive way; (2) be there so they feel connected; (3) keep them safe; (4) help them connect to supports; and (5) follow up to see how they are doing. Respond is also about putting additional strategies in place, such as increased regular mental health check-ins, during times of increased stress and reduced coping.

Keep in mind that the data reviewed here were collected prior to the outbreaks of COVID-19, the subsequent economic downturn, and the nationwide protests against police brutality. We are only beginning to get a glimpse of the challenges facing our mental health and emotional well-being; a quick web search shows numerous media reports of record numbers of suicide and overdose since early spring. Forecasts of reactions and responses to disaster suggest we are heading into a period in which we will see spikes in suicidality that could even be underestimated given the magnitude and duration of our situation. We need to sound the alarms.

Every September brings National Suicide Prevention Month. What if each of us uses this year to take action in confronting the data on suicide? Unlike COVID-19, we already know the solution to prevent, recognize, and respond to teen suicide.
If you or someone you know is showing warning sides of suicide risk, reach out to the National Suicide Prevention Lifeline at 1-800-273-TALK or at suicidepreventionlifeline.org. You can also reach out to Crisis Text Line by texting TALK to 741741. To find therapists near you, see the Psychology Today Therapy Directory.

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America Is Facing a Teen Suicide Pandemic

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Six months ago, we could not have imagined that our daily vocabulary would be filled with the p-word. And while perhaps we are getting tired of hearing the word pandemic, I can't help but ask why we haven't used it to bring urgency to confronting teen suicide.

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COVID-19 Takes Adolescent Suicide Prevention to Less Charted Territory - Aug 2020

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COVID-19 Takes Adolescent Suicide Prevention to Less Charted Territory - Aug 2020

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The last decade saw an increase in national attention to suicide as the second leading cause of death among adolescents [] and for increased youth suicide prevention efforts. Adolescents at highest risk are typically referred to emergency departments for assessment and immediate safety management, and those who cannot be maintained safely at home are often hospitalized on inpatient psychiatric units until risk decreases. At the outpatient level, mental health interventions include individual and group psychotherapy, family and collateral sessions, and medication management. However, the implementation of social distancing for minimizing the spread of coronavirus disease 2019 (COVID-19) has limited the availability of traditional "in-person" interventions to treat adolescents at risk for suicide. How do we best address the mental health needs of suicidal adolescents during the largest public health crisis of our lifetimes? This question presents an unprecedented challenge for mental health providers, researchers, and families.

The COVID-19 outbreak has hit the U.S. health care system at its weakest points-health care access, affordability, and sufficient workforce and supplies. To maintain the availability of vital resources for youth suicide prevention, mental health providers have rapidly transitioned to offer outpatient services online via "telehealth"-the virtual delivery, coordination, and evaluation of health care []-while facing a surge in demand of care and a decreasing number of available professionals and acute services. Although telehealth is a newer modality of service delivery for mental health, technology has been used to enhance the access, delivery, and quality of mental health care for decades. Telephone-based crisis lines, for instance, have played a prominent role in suicide prevention efforts in the U.S. since the mid-20th century []. However, there is a dearth in evidence-based studies on the effectiveness of telehealth as a first-line approach for the assessment and treatment of adolescents with suicidal behavior. For example, we know that having a strong relationship with a therapist is a protective factor against suicidal behavior; however, whether "virtual" interactions with a therapist adequately substitute for in-person interactions has not been tested. It is also unclear to what extent suicide risk assessment conducted via telehealth is equivalent in accuracy to in-person assessment.

Furthermore, the lack of coverage of telehealth by some insurance plans has pressured mental health providers to advocate for coverage for their young clients, to scale fees, and to be creative in how they reach their clients. Not all families have access to the necessary technology and reliable internet coverage to receive telehealth services, nor have the digital literacy to use these services []. Even when families are prepared to access telehealth services, the system may not be ready to serve clients who cannot speak English. Therefore, disparities in telehealth service use may mirror or surpass the racial and socioeconomic disparities observed for in-person mental health service use. These families with fewer resources, who will be hit the hardest by this outbreak, may already be the most in need of mental health services.

Whether the COVID-19 outbreak will result in increases in youth suicidal thoughts and behavior is currently unknown. Adapting to sheltering-in-place and remote schooling, unemployment, unstable housing, and the potential of family sickness and loss may fuel stress and conflict among household members. Such conflict may increase vulnerability to depression, anxiety, and trauma-related disorders and therefore suicide risk among vulnerable adolescents [,]. Yet, the COVID-19 outbreak may provide unforeseen benefits for some adolescents. A break from school attendance and problematic peer interactions may offer a temporary reprieve from suicidal thoughts []. Being at home may also increase parents' ability to limit access to lethal means and to closely monitor their children.

Telehealth services may also offer unique advantages and solutions to provide patient-centered care. Some adolescents may prefer "online" versus in-person therapy sessions, as electronic methods of communication are commonly selected by this age group. Telehealth can also address and potentially eliminate some of the barriers to accessing mental health services for both adolescents and their caregivers and improve session attendance [], such as finding time for an in-person session within a busy schedule and commuting to a provider. Telehealth sessions may also allow the parent to have greater participation in the teen's treatment without having to miss work, spend time in a waiting room, or find childcare for other children in the home. Access to telehealth services may also facilitate nonhospital opportunities for adolescents and their parents to manage a suicidal crisis in the real-world contexts in which they occur.

Based on the authors' interactions with colleagues and professional organizations during the COVID-19 pandemic, mental health providers working with suicidal youth have reported providing the full range of in-person treatment modalities via video-conferencing platforms. The second author is one of the leaders of an intensive outpatient program for suicidal and self-harming adolescents that has been conducted entirely via Zoom for the past 2 months. The program uses dialectical behavior therapy [] and includes individual therapy sessions, adolescent group sessions, and multifamily skills groups. The ability to provide the intensive outpatient program via telehealth has allowed for the continued availability of intensive outpatient care, which typically services as a bridge between inpatient/residential and standard outpatient treatment. At the same time, because treatments such as dialectical behavior therapy are time intensive and resource intensive, this may be an opportunity to use telehealth and other forms of technology to increase access to such treatments among adolescents and families served by clinics with fewer existing resources.

Clinicians offering services via telehealth can benefit from using mobile phone applications specifically designed for suicide prevention and safety planning, which allow them to standardize and personalize safety and coping plans for adolescents [, , ]. Finally, collecting patient-reported outcome measures between telehealth visits have the potential to facilitate close monitoring, relationship development, and continuity of care for adolescents at high risk for suicide, especially in the absence of the in-person contact. Those measures can also be collected through online platforms or applications designed to administer standardized self-report measures and collect information to assess suicide risk in real time and in the natural environment.

Providing telehealth services is not without its challenges, including issues related to privacy and data security. Institutions should be aware of the risks of conducting telehealth visits through third-party digital platforms and make sure that protected health information is not stored in those systems or that the platforms can guarantee a minimum risk of data breach. Therapists can also have "ground rules" for individual and group sessions. To maintain both privacy and safety, youth may be required to verify their address at the beginning of the session and to have a parent in the home and accessible during the session. In addition, youth should participate in a private setting and be encouraged to use headphones to prevent conversations from being overheard. Zoom also provides functions for the therapist to mute or end participation for youth who are violating group rules and/or are engaging in behaviors that may be problematic for other group members.

Despite best efforts to keep adolescents safe at home, we recognize that some families may still need professional guidance. We recommend that parents and caregivers use the following evidence-based strategies to decrease suicide risk and the need for emergency services among vulnerable adolescents during the COVID-19 outbreak:

Restrict access to dangerous or potentially life-threatening items in the home, such as firearms, knives, medications, and other harmful substances.

Closely supervise adolescents with a history of suicide attempts and nonsuicidal self-injurious behavior and limit time spent alone to prevent opportunities to engage in self-harm.

Collaboratively monitor the adolescents' phone calls, texts, and social media use. Make sure they are not watching videos about self-harm or suicide. Adolescents are particularly vulnerable to "contagion" of self-harm behavior via both peer interactions and media exposure []. Another reason to monitor their social media is that adolescent bullying often occurs online. During shelter-in-place, set limits around internet usage and encourage other activities to prevent excessive exposure to or use of harmful social media.

Attempt to keep conflict in the home low, so that adolescents feel comfortable turning to their parents or caregivers for help. This is particularly relevant during shelter-in-place, during which families are spending an increased amount of time together under stressful circumstances.

Frequently check how the adolescent is feeling and create spaces for dialog, even when the adolescent does not engage in the conversion.

Treat any talk of self-harm or suicide seriously and go to the nearest emergency room or call 911 if the adolescent cannot be kept safe in the home.

This is a critical time for studying the short- and long-term impact of COVID-19 on adolescent suicide rates, the effectiveness of telehealth interventions, and disparities in telehealth access. Adolescents are experts in connecting with friends and family over technology. Therefore, they should be regarded as invaluable consultants in research studies seeking to assess telehealth interventions for suicide prevention. Similarly, parents and caregivers are at the frontline for youth suicide prevention and can provide input as to which strategies are working to reduce youth suicide risk in the home. Finally, we need to include input from mental health providers who are outside of academia in pilot studies testing the feasibility and acceptability of translating evidence-based practices to telehealth platforms.

Although the COVID-19 outbreak has highlighted cracks in our health care system and fears about the "unknown," it is crucial that mental health care providers, families, and adolescents focus on what they do know in preventing suicide. Mental health care providers, no matter their current comfort with virtual care, have years of experience supporting people through crises. We have the tools to weather this storm. In doing so, we must seek to improve our telehealth services for suicide prevention, positioning us to be better prepared for future crises where social distancing and quarantine may be necessary, as well as for providing alternatives to in-person treatment to reduce barriers to care.

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COVID-19 Takes Adolescent Suicide Prevention to Less Charted Territory

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The last decade saw an increase in national attention to suicide as the second leading cause of death among adolescents [] and for increased youth suicide prevention efforts. Adolescents at highest risk are typically referred to emergency departments for assessment and immediate safety management, and those who cannot be maintained safely at home are often hospitalized on inpatient psychiatric units until risk decreases.

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If you are in crisis, call the toll-free National Suicide Prevention Lifeline at 1-800-273-TALK (8255), available 24 hours a day, 7 days a week. The service is available to anyone. All calls are confidential. http://www.suicidepreventionlifeline.org

Demographics

Crude suicide rate calculations take population size within subgroups in any given year or timeframe into account. They can be a useful tool for understanding the relative proportion of people affected within different demographic groups.

Figure 2 shows the crude rates of suicide within sex and age categories in 2019.

Among females, the suicide rate was highest for those aged 45-64 (9.6 per 100,000).

Among males, the suicide rate was highest for those aged 75 and older (39.9 per 100,000).

Figure 2

Figure 3 shows the crude rates of suicide for race/ethnicity groups in 2019 based on data from the CDC's WISQARS Fatal Injury Data Visualization Tool.

The crude rates of suicide were highest for American Indian, Non-Hispanic males (33.4 per 100,000) and, followed by White, Non-Hispanic males (29.8 per 100,000). Among females the crude rates of suicide were highest for American Indian, Non-Hispanic females (11.1 per 100,000) and White, Non-Hispanic females (8.0 per 100,000).

Figure 3

Suicide Rates by State

Just as state population numbers and age distributions vary, suicide rates can vary widely from state to state. Based on data from the CDC WISQARS Fatal Injury Data Visualization Tool, Figure 4 shows a map of the United States with each state's age-adjusted suicide rate in 2019 indicated by color.

Figure 4

Source: CDC - WISQARS (Web-based Injury Statistics Query and Reporting System) Fatal Injury Mapping
Website: https://wisqars.cdc.gov:8443/cdcMapFramework/mapModuleInterface.jsp Applied Filters: Suicide All Injury Deaths
States: All States
Race: All Races
Ethnicity: All Ethnicities
Sex: All Sexes
Year Range: 2019-2019
Age Range: All Ages

Percent of Suicide Deaths by Method

Figure 5 shows the percentages of suicide deaths by method among females and males in 2019. Among females, the most common methods of suicide were firearm (31.4%), poisoning (30.0%), and suffocation (29.0%). Among males, the most common methods of suicide were firearm (55.6%) followed by suffocation (28.4%).

Figure 5

Figure 6 shows that 4.8% of adults age 18 and older in the United States had serious thoughts about suicide in 2019.

Among adults across all age groups, the prevalence of serious suicidal thoughts was highest among young adults aged 18-25 (11.8%).

The prevalence of serious suicidal thoughts was highest among adults age 18 and older who report having multiple (two or more) race (6.9%).

Figure 6

* Persons of Hispanic origin may be of any race; all other racial/ethnic groups are non-Hispanic.
NH/OPI = Native Hawaiian / Other Pacific Islander / AI/AN = American Indian / Alaskan Native

Figure 7 shows that in 2019, 0.6% of adults age 18 and older in the United States report they attempted suicide in in the past year.

Among adults across all age groups, the prevalence of suicide attempt in the past year was highest among young adults 18-25 years old (1.8%).

Among adults age 18 and older, the prevalence of suicide attempts in the past year was highest among those who report having multiple (two or more) races (1.5%).

Figure 7

* Persons of Hispanic origin may be of any race; all other racial/ethnic groups are non-Hispanic.
NH/OPI = Native Hawaiian / Other Pacific Islander / AI/AN = American Indian / Alaskan Native

Figure 8 shows that in 2019, 12.0 million adults aged 18 or older reported having serious thoughts of suicide, and 1.4 million adults attempted suicide during the past year.

Figure 8

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If you are in crisis, call the toll-free National Suicide Prevention Lifeline at 1-800-273-TALK (8255), available 24 hours a day, 7 days a week. The service is available to anyone. All calls are confidential. http://www.suicidepreventionlifeline.org Crude suicide rate calculations take population size within subgroups in any given year or timeframe into account.

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Adaptation of Evidenced-Based Suicide Prevention 

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Adaptation of Evidenced-Based Suicide Prevention 

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Abstract

Suicide is preventable. Nevertheless, each year 800,000 people die of suicide in the world. While there is evidence indicating that suicide rates de-crease during times of crises, they are expected to increase once the immediate crisis has passed. The COVID-19 pandemic affects risk and pro-tective factors for suicide at each level of the socio-ecological model. Economic downturn, augmented barriers to accessing health care, increased access to suicidal means, inappropriate media reporting at the societal level; deprioritization of mental health and preventive activities at the community level; interpersonal conflicts, neglect and violence at the relationship level; unemployment, poverty, loneliness and hopelessness at the individual level: all these variables contribute to an increase of depression, anxiety, post-traumatic stress disorder, harmful use of alcohol, substance abuse, and ultimately suicide risk. Suicide should be prevented by strengthening universal strategies directed to the entire population, including mitigation of unemployment, poverty and inequalities; prioritization of access to mental health care; responsible media reporting, with information about available support; prevention of increased alcohol intake; and restriction of access to lethal means of suicide. Selective interventions should continue to target known vulnerable groups who are socio-economically disadvantaged, but also new ones such as first responders and health care staff, and the bereaved by COVID-19 who have been deprived of the final contact with loved ones and funerals. Indicated preventive strategies targeting individuals who display suicidal behaviour should focus on available pharmacological and psychological treatments of mental disorders, ensuring proper follow-up and chain of care by increased use of telemedicine and other digital means. The scientific community, health care professionals, politicians and decision-makers will find in this paper a systematic description of the effects of the pandemic on suicide risk at the society, community, family and individual levels, and an overview of how evidence-based suicide preventive interventions should be adapted. Research is needed to investigate which adaptations are effective and in which con-texts.

Approximately 800,000 people die of suicide each year, with a rate of 10.5 per 100,000 people (males: 13.7 per 100,000; females 7.5 per 100,000). This number is underestimated, due to variations in the methods of monitoring and death registration as well as cultural factors. Suicide is the second leading cause of death among people aged 15-24 worldwide, and for each death by suicide 10 to 20 suicide attempts are estimated.

It has been reported that, during times of natural disasters, war, or epidemics such as the severe acute respiratory syndrome (SARS), suicide rates may momentarily decrease. However, after the immediate crisis has passed, suicide rates increase. The COVID-19 pandemic poses a special challenge to people around the world, as it affects both physical and mental health, economy, and social life.

Physical distancing and lockdown measures, work disruptions and school closures have suddenly changed social life and daily routines. A major effect of these measures has been the reduction of social contacts, with a consequent increase in social isolation and feelings of loneliness, both in turn associated with increased anxiety, depression and suicidal behaviour.

Even if some positive outcomes related to staying at home have been highlighted, such as the adoption of healthier eating habits and the increase of sleep hours, reports show that movement restrictions aimed to stop the spread of the virus are causing a worldwide increase in family problems and domestic violence. A systematic review documented that family conflict is the most commonly reported precipitant of suicidal acts among children. A high prevalence of domestic violence victimization has been reported among people seeking treatment for self-harm in the UK. Furthermore, intimate partner violence and childhood abuse and neglect have been found to be associated with suicide attempts.

As a consequence of the lockdown and other public health measures implemented in many countries, a global economic crisis at least as bad as the one occurring in 2008 is expected. In the European Union, the unemployment rate is predicted to rise from 6.7% in 2019 to 9% in 2020. In the US, more than 20 million people lost their jobs in April 2020. The unemployment rate increased to 14.7%, while it was 3.5% in February 2020, before the spreading of the virus in the country.

According to the United Nations, the pandemic hit the Latin America and the Caribbean in a period in which their economy was already weak and indebted. Consequently, a 3.4% increase in the unemployment rate for 2020 (from an already high 8.1% rate in 2019) is forecast, resulting in an increase of 44.7 million people in poverty or extreme poverty. Furthermore, at least 11 million people will fall into poverty across East Asia and the Pacific, and 27 million people will face extreme poverty in Africa.

There is consistent evidence of an association between economic crises and increased suicide rates, especially in high-income countries, such as those in Europe and North America, and among men in working age or unemployed. Analyzing data between 1970 and 2007 for 26 European Union countries, it has been estimated that every 1% increase in the unemployment rate is associated with a 0.79% rise in suicides at ages below 65, with 60 to 550 potential excess deaths. An estimate of the impact of the COVID-19 recession forecasts a 3.3% to 8.4% increase in suicide rate in the US. However, previous research also shows that policy responses and governmental expenditures may be able to mitigate the impact of unemployment and economic crises on suicide rates.

According to the World Health Organization (WHO), as of August 30, 2020, there were more than 838,000 confirmed deaths worldwide attributable to COVID-19. Other analyses suggest that the real death toll of the pandemic is higher than what official statistics show. COVID-19 deaths lead to bereavement overload, because of the frequent multiple deaths within the families, and the impossibility to visit and assist the dying person or even join the funeral or ritual ceremonies due to the prohibition of public gatherings. The accumulation of deaths and the fact that COVID-19 mortality mostly affects the elderly may induce, in the society, indifference and attitudes to overlook the deep pain and distress of bereaved families, further contributing to complicate the grief.

Reports predicting a rise in suicide rates as well as in mental health problems call for appropriate actions during and after the crisis. Suicide is an unnecessary death and can be prevented by using evidence-based methods. However, a broad approach according to the socio-ecological model is needed.

The aim of this paper is to systematically evaluate the influence of the COVID-19 pandemic on risk and protective factors for suicide at the societal, community, relationship and individual levels. Adjustments of evidence-based universal, selective and indicated suicide prevention strategies are recommended to provide guidance to clinicians, public mental health professionals, politicians and decision-makers.

IMPACT OF THE COVID-19 PANDEMIC ON RISK AND PROTECTIVE FACTORS FOR SUICIDE

According to the WHO, risk and protective factors for suicidal behaviour are categorized, in line with the socio-ecological model, into four levels: society, community, relationship and individual.

Risk and protective factors are likely to be influenced by the COVID-19 pandemic in different ways. Some risk factors, such as a family history of suicide, will not be affected at all. Many modifiable risk factors may be exacerbated, leading to an increase in the risk of suicide over time. The prevalence of stress, sleep disturbances, anxiety, depression, alcohol and drug abuse, with suicide as their utmost consequence, is likely to increase. Financial problems and worries about the uncertain future and unemployment will also contribute to an increase in suicide rates.

Protective factors for suicide have been described, such as effective mental health care, strong personal relationships, a supportive social network, life skills and ability to adapt, practice of positive coping strategies, and religious or spiritual beliefs.

Protective factors may be influenced positively or negatively, depending on the economic and social actions that will be taken by politicians and decision-makers in response to the COVID-19 pandemic. Strategies may be of varying effectiveness in different regions or countries. With an adequate and effective response, the pandemic may even represent an opportunity to strengthen suicide preventive efforts.

The expected effects of the pandemic on each risk and protective factor at the society, community, relationship and individual level are summarized in Tables 1-4.

EVIDENCE-BASED SUICIDE PREVENTION STRATEGIES DURING THE COVID-19 PANDEMIC

The universal-selective-indicated (USI) model, in which different populations are targeted depending on the level of suicide risk, is mostly used for the categorization of suicide preventive interventions.

Universal suicide preventive strategies target everyone in a defined population (e.g., a nation, a county, a local community). They are aimed at increasing awareness about suicide and mental health, removing barriers to care, promoting help-seeking behaviours and protective factors such as social support and coping skills, and mitigating the impact of economic downturns. Examples of universal interventions include awareness campaigns and educational programs, limiting access to suicide means, guidelines for responsible media reporting, and governmental measures to address economic crises.

Selective suicide preventive strategies are meant for specific groups who are at increased vulnerability for suicidal behaviour, such as people with mental health problems, alcohol and drug abusers, prisoners, victims of physical and sexual violence, members of the lesbian, gay, bisexual, transgender and queer (LGBTQ) community, migrants, and the bereaved. Screening programs in health care or other facilities, gatekeeper training for frontline helpers, psychological support and treatment of mental health problems and substance abuse in people who do not display signs of suicidality as yet, are all considered selective suicide preventive interventions.

Indicated suicide preventive strategies target high-risk individuals who are displaying signs of suicidal behaviour, and are aimed at timely and appropriately assessing and dealing with the suicide risk using case management, referral to psychiatric treatment and care, skill-building interventions and support groups.

The suicide preventive interventions proven to be most effective include: restriction of access to lethal means, policies to reduce harmful use of alcohol, school-based awareness programs, pharmacological and psychological treatment of depression, chain of care and follow-up of at-risk individuals, responsible media reporting, and policy responses to mitigate the impact of economic downturns. Other interventions, such as gatekeeper training, are also theoretically valid, even if conclusive evidence of their effectiveness on reducing suicidal behaviour is not yet available.

All preventive strategies require adjustments and adaptation in the light of the new challenges that are posed by the COVID-19 pandemic.

Universal interventions

Mitigating the impact of unemployment, poverty and inequalities

Active labour market policies, including job search assistance, job training and subsidized employment, have a positive impact on health and quality of life. More specifically, at the individual level, job search assistance programs with a psychological component, such as improving self-confidence and self-efficacy, have been found to exert positive effects on mental health, such as reduced depression, anxiety and distress symptoms. At the national level, increases in government spending on active labour market policies have been shown to reduce the effect of unemployment on suicide rates. It has been calculated that, for each US$10 per person increased investment in these policies, the effect of unemployment on suicides was reduced by 0.038%. In another study, it has been reported that the same amount of increased spending would correspond to a 0.026% decrease in male suicide rate. If spending for active labour market policies were higher than US$190 per person per year, rises in unemployment would have no effect on suicide rates. These findings advocate for specific governmental actions.

In the US, the maximum allowable unemployment benefit was found to be associated with a reduced impact of economic downturns on suicide rates. Similarly, in European countries, the unemployment protection system was reported to mitigate the negative impact of unemployment on suicide rates. In this context, the adoption of policies related to universal basic income (UBI) during and in the aftermath of the COVID-19 pandemic could significantly decrease its social and psychological costs. UBI is defined as "a periodic cash payment unconditionally delivered to all on an individual basis, without means-test or work requirement". Interventions which unconditionally provided substantial cash transfers to individuals or families have been found to have positive effects on educational participation and on some health outcomes, including mental health. In Indonesia, a cash transfer program providing between $39 and $220 per person annually was found to reduce the yearly suicide rate by 0.36 per 100,000 people, corresponding to an 18% decrease.

Housing loss may represent a significant trigger for suicidal crisis. For example, eviction- and foreclosure-related suicides doubled between 2005 and 2010, during the US housing crisis, and significantly contributed to the increase of suicide rates. Housing interventions, such as relocating disadvantaged people to less deprived areas or improving physical housing conditions, are reported to be successful in reducing mental health problems. Policies to subsidize housing costs have been used during the pandemic in some countries and their effect on mental health should be evaluated.

Restricting access to lethal means of suicide

There are few reliable data on suicide methods. One global overview showed several differences in preferred suicide means between countries and even between different regions in the same country, with hanging, self-poisoning and firearms as the most frequently used methods. A recent systematic review of 16 studies confirmed that hanging (81.3%), firearms (56.3%), poisoning/overdose (43.7%) and jumping from a height (18.7%) are the most common reported suicide methods.

In most European countries, hanging is reported to be the predominant method of suicide. Pesticide self-poisoning accounts for around 20% of suicides globally and 48.3% of those in low- and middle-income countries in the Western Pacific region. Firearms account for 50.5% of suicide deaths in the US, followed by suffocation (28.6%) and self-poisoning (12.9%). Although jumping from a height is a relatively uncommon method of suicide in most countries, it plays an important role in urban settings such as Hong Kong, Singapore, Luxembourg and Malta, and is considered a highly lethal method.

Restricting access to lethal means of suicide entails various points of application, such as limitations in the size of packs of medications, use of antidepressants which are not dangerous in overdose, safety procedures and safer room design for hospitals and prisons (e.g., not wearing belts or shoes with laces, minimizing the number of suspension points available for hanging), more stringent firearm regulations, installation of barriers and safety nets at jumping sites, and limitation of access to highly lethal pesticides. The effectiveness of these strategies is supported by robust evidence. Planned suicidal acts may be delayed if people are precluded from implementing the chosen method, increasing the chance of suicide prevention. Moreover, in impulsive suicidal acts, people tend to use the most readily accessible method. If there are no lethal methods available, the suicidal crisis may pass or the use of a less lethal method may result in non-fatal outcomes.

Governments, at the national and regional level, are advised to restrict and increase monitoring of sales of lethal means for suicide, such as firearms and pesticides. Additionally, temporary restrictions on the amount of some medications (e.g., analgesics) bought per person should be considered. Public awareness strategies and policies to ensure or reinforce safe storage of firearms and medications at home as well as pesticides at warehouses are of importance. Public awareness should be increased by informing about the significance of reducing access to lethal means of suicide.

Policies to reduce harmful use of alcohol

Evidence exists that alcohol use is associated with increased risk of suicidal behaviour. Reducing harmful use of alcohol through policies and interventions has been shown to reduce suicide rates effectively, especially for males. The best example was probably the restructuring of the former Soviet Union ( perestroika), when heavy restrictions of alcohol use were introduced: between 1984 and 1990, suicide rates decreased for males by 32%, in comparison with 8% in Europe.

Public awareness about mental health and suicide

As a result of the increasing concerns for the mental health consequences of the COVID-19 pandemic, international organizations, such as the WHO and the United Nations, and national and local authorities are releasing resources and guidelines for the promotion of mental health and raising awareness about the potential increase of mental health problems and suicide during the pandemic.

Besides increasing mental health knowledge and literacy, key aspects of suicide prevention resources should empower the general population with coping skills by providing useful advice, promoting help-seeking behaviour and making information avail-able about where to get help.

School-based interventions

Young people are a vulnerable group for risk of suicide. Suicide is the second leading cause of death worldwide among the 15-24 year old. Evidence suggests that 13.4% of children and adolescents have a diagnosed mental disorder. A much higher proportion reports mental health symptoms such as depression or anxiety (30.4% and 23.3%, respectively).

Strong evidence for the effectiveness of school-based interventions has been shown in increasing help-seeking behaviour, enhancing awareness about mental health and risk and protective factors for suicide, and decreasing the incidence of suicide attempts and severe suicidal ideation.

During the COVID-19 pandemic, schools have frequently been closed or physical attendance has substantially decreased, which has been reducing or completely stopping school-based mental health interventions. Schools have a major role in children and adolescents' social development. During the pandemic, peer relationships, which are important to foster autonomy and independence in adolescence, are substantially affected. The increased use of social media, substituting real-life peer relations, may result in pathological Internet use, a higher risk of cyberbullying and other negative health outcomes, such as anxiety, depression and suicidality. Feelings of anxiety and distress may also arise as a consequence of the uncertainty about final exams and future school re-opening.

Governments, at the national and regional level, are encouraged to resume school-based interventions as soon as schools re-open. Availability of online resources for youth mental health, such as helplines and information about how to get support, should be increased. Additionally, teachers and parents are advised to discuss the pandemic and feelings about it with children and adolescents.

Responsible media reporting

Irresponsible media coverage may promote suicidal behaviours in recipients by sensationalizing suicide or paying unproportioned attention to spectacular suicides. However, protective effects may be established through responsible reporting of suicide as well as public education.

Access to health care

Appropriate and accessible care for mental disorders, substance use, and physical illnesses is effective in reducing suicide risk. Due to increased pressure on the health care system during the COVID-19 pandemic, an adequate care for mental disorders may be deprioritized. An additional reduction in access is likely due to closed practices and increased sick-leave of mental health care professionals.

The mental health problems and suicidal behaviour of frontline health care professionals, first responders (e.g., ambulance operators) and other health care workers may increase due to their crucial role during the pandemic, associated with high stress.

Actions are required to provide financial support to mental health services, ensure accessibility, increase staff, develop digital services, and provide tools for self-care online. Moreover, the local health care systems are encouraged to plan and adjust resources to maintain or improve treatment and follow-up of patients with mental disorders, and adopt and reinforce the use of telemedicine.

Selective interventions

Gatekeeper training

Gatekeeper training is a widely used strategy to reduce suicide risk, even if supportive evidence for its effectiveness mostly comes from uncontrolled studies. It entails training of key people, such as teachers, first responders, or human resource managers, to identify suicidal individuals and refer them to appropriate services.

Most of the already trained gatekeepers probably belong to frontline responders (e.g., general practitioners, nurses, officers) and, for this reason, they are full-time involved in the emergency battle against the virus or even sick themselves. On the other hand, gatekeepers belonging to the general population (e.g., religious officials, teachers) may be prevented to identify and interact with suicidal individuals due to lockdown measures. Furthermore, a decrease in the availability of gatekeepers may be the result of paused or reduced gatekeeper training during the COVID-19 pandemic.

During the pandemic, continued training online or in person, in line with local regulations about appropriate physical distance, should be ensured. Also, actions to increase the number of volunteers to participate in the programs is advised. Successful examples of the adaptation of standard gatekeeper training to the current situation are the Alliance Project and the Zero Suicide Alliance, that are offering brief online trainings. The Mental Health First Aid is an Australian gatekeeper training evolved into global initiatives, and now organizes online courses. It proved to be effective in improving knowledge, attitudes and helping behaviours towards adults with mental health problems.

Interventions for vulnerable groups

Individuals with psychiatric conditions are recognized as those most severely impacted by the psychosocial effects of the pandemic and, due to the existing association between psychiatric disorders and health risk behaviours (e.g., smoking, obesity, alcohol use, low adherence to precautionary measures), they are also at increased risk of infection and its complications. Outreach interventions and a closer follow-up of patients with severe psychiatric disorders may allow to enhance treatment adherence and to timely identify and intervene on psychiatric emergencies. The creation of online networks may provide adequate social support and mitigate the temporary unavailability of community services.

Besides increasing the unemployment rate, the current global crisis is exacerbating existing socio-economic inequalities. Indeed, migrants, different cultural and ethnic minorities as well as socio-economically disadvantaged groups have been found to be less able to adhere to "stay at home" recommendations and, consequently, to be more affected by the virus. These groups largely overlap with those at increased risk for suicide.

Specific interventions are needed for these vulnerable populations aimed at increasing access to health care and reducing socio-economic inequalities through labour and welfare policies. Reinforcing crisis helplines may be also pivotal to timely identify and intervene on emerging psychosocial crises potentially leading to suicidal behaviour.

Another important effect of this global crisis is the increase in domestic and intimate partner conflicts and violence. Public health actions to prevent domestic violence are needed and should be adapted to the current situation. Surveillance methods through text messages, hidden smartphone notifications or other methods that allow victims of domestic violence to safely ask for help should be used. Police and health records can be linked according to local legislation to timely identify individuals at risk. Adequate surveillance should be ensured through routine inquiries and remote consultation with the health care system. To mitigate and prevent the negative mental health impact, victims of domestic and intimate partner violence should be referred to online or in person evidence-based interventions, such as those based on cognitive behavioural therapy.

COVID-19 patients and frontline health workers are also particularly vulnerable to negative psychological outcomes. Therefore, interventions to increase mental health awareness, promote effective coping skills, reduce primary and secondary post-traumatic stress disorder (PTSD) symptoms and decrease social isolation should be implemented. Mental health screenings and assessments should be scheduled, and referral to evidence-based treatments be ensured.

Bereavement from COVID-19 may be very challenging. Traumatic death, a lack of preparation for the death, and low social support have been described as risk factors for complicated grief, which in turn results in increased risk for suicidal behaviours, independently from other psychiatric disorders such as major depressive disorder and PTSD.

Finally, the previously described impact of the pandemic in increasing social isolation and loneliness becomes particularly concerning when considering older people. A recent study reported that being 59-80 years old was significantly associated with higher levels of depression, anxiety and PTSD symptoms during the pandemic, compared to the younger age groups. Phone calls and online platforms may represent valuable instruments to mitigate the sense of loneliness and social isolation, even if there might be disparities in access to or literacy in digital resources among older people.

Indicated interventions

Treatment of mental disorders

Strong evidence for the effectiveness of pharmacological and psychological treatment of psychiatric disorders in order to reduce suicidal behaviour exists. National and regional pharmaco-epidemiologic studies show a protective effect of the prescription of antidepressants on suicide. Antidepressants have been reported to decrease suicidal thoughts and behaviours in adult and geriatric patients. Literature consistently reports anti-suicidal effects of lithium, both in clinical samples and in the general population. Other mood stabilizers, such as valproate, lamotrigine and carbamazepine, may also have an anti-suicidal effect. It has been reported that second-generation antipsychotics are effective in reducing suicidal risk in patients with schizophrenia. Promising results are reported for the use of ketamine: a single infusion was found to rapidly reduce suicidal thoughts, within one day and for up to one week, in depressed patients with suicidal ideation, but long-term effects are not yet evaluated.

Among psychotherapies, individual cognitive behavioural therapy has been reported to significantly reduce suicidal thoughts and behaviour compared to treatment as usual. In a recent meta-analysis, dialectical behaviour therapy was found to be effective in reducing suicidal behaviour and re-attempt, especially in females with borderline personality disorder. Brief interventions, focused on the identification of warning signs, coping skills and available social support, professional help and crisis planning, have been shown to be effective in preventing suicidal thoughts and behaviour. The brief intervention and contact (BIC) implemented in the WHO Multisite Intervention Study on Suicidal Behaviours (SUPRE-MISS) randomized controlled trial showed a significant decrease in suicide after 18-month follow-up in comparison with treatment as usual.

During the COVID-19 pandemic, containment measures affect treatment availability, as practices and other psychiatric services may be closed. A worsening of symptoms of mental disorders - such as anxiety, depression and PTSD - among psychiatric patients, and an increase in mental health disorders in the general population, including first responders, may occur. Consequently, suicidal behaviour may increase.

Chain of care and follow-up

A continuous and functioning chain of care, with adequate follow-up of patients, has been shown to be effective in reducing suicide for at-risk individuals. Due to the increasing demands on health care systems during the COVID-19 pandemic, a disruption of the chain of care and delayed follow-up of psychiatric patients is likely to occur, with potential negative effects on suicide risk.

Critical in continuity of care is the promotion of treatment engagement. Providing patients with psychoeducation regarding the importance of follow-up treatment and an outpatient appointment within the first week after discharge are recommended strategies for engaging suicidal individuals. Post-discharge follow-up contacts, including phone calls, postcards, letters and technology-based methods (e.g., e-mails and texting) have showed promising results in enhancing treatment adherence and reducing suicidal behaviour.

Appropriate actions are required to develop new helplines and reinforce the existing ones for suicidal patients and individuals affected by the pandemic and to increase the training of volunteer workers in mental health. The use of telemedicine appears to be critical in maintaining an effective chain of care surrounding suicidal patients.

TELEMEDICINE DURING THE COVID-19 PANDEMIC

During the ongoing pandemic, mental health care faces significant challenges related to staff shortages, decrease of resources, and the risk of health care services becoming hotspots for contagion. Telemedicine is one of the best tools to tackle these challenges and simultaneously address the expected increase in demand for mental health care.

Telemedicine is defined as the remote delivery of health care with the aid of technology. It usually includes two-way audio and video remote communication between patients and health care professionals. However, other forms, such as self-help applications or websites, may support the tele-mental health care and offer additional opportunities for treatment.

There are several advantages of expanding telemedicine in mental health care. First, psychiatric diagnosis and treatment constitute a reasonable setting for telemedicine because they are conducted through interviews as opposed to physical assessment. Second, costs of telemedicine may be lower compared to traditional mental health care. Third, other barriers of traditional approaches to mental health care, such as stigma, are reduced. The potential to increase care has also been recognized for suicide prevention efforts.

Barriers that limit the use of telemedicine include the lack of access to the Internet, the required electronic devices, or the technological capabilities of recipients, especially individuals in old age or with serious mental health illnesses. The coverage of telemedicine through insurances may be limited, and integration into the health care systems is required to ensure the broad availability of digital medical services to the population.

Legal and ethical challenges are related to the storage and sharing of sensitive personal data, security of the communication with patients, privacy for the patient at the location where the remote consultation is held, and difficult choices in situations in which a traditional in-person visit is required to achieve the best treatment effects. The remote management of patients with acute suicide risk poses very significant ethical questions and should be managed by involving the family and the social network. Direct communication with emergency services should be available when the attempts to motivate the suicidal person to seek help are unsuccessful. Legal regulation for tele-medicine is missing in most countries and is urgently required.

There is some evidence for the effectiveness of technology-enhanced suicide preventive interventions. Unguided digital self-management interventions have shown to reduce suicidal ideation and suicide-related symptoms in individuals with severe psychiatric difficulties or self-harm, while others showed reductions of suicidal ideation, but not of self-harm or attempted suicide, compared to wait-list controls or self-management interventions. Technology-enhanced suicide preventive interventions may be more effective in younger people, due to their higher acceptance and affinity with technology. Brief texting contact has shown potential to reduce re-attempt after a suicide attempt through initiating contact with crisis support.

The agreement of psychiatric diagnoses between in-person and telemedicine assessment appears to be high, indicating its potential utility. Additionally, telepsychiatry has been found to be cost-effective and appears to be useful as crisis intervention. Hence, various advantages of implementing telemedicine and some evidence for its use in suicide prevention are available. Due to the limited methodologies used in previous studies about telemedicine, more high-quality research is required.

During the COVID-19 pandemic, it has become apparent that a large number of visits can be managed on distance, that the infrastructure for telemedicine is widely available, and that the pandemic itself represents an opportunity to expand the use of telemedicine. It has been reported that telepsychiatry may be efficient to screen for mental health symptoms in COVID-19 patients and to optimize treatment, or that online assessments are helpful prior to appointments and as follow-up. Continued care is, thus, enabled in a time when the health care systems are overwhelmed.

Existing and additional challenges to utilizing telemedicine in mental health care have become apparent as well. New protocols for assessment and therapy must be established quickly. Privacy, confidentiality and access issues remain. Quiet places and headphones are required and, in case of limited privacy, yes/no questions should be adopted. These issues may affect certain people more than others. For example, lower socio-economic status may result in smaller living spaces and consequently reduced privacy. Lack of access to electronic devices may occur for elderly patients. Disabilities and technology illiteracy pose a major obstacle to access. Social aspects of traditional medical approaches are lost with telemedicine, and this may be a significant problem for some categories of psychiatric patients.

The continued evaluation of telemedicine is essential. The in-frastructure requires improvement and growth to counter the unique challenges during the pandemic in the short term. The prospect to sustain these changes in the long term and improve care is a valuable opportunity that should guide the efforts of policy-makers. Even though evidence for telemedicine designed specifically for suicide prevention is limited, some advantages have already been highlighted.

CONCLUSIONS

The continued and strengthened implementation of suicide preventive measures during and after the COVID-19 pandemic is of global importance. Suicide prevention should be a priority for policy-makers and health care professionals alike and should not be postponed while facing this pandemic. This paper aims at informing the scientific community, health care professionals, policy-makers and politicians about plausible adaptations and/or reinforcements of evidence-based suicide preventive strategies, which should be undertaken due to the severe impact of the pandemic on everyday life.

The analysis of risk and protective factors shows that most of them are affected and the pandemic may have both positive and negative impacts. However, the negative effect appears to be greater. Thus, the foreseen increase of mental health issues and suicides is likely to happen.

Selecting suicide prevention strategies based on strong evidence remains essential throughout this crisis. However, we face unique challenges due to the need of urgent measures and lack of evidence that indicates how interventions should be adapted. The adaptations and reinforcements may be more effective in some regions or countries compared to others, due to differences in local suicide rates, interventions already in place, the status of the local health care and mental health care system, or local and national policies. Confirmatory research is needed to investigate which adaptations are effective taking the different cultural, economic and health care context into account.

Abstract

Suicide is preventable. Nevertheless, each year 800,000 people die of suicide in the world. While there is evidence indicating that suicide rates de-crease during times of crises, they are expected to increase once the immediate crisis has passed. The COVID-19 pandemic affects risk and pro-tective factors for suicide at each level of the socio-ecological model. Economic downturn, augmented barriers to accessing health care, increased access to suicidal means, inappropriate media reporting at the societal level; deprioritization of mental health and preventive activities at the community level; interpersonal conflicts, neglect and violence at the relationship level; unemployment, poverty, loneliness and hopelessness at the individual level: all these variables contribute to an increase of depression, anxiety, post-traumatic stress disorder, harmful use of alcohol, substance abuse, and ultimately suicide risk. Suicide should be prevented by strengthening universal strategies directed to the entire population, including mitigation of unemployment, poverty and inequalities; prioritization of access to mental health care; responsible media reporting, with information about available support; prevention of increased alcohol intake; and restriction of access to lethal means of suicide. Selective interventions should continue to target known vulnerable groups who are socio-economically disadvantaged, but also new ones such as first responders and health care staff, and the bereaved by COVID-19 who have been deprived of the final contact with loved ones and funerals. Indicated preventive strategies targeting individuals who display suicidal behaviour should focus on available pharmacological and psychological treatments of mental disorders, ensuring proper follow-up and chain of care by increased use of telemedicine and other digital means. The scientific community, health care professionals, politicians and decision-makers will find in this paper a systematic description of the effects of the pandemic on suicide risk at the society, community, family and individual levels, and an overview of how evidence-based suicide preventive interventions should be adapted. Research is needed to investigate which adaptations are effective and in which con-texts.

Approximately 800,000 people die of suicide each year, with a rate of 10.5 per 100,000 people (males: 13.7 per 100,000; females 7.5 per 100,000). This number is underestimated, due to variations in the methods of monitoring and death registration as well as cultural factors. Suicide is the second leading cause of death among people aged 15-24 worldwide, and for each death by suicide 10 to 20 suicide attempts are estimated.

It has been reported that, during times of natural disasters, war, or epidemics such as the severe acute respiratory syndrome (SARS), suicide rates may momentarily decrease. However, after the immediate crisis has passed, suicide rates increase. The COVID-19 pandemic poses a special challenge to people around the world, as it affects both physical and mental health, economy, and social life.

Physical distancing and lockdown measures, work disruptions and school closures have suddenly changed social life and daily routines. A major effect of these measures has been the reduction of social contacts, with a consequent increase in social isolation and feelings of loneliness, both in turn associated with increased anxiety, depression and suicidal behaviour.

Even if some positive outcomes related to staying at home have been highlighted, such as the adoption of healthier eating habits and the increase of sleep hours, reports show that movement restrictions aimed to stop the spread of the virus are causing a worldwide increase in family problems and domestic violence. A systematic review documented that family conflict is the most commonly reported precipitant of suicidal acts among children. A high prevalence of domestic violence victimization has been reported among people seeking treatment for self-harm in the UK. Furthermore, intimate partner violence and childhood abuse and neglect have been found to be associated with suicide attempts.

As a consequence of the lockdown and other public health measures implemented in many countries, a global economic crisis at least as bad as the one occurring in 2008 is expected. In the European Union, the unemployment rate is predicted to rise from 6.7% in 2019 to 9% in 2020. In the US, more than 20 million people lost their jobs in April 2020. The unemployment rate increased to 14.7%, while it was 3.5% in February 2020, before the spreading of the virus in the country.

According to the United Nations, the pandemic hit the Latin America and the Caribbean in a period in which their economy was already weak and indebted. Consequently, a 3.4% increase in the unemployment rate for 2020 (from an already high 8.1% rate in 2019) is forecast, resulting in an increase of 44.7 million people in poverty or extreme poverty. Furthermore, at least 11 million people will fall into poverty across East Asia and the Pacific, and 27 million people will face extreme poverty in Africa.

There is consistent evidence of an association between economic crises and increased suicide rates, especially in high-income countries, such as those in Europe and North America, and among men in working age or unemployed. Analyzing data between 1970 and 2007 for 26 European Union countries, it has been estimated that every 1% increase in the unemployment rate is associated with a 0.79% rise in suicides at ages below 65, with 60 to 550 potential excess deaths. An estimate of the impact of the COVID-19 recession forecasts a 3.3% to 8.4% increase in suicide rate in the US. However, previous research also shows that policy responses and governmental expenditures may be able to mitigate the impact of unemployment and economic crises on suicide rates.

According to the World Health Organization (WHO), as of August 30, 2020, there were more than 838,000 confirmed deaths worldwide attributable to COVID-19. Other analyses suggest that the real death toll of the pandemic is higher than what official statistics show. COVID-19 deaths lead to bereavement overload, because of the frequent multiple deaths within the families, and the impossibility to visit and assist the dying person or even join the funeral or ritual ceremonies due to the prohibition of public gatherings. The accumulation of deaths and the fact that COVID-19 mortality mostly affects the elderly may induce, in the society, indifference and attitudes to overlook the deep pain and distress of bereaved families, further contributing to complicate the grief.

Reports predicting a rise in suicide rates as well as in mental health problems call for appropriate actions during and after the crisis. Suicide is an unnecessary death and can be prevented by using evidence-based methods. However, a broad approach according to the socio-ecological model is needed.

The aim of this paper is to systematically evaluate the influence of the COVID-19 pandemic on risk and protective factors for suicide at the societal, community, relationship and individual levels. Adjustments of evidence-based universal, selective and indicated suicide prevention strategies are recommended to provide guidance to clinicians, public mental health professionals, politicians and decision-makers.

IMPACT OF THE COVID-19 PANDEMIC ON RISK AND PROTECTIVE FACTORS FOR SUICIDE

According to the WHO, risk and protective factors for suicidal behaviour are categorized, in line with the socio-ecological model, into four levels: society, community, relationship and individual.

Risk and protective factors are likely to be influenced by the COVID-19 pandemic in different ways. Some risk factors, such as a family history of suicide, will not be affected at all. Many modifiable risk factors may be exacerbated, leading to an increase in the risk of suicide over time. The prevalence of stress, sleep disturbances, anxiety, depression, alcohol and drug abuse, with suicide as their utmost consequence, is likely to increase. Financial problems and worries about the uncertain future and unemployment will also contribute to an increase in suicide rates.

Protective factors for suicide have been described, such as effective mental health care, strong personal relationships, a supportive social network, life skills and ability to adapt, practice of positive coping strategies, and religious or spiritual beliefs.

Protective factors may be influenced positively or negatively, depending on the economic and social actions that will be taken by politicians and decision-makers in response to the COVID-19 pandemic. Strategies may be of varying effectiveness in different regions or countries. With an adequate and effective response, the pandemic may even represent an opportunity to strengthen suicide preventive efforts.

The expected effects of the pandemic on each risk and protective factor at the society, community, relationship and individual level are summarized in Tables 1-4.

EVIDENCE-BASED SUICIDE PREVENTION STRATEGIES DURING THE COVID-19 PANDEMIC

The universal-selective-indicated (USI) model, in which different populations are targeted depending on the level of suicide risk, is mostly used for the categorization of suicide preventive interventions.

Universal suicide preventive strategies target everyone in a defined population (e.g., a nation, a county, a local community). They are aimed at increasing awareness about suicide and mental health, removing barriers to care, promoting help-seeking behaviours and protective factors such as social support and coping skills, and mitigating the impact of economic downturns. Examples of universal interventions include awareness campaigns and educational programs, limiting access to suicide means, guidelines for responsible media reporting, and governmental measures to address economic crises.

Selective suicide preventive strategies are meant for specific groups who are at increased vulnerability for suicidal behaviour, such as people with mental health problems, alcohol and drug abusers, prisoners, victims of physical and sexual violence, members of the lesbian, gay, bisexual, transgender and queer (LGBTQ) community, migrants, and the bereaved. Screening programs in health care or other facilities, gatekeeper training for frontline helpers, psychological support and treatment of mental health problems and substance abuse in people who do not display signs of suicidality as yet, are all considered selective suicide preventive interventions.

Indicated suicide preventive strategies target high-risk individuals who are displaying signs of suicidal behaviour, and are aimed at timely and appropriately assessing and dealing with the suicide risk using case management, referral to psychiatric treatment and care, skill-building interventions and support groups.

The suicide preventive interventions proven to be most effective include: restriction of access to lethal means, policies to reduce harmful use of alcohol, school-based awareness programs, pharmacological and psychological treatment of depression, chain of care and follow-up of at-risk individuals, responsible media reporting, and policy responses to mitigate the impact of economic downturns. Other interventions, such as gatekeeper training, are also theoretically valid, even if conclusive evidence of their effectiveness on reducing suicidal behaviour is not yet available.

All preventive strategies require adjustments and adaptation in the light of the new challenges that are posed by the COVID-19 pandemic.

Universal interventions

Mitigating the impact of unemployment, poverty and inequalities

Active labour market policies, including job search assistance, job training and subsidized employment, have a positive impact on health and quality of life. More specifically, at the individual level, job search assistance programs with a psychological component, such as improving self-confidence and self-efficacy, have been found to exert positive effects on mental health, such as reduced depression, anxiety and distress symptoms. At the national level, increases in government spending on active labour market policies have been shown to reduce the effect of unemployment on suicide rates. It has been calculated that, for each US$10 per person increased investment in these policies, the effect of unemployment on suicides was reduced by 0.038%. In another study, it has been reported that the same amount of increased spending would correspond to a 0.026% decrease in male suicide rate. If spending for active labour market policies were higher than US$190 per person per year, rises in unemployment would have no effect on suicide rates. These findings advocate for specific governmental actions.

In the US, the maximum allowable unemployment benefit was found to be associated with a reduced impact of economic downturns on suicide rates. Similarly, in European countries, the unemployment protection system was reported to mitigate the negative impact of unemployment on suicide rates. In this context, the adoption of policies related to universal basic income (UBI) during and in the aftermath of the COVID-19 pandemic could significantly decrease its social and psychological costs. UBI is defined as "a periodic cash payment unconditionally delivered to all on an individual basis, without means-test or work requirement". Interventions which unconditionally provided substantial cash transfers to individuals or families have been found to have positive effects on educational participation and on some health outcomes, including mental health. In Indonesia, a cash transfer program providing between $39 and $220 per person annually was found to reduce the yearly suicide rate by 0.36 per 100,000 people, corresponding to an 18% decrease.

Housing loss may represent a significant trigger for suicidal crisis. For example, eviction- and foreclosure-related suicides doubled between 2005 and 2010, during the US housing crisis, and significantly contributed to the increase of suicide rates. Housing interventions, such as relocating disadvantaged people to less deprived areas or improving physical housing conditions, are reported to be successful in reducing mental health problems. Policies to subsidize housing costs have been used during the pandemic in some countries and their effect on mental health should be evaluated.

Restricting access to lethal means of suicide

There are few reliable data on suicide methods. One global overview showed several differences in preferred suicide means between countries and even between different regions in the same country, with hanging, self-poisoning and firearms as the most frequently used methods. A recent systematic review of 16 studies confirmed that hanging (81.3%), firearms (56.3%), poisoning/overdose (43.7%) and jumping from a height (18.7%) are the most common reported suicide methods.

In most European countries, hanging is reported to be the predominant method of suicide. Pesticide self-poisoning accounts for around 20% of suicides globally and 48.3% of those in low- and middle-income countries in the Western Pacific region. Firearms account for 50.5% of suicide deaths in the US, followed by suffocation (28.6%) and self-poisoning (12.9%). Although jumping from a height is a relatively uncommon method of suicide in most countries, it plays an important role in urban settings such as Hong Kong, Singapore, Luxembourg and Malta, and is considered a highly lethal method.

Restricting access to lethal means of suicide entails various points of application, such as limitations in the size of packs of medications, use of antidepressants which are not dangerous in overdose, safety procedures and safer room design for hospitals and prisons (e.g., not wearing belts or shoes with laces, minimizing the number of suspension points available for hanging), more stringent firearm regulations, installation of barriers and safety nets at jumping sites, and limitation of access to highly lethal pesticides. The effectiveness of these strategies is supported by robust evidence. Planned suicidal acts may be delayed if people are precluded from implementing the chosen method, increasing the chance of suicide prevention. Moreover, in impulsive suicidal acts, people tend to use the most readily accessible method. If there are no lethal methods available, the suicidal crisis may pass or the use of a less lethal method may result in non-fatal outcomes.

Governments, at the national and regional level, are advised to restrict and increase monitoring of sales of lethal means for suicide, such as firearms and pesticides. Additionally, temporary restrictions on the amount of some medications (e.g., analgesics) bought per person should be considered. Public awareness strategies and policies to ensure or reinforce safe storage of firearms and medications at home as well as pesticides at warehouses are of importance. Public awareness should be increased by informing about the significance of reducing access to lethal means of suicide.

Policies to reduce harmful use of alcohol

Evidence exists that alcohol use is associated with increased risk of suicidal behaviour. Reducing harmful use of alcohol through policies and interventions has been shown to reduce suicide rates effectively, especially for males. The best example was probably the restructuring of the former Soviet Union ( perestroika), when heavy restrictions of alcohol use were introduced: between 1984 and 1990, suicide rates decreased for males by 32%, in comparison with 8% in Europe.

Public awareness about mental health and suicide

As a result of the increasing concerns for the mental health consequences of the COVID-19 pandemic, international organizations, such as the WHO and the United Nations, and national and local authorities are releasing resources and guidelines for the promotion of mental health and raising awareness about the potential increase of mental health problems and suicide during the pandemic.

Besides increasing mental health knowledge and literacy, key aspects of suicide prevention resources should empower the general population with coping skills by providing useful advice, promoting help-seeking behaviour and making information avail-able about where to get help.

School-based interventions

Young people are a vulnerable group for risk of suicide. Suicide is the second leading cause of death worldwide among the 15-24 year old. Evidence suggests that 13.4% of children and adolescents have a diagnosed mental disorder. A much higher proportion reports mental health symptoms such as depression or anxiety (30.4% and 23.3%, respectively).

Strong evidence for the effectiveness of school-based interventions has been shown in increasing help-seeking behaviour, enhancing awareness about mental health and risk and protective factors for suicide, and decreasing the incidence of suicide attempts and severe suicidal ideation.

During the COVID-19 pandemic, schools have frequently been closed or physical attendance has substantially decreased, which has been reducing or completely stopping school-based mental health interventions. Schools have a major role in children and adolescents' social development. During the pandemic, peer relationships, which are important to foster autonomy and independence in adolescence, are substantially affected. The increased use of social media, substituting real-life peer relations, may result in pathological Internet use, a higher risk of cyberbullying and other negative health outcomes, such as anxiety, depression and suicidality. Feelings of anxiety and distress may also arise as a consequence of the uncertainty about final exams and future school re-opening.

Governments, at the national and regional level, are encouraged to resume school-based interventions as soon as schools re-open. Availability of online resources for youth mental health, such as helplines and information about how to get support, should be increased. Additionally, teachers and parents are advised to discuss the pandemic and feelings about it with children and adolescents.

Responsible media reporting

Irresponsible media coverage may promote suicidal behaviours in recipients by sensationalizing suicide or paying unproportioned attention to spectacular suicides. However, protective effects may be established through responsible reporting of suicide as well as public education.

Access to health care

Appropriate and accessible care for mental disorders, substance use, and physical illnesses is effective in reducing suicide risk. Due to increased pressure on the health care system during the COVID-19 pandemic, an adequate care for mental disorders may be deprioritized. An additional reduction in access is likely due to closed practices and increased sick-leave of mental health care professionals.

The mental health problems and suicidal behaviour of frontline health care professionals, first responders (e.g., ambulance operators) and other health care workers may increase due to their crucial role during the pandemic, associated with high stress.

Actions are required to provide financial support to mental health services, ensure accessibility, increase staff, develop digital services, and provide tools for self-care online. Moreover, the local health care systems are encouraged to plan and adjust resources to maintain or improve treatment and follow-up of patients with mental disorders, and adopt and reinforce the use of telemedicine.

Selective interventions

Gatekeeper training

Gatekeeper training is a widely used strategy to reduce suicide risk, even if supportive evidence for its effectiveness mostly comes from uncontrolled studies. It entails training of key people, such as teachers, first responders, or human resource managers, to identify suicidal individuals and refer them to appropriate services.

Most of the already trained gatekeepers probably belong to frontline responders (e.g., general practitioners, nurses, officers) and, for this reason, they are full-time involved in the emergency battle against the virus or even sick themselves. On the other hand, gatekeepers belonging to the general population (e.g., religious officials, teachers) may be prevented to identify and interact with suicidal individuals due to lockdown measures. Furthermore, a decrease in the availability of gatekeepers may be the result of paused or reduced gatekeeper training during the COVID-19 pandemic.

During the pandemic, continued training online or in person, in line with local regulations about appropriate physical distance, should be ensured. Also, actions to increase the number of volunteers to participate in the programs is advised. Successful examples of the adaptation of standard gatekeeper training to the current situation are the Alliance Project and the Zero Suicide Alliance, that are offering brief online trainings. The Mental Health First Aid is an Australian gatekeeper training evolved into global initiatives, and now organizes online courses. It proved to be effective in improving knowledge, attitudes and helping behaviours towards adults with mental health problems.

Interventions for vulnerable groups

Individuals with psychiatric conditions are recognized as those most severely impacted by the psychosocial effects of the pandemic and, due to the existing association between psychiatric disorders and health risk behaviours (e.g., smoking, obesity, alcohol use, low adherence to precautionary measures), they are also at increased risk of infection and its complications. Outreach interventions and a closer follow-up of patients with severe psychiatric disorders may allow to enhance treatment adherence and to timely identify and intervene on psychiatric emergencies. The creation of online networks may provide adequate social support and mitigate the temporary unavailability of community services.

Besides increasing the unemployment rate, the current global crisis is exacerbating existing socio-economic inequalities. Indeed, migrants, different cultural and ethnic minorities as well as socio-economically disadvantaged groups have been found to be less able to adhere to "stay at home" recommendations and, consequently, to be more affected by the virus. These groups largely overlap with those at increased risk for suicide.

Specific interventions are needed for these vulnerable populations aimed at increasing access to health care and reducing socio-economic inequalities through labour and welfare policies. Reinforcing crisis helplines may be also pivotal to timely identify and intervene on emerging psychosocial crises potentially leading to suicidal behaviour.

Another important effect of this global crisis is the increase in domestic and intimate partner conflicts and violence. Public health actions to prevent domestic violence are needed and should be adapted to the current situation. Surveillance methods through text messages, hidden smartphone notifications or other methods that allow victims of domestic violence to safely ask for help should be used. Police and health records can be linked according to local legislation to timely identify individuals at risk. Adequate surveillance should be ensured through routine inquiries and remote consultation with the health care system. To mitigate and prevent the negative mental health impact, victims of domestic and intimate partner violence should be referred to online or in person evidence-based interventions, such as those based on cognitive behavioural therapy.

COVID-19 patients and frontline health workers are also particularly vulnerable to negative psychological outcomes. Therefore, interventions to increase mental health awareness, promote effective coping skills, reduce primary and secondary post-traumatic stress disorder (PTSD) symptoms and decrease social isolation should be implemented. Mental health screenings and assessments should be scheduled, and referral to evidence-based treatments be ensured.

Bereavement from COVID-19 may be very challenging. Traumatic death, a lack of preparation for the death, and low social support have been described as risk factors for complicated grief, which in turn results in increased risk for suicidal behaviours, independently from other psychiatric disorders such as major depressive disorder and PTSD.

Finally, the previously described impact of the pandemic in increasing social isolation and loneliness becomes particularly concerning when considering older people. A recent study reported that being 59-80 years old was significantly associated with higher levels of depression, anxiety and PTSD symptoms during the pandemic, compared to the younger age groups. Phone calls and online platforms may represent valuable instruments to mitigate the sense of loneliness and social isolation, even if there might be disparities in access to or literacy in digital resources among older people.

Indicated interventions

Treatment of mental disorders

Strong evidence for the effectiveness of pharmacological and psychological treatment of psychiatric disorders in order to reduce suicidal behaviour exists. National and regional pharmaco-epidemiologic studies show a protective effect of the prescription of antidepressants on suicide. Antidepressants have been reported to decrease suicidal thoughts and behaviours in adult and geriatric patients. Literature consistently reports anti-suicidal effects of lithium, both in clinical samples and in the general population. Other mood stabilizers, such as valproate, lamotrigine and carbamazepine, may also have an anti-suicidal effect. It has been reported that second-generation antipsychotics are effective in reducing suicidal risk in patients with schizophrenia. Promising results are reported for the use of ketamine: a single infusion was found to rapidly reduce suicidal thoughts, within one day and for up to one week, in depressed patients with suicidal ideation, but long-term effects are not yet evaluated.

Among psychotherapies, individual cognitive behavioural therapy has been reported to significantly reduce suicidal thoughts and behaviour compared to treatment as usual. In a recent meta-analysis, dialectical behaviour therapy was found to be effective in reducing suicidal behaviour and re-attempt, especially in females with borderline personality disorder. Brief interventions, focused on the identification of warning signs, coping skills and available social support, professional help and crisis planning, have been shown to be effective in preventing suicidal thoughts and behaviour. The brief intervention and contact (BIC) implemented in the WHO Multisite Intervention Study on Suicidal Behaviours (SUPRE-MISS) randomized controlled trial showed a significant decrease in suicide after 18-month follow-up in comparison with treatment as usual.

During the COVID-19 pandemic, containment measures affect treatment availability, as practices and other psychiatric services may be closed. A worsening of symptoms of mental disorders - such as anxiety, depression and PTSD - among psychiatric patients, and an increase in mental health disorders in the general population, including first responders, may occur. Consequently, suicidal behaviour may increase.

Chain of care and follow-up

A continuous and functioning chain of care, with adequate follow-up of patients, has been shown to be effective in reducing suicide for at-risk individuals. Due to the increasing demands on health care systems during the COVID-19 pandemic, a disruption of the chain of care and delayed follow-up of psychiatric patients is likely to occur, with potential negative effects on suicide risk.

Critical in continuity of care is the promotion of treatment engagement. Providing patients with psychoeducation regarding the importance of follow-up treatment and an outpatient appointment within the first week after discharge are recommended strategies for engaging suicidal individuals. Post-discharge follow-up contacts, including phone calls, postcards, letters and technology-based methods (e.g., e-mails and texting) have showed promising results in enhancing treatment adherence and reducing suicidal behaviour.

Appropriate actions are required to develop new helplines and reinforce the existing ones for suicidal patients and individuals affected by the pandemic and to increase the training of volunteer workers in mental health. The use of telemedicine appears to be critical in maintaining an effective chain of care surrounding suicidal patients.

TELEMEDICINE DURING THE COVID-19 PANDEMIC

During the ongoing pandemic, mental health care faces significant challenges related to staff shortages, decrease of resources, and the risk of health care services becoming hotspots for contagion. Telemedicine is one of the best tools to tackle these challenges and simultaneously address the expected increase in demand for mental health care.

Telemedicine is defined as the remote delivery of health care with the aid of technology. It usually includes two-way audio and video remote communication between patients and health care professionals. However, other forms, such as self-help applications or websites, may support the tele-mental health care and offer additional opportunities for treatment.

There are several advantages of expanding telemedicine in mental health care. First, psychiatric diagnosis and treatment constitute a reasonable setting for telemedicine because they are conducted through interviews as opposed to physical assessment. Second, costs of telemedicine may be lower compared to traditional mental health care. Third, other barriers of traditional approaches to mental health care, such as stigma, are reduced. The potential to increase care has also been recognized for suicide prevention efforts.

Barriers that limit the use of telemedicine include the lack of access to the Internet, the required electronic devices, or the technological capabilities of recipients, especially individuals in old age or with serious mental health illnesses. The coverage of telemedicine through insurances may be limited, and integration into the health care systems is required to ensure the broad availability of digital medical services to the population.

Legal and ethical challenges are related to the storage and sharing of sensitive personal data, security of the communication with patients, privacy for the patient at the location where the remote consultation is held, and difficult choices in situations in which a traditional in-person visit is required to achieve the best treatment effects. The remote management of patients with acute suicide risk poses very significant ethical questions and should be managed by involving the family and the social network. Direct communication with emergency services should be available when the attempts to motivate the suicidal person to seek help are unsuccessful. Legal regulation for tele-medicine is missing in most countries and is urgently required.

There is some evidence for the effectiveness of technology-enhanced suicide preventive interventions. Unguided digital self-management interventions have shown to reduce suicidal ideation and suicide-related symptoms in individuals with severe psychiatric difficulties or self-harm, while others showed reductions of suicidal ideation, but not of self-harm or attempted suicide, compared to wait-list controls or self-management interventions. Technology-enhanced suicide preventive interventions may be more effective in younger people, due to their higher acceptance and affinity with technology. Brief texting contact has shown potential to reduce re-attempt after a suicide attempt through initiating contact with crisis support.

The agreement of psychiatric diagnoses between in-person and telemedicine assessment appears to be high, indicating its potential utility. Additionally, telepsychiatry has been found to be cost-effective and appears to be useful as crisis intervention. Hence, various advantages of implementing telemedicine and some evidence for its use in suicide prevention are available. Due to the limited methodologies used in previous studies about telemedicine, more high-quality research is required.

During the COVID-19 pandemic, it has become apparent that a large number of visits can be managed on distance, that the infrastructure for telemedicine is widely available, and that the pandemic itself represents an opportunity to expand the use of telemedicine. It has been reported that telepsychiatry may be efficient to screen for mental health symptoms in COVID-19 patients and to optimize treatment, or that online assessments are helpful prior to appointments and as follow-up. Continued care is, thus, enabled in a time when the health care systems are overwhelmed.

Existing and additional challenges to utilizing telemedicine in mental health care have become apparent as well. New protocols for assessment and therapy must be established quickly. Privacy, confidentiality and access issues remain. Quiet places and headphones are required and, in case of limited privacy, yes/no questions should be adopted. These issues may affect certain people more than others. For example, lower socio-economic status may result in smaller living spaces and consequently reduced privacy. Lack of access to electronic devices may occur for elderly patients. Disabilities and technology illiteracy pose a major obstacle to access. Social aspects of traditional medical approaches are lost with telemedicine, and this may be a significant problem for some categories of psychiatric patients.

The continued evaluation of telemedicine is essential. The in-frastructure requires improvement and growth to counter the unique challenges during the pandemic in the short term. The prospect to sustain these changes in the long term and improve care is a valuable opportunity that should guide the efforts of policy-makers. Even though evidence for telemedicine designed specifically for suicide prevention is limited, some advantages have already been highlighted.

CONCLUSIONS

The continued and strengthened implementation of suicide preventive measures during and after the COVID-19 pandemic is of global importance. Suicide prevention should be a priority for policy-makers and health care professionals alike and should not be postponed while facing this pandemic. This paper aims at informing the scientific community, health care professionals, policy-makers and politicians about plausible adaptations and/or reinforcements of evidence-based suicide preventive strategies, which should be undertaken due to the severe impact of the pandemic on everyday life.

The analysis of risk and protective factors shows that most of them are affected and the pandemic may have both positive and negative impacts. However, the negative effect appears to be greater. Thus, the foreseen increase of mental health issues and suicides is likely to happen.

Selecting suicide prevention strategies based on strong evidence remains essential throughout this crisis. However, we face unique challenges due to the need of urgent measures and lack of evidence that indicates how interventions should be adapted. The adaptations and reinforcements may be more effective in some regions or countries compared to others, due to differences in local suicide rates, interventions already in place, the status of the local health care and mental health care system, or local and national policies. Confirmatory research is needed to investigate which adaptations are effective taking the different cultural, economic and health care context into account.

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Adaptation of evidence‐based suicide prevention strategies during and after the COVID‐19 pandemic

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Suicide is preventable. Nevertheless, each year 800,000 people die of suicide in the world. While there is evidence indicating that suicide rates de-crease during times of crises, they are expected to increase once the immediate crisis has passed. The COVID-19 pandemic affects risk and pro-tective factors for suicide at each level of the socio-ecological model.

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COVID-19 has brought a raft of intense new stressors while removing many of the resources people have traditionally used to cope with stress. Millions of people have lost their jobs; some have lost their homes or businesses. Families cooped up together because of stay-at-home orders are chafing under the stress, which may increase the risk of intimate partner violence and child abuse. Disrupted routines and the potential for contracting a life-threatening disease may be exacerbating preexisting problems such as mental illness or substance use. At the same time, physical distancing is endangering mental health even as it protects physical health. People in crisis may avoid hospitals, whether for fear of adding to the burden of already overwhelmed facilities or of catching the virus. Gun sales are up.

The result could be a "perfect storm" when it comes to risk of suicide, says Mark Reger, PhD, chief of psychology services at the VA Puget Sound Health Care System in Seattle and an associate professor of psychiatry and behavioral sciences at the University of Washington School of Medicine. But despite those concerns, COVID-19's impact on suicide is still unknown. And there's much that practicing psychologists can do to make sure that people weather the storm without resorting to suicide, including screening all of their patients, coming up with safety plans appropriate for the pandemic and advocating for improved mental health services.

"Suicide is preventable," says Reger. "We must use what we know can work to mitigate the risk in this time."

Increased risk?

The media has reported on several heart-wrenching suicides believed to be linked to the toll COVID-19 is taking on individuals. High-profile suicides include a state finance minister in Germany who despaired over the virus's economic impact in March and a Manhattan emergency room physician on the front line of treating coronavirus patients in April.

But it will be a while before COVID-19's actual impact on the nation's suicide rate is known, says psychologist Jill Harkavy-Friedman, PhD, vice president of research at the American Foundation for Suicide Prevention. "We're two years away from having data," she says. And it's not a given that the pandemic will cause suicide rates to increase, emphasizes Harkavy-Friedman, who is also an associate professor of clinical psychology, in psychiatry, at Columbia University.

"One event can bring stress, but it's not going to make someone suicidal out of the blue," she says, explaining that it is typically a combination of biological, psychological, environmental and other factors that renders people vulnerable to suicide. Take the Great Recession of 2008, she points out. "About 4.8 million people lost their jobs, and the suicide rate didn't skyrocket," she says. "We're much more resilient than we give people credit for."

Plus, she says, the media and the mental health field have done a good job getting out the message that stress is a normal reaction to the current crisis and that routines, healthy habits, social connections and relaxation techniques can help ease that stress.

For some, the fight against the virus may even result in a sense of solidarity that protects them from thoughts of suicide. "Sometimes in periods of stress, people find strengths in themselves they didn't know they had," says Joan Asarnow, PhD, a professor of psychiatry and biobehavioral sciences at the David Geffen School of Medicine at the University of California, Los Angeles. "In World War II, for example, they were anticipating all kinds of problems during the Blitz, but it turned out people for the most part didn't have any additional mental health symptoms."

And for some populations, being stuck at home may even be a plus. Children, for example, are being more closely monitored by their parents, which can help prevent suicide. "We've actually seen quite a number of kids doing well without school and at home with their parents," says Asarnow. "It's not always a negative story."

How clinicians can help

Practicing psychologists can help ensure that the suicide rate doesn't exhibit a COVID-19-related bump. Harkavy-Friedman and other experts suggest several steps psychologists can take to achieve that goal:

Learn more about suicide and suicide prevention techniques. "Suicides are a pretty rare occurrence, thankfully," says Lynn Bufka, PhD, associate executive director for practice research and policy at APA. But the result of that lack of familiarity, she says, can be anxiety among psychologists and other mental health practitioners about whether they are prepared to assess and address suicidal ideation, suicidal behaviors or suicide attempts. The shift to what may be the unfamiliar medium of telehealth can exacerbate those worries, adds Bufka. To boost their understanding of suicide, psychologists can review the suicide prevention literature and clinical resources. Practitioners should make sure they are up to date on newer approaches to preventing and treating suicide, says Harkavy-Friedman, citing as examples specific interventions such as the Safety Planning Intervention and the Collaborative Assessment and Management of Suicidality as well as more general approaches like crisis response planning and dialectical behavior therapy. Psychologists might also want to identify apps that can provide supplemental support to patients between therapy sessions. In addition to apps offering help with mindfulness, relaxation and coping, there are resources specifically focused on suicide, such as the MY3 and Safety Plan apps and NowMattersNow.org, an online repository of videos. "It is best if someone searches and tests them out to see which apps work for them," says Harkavy-Friedman.

Screen every patient. "This is a time when we really need to be hypervigilant about suicidal thoughts and behaviors," says Mitch Prinstein, PhD, ABPP, a professor of psychology and neuroscience at the University of North Carolina at Chapel Hill. "Of course, our most serious attention should be on those with prior emotional or behavioral difficulties," he says. "But even people who may never have thought about suicide before could also be at greater risk because of the level of stress we're all experiencing." One way to normalize such screening is for psychologists to ask patients at the beginning of every session how they're feeling physically, then segue into checking on their emotional states.

Providers also need to be on the lookout for another risk factor that has become more of an issue during the pandemic: discrimination against Asian Americans. "There has been an uptick in discriminatory events," says Joyce Chu, PhD, a psychology professor at Palo Alto University in California. "Those can be culturally specific risk factors for suicide."

Develop an action plan. If a psychologist suspects that a patient is experiencing suicidal ideation, he or she should work with the patient to create or update a safety plan (see "Suicide Safety Plan" below) that includes a list of warning signs, coping strategies like exercise or relaxation techniques, and contact information for the psychologist, other professionals and friends they can ask for help. "Help them write down and print out some sheets they can put in places in their house they are very likely to see with the phone number for their therapist and someone else they can call if they experience difficulties," says Prinstein. "You want anything that creates a reminder, a barrier, a moment to stop and make a call before they engage in self-injury impulsively." Be sure the plan is appropriate for use during the pandemic. Going to a gym or dining at a restaurant are no longer appropriate coping strategies, for example. Psychologists should also persuade patients to get guns, pills and other potentially lethal objects out of their homes if they can do so while practicing physical distancing and should get permission to contact someone else in a patient's home if the patient doesn't show up for a virtual session.

Follow telehealth guidelines. Some practitioners are leery of using telehealth with patients who may be suicidal. For one, they worry that they won't be able to pick up on nonverbal cues as easily, says Bufka. "On the phone, I'm not going to see a person avert their eyes when I'm asking about thoughts of suicide. On video, I might. In the room, I will see it," she says. Another concern is the physical distance from the patient. "If someone is in my office and tells me they are actively thinking about suicide, I don't have to let them leave until we have a plan figured out for a more intensive level of care," she says. "Over video or a cellphone, the person can just hang up."

However, the evidence shows that mental health professionals can follow best practices for assessing and managing suicide risk, even if they're doing so by way of a laptop or telephone (McGinn, M.M., et al., Psychiatric Clinics, Vol. 42, No. 4, 2019). And psychologists can prevent problems by being sure to follow APA's Guidelines for the Practice of Telepsychology. Psychologists should always know the patient's location and how to call for emergency help, for example. Of particular concern at this time of stay-at-home orders is ensuring patient privacy so that family members or roommates can't overhear therapy sessions, says Cheryl King, PhD, a professor of psychiatry and psychology at the University of Michigan. Patients may need a few minutes to get to someplace private-even a car-before a therapy session begins. Some may need reassurance about the technology itself and how privacy is ensured, King adds.

Educate patients, their families and the public. Psychologists should do their best to educate patients and everyone else on ways to recognize warning signs of suicide and how to keep those at heightened risk safe and make sure they get the care they need. "During a pandemic or other national crisis, one of the most important things is for folks in the community to be eyes and ears," says Chu. "They need to reach out often, especially if they think someone is more isolated or if they see some of the warning signs of suicide." Chu offers advice on how to do this in a webinar, which she originally presented to more than 500 community members and health-care professionals in April.

Prioritize self-care. The COVID-19 pandemic is just as stressful for practitioners, who must also spend their days hearing about other people's worries. "We have to do the same things we're telling everyone else," says Harkavy-Friedman, citing breathing exercises, time off and the basics of sufficient sleep, healthy food and regular exercise. "If we want to have the stamina and capacity to help other people, we have to take care of ourselves."

Be an advocate. Psychologists can help push for increased mental health services, especially for the underserved populations disproportionately affected by the pandemic and for patients and families who have experienced illness, says Prinstein.

For example, psychologists successfully advocated for the Centers for Medicare and Medicaid Services to allow audio-only telehealth for Medicare beneficiaries-a priority during the pandemic since many older adults don't have smartphones or broadband for telehealth (see Telepsychology expands to meet demand). To learn more about APA's suicide-related advocacy priorities, sign up for legislative alerts and learn how to make your advocacy with Congress more effective.

Advocacy will have to continue even after the initial crisis passes, adds Prinstein. "Flattening the curve on physical health is only the first half of the story," he says. "The second curve will be the national rise in mental health concerns that will follow very soon after."

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COVID-19 has brought a raft of intense new stressors while removing many of the resources people have traditionally used to cope with stress. Millions of people have lost their jobs; some have lost their homes or businesses. Families cooped up together because of stay-at-home orders are chafing under the stress, which may increase the risk of intimate partner violence and child abuse.

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Recognize How Covid-19 , SI Rates Increase October 2020

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Recognize How Covid-19 , SI Rates Increase October 2020

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Editor's note: This editorial explores the risks of suicide. If you or a loved one are at risk, please stop here and contact the U.S. National Suicide Prevention Lifeline at 800-273-8255 or text TALK to 741741.
In the midst of a pandemic as well as a non-stop parade of breaking news, the year 2020 is feeling more like a waking nightmare each day. And as the coronavirus pandemic continues to affect our daily lives, people around the world wake up each morning to something new to add to the devastation.

From a polarizing presidential election and an economic downturn to social unrest and racial injustice on top of a pandemic, the state of the world can feel overwhelming.

Even as we attempt to cope with the initial waves of the pandemic, an article published on Oct. 12 in the medical journal JAMA claimed that there is evidence that a "second wave" is coming. This "second wave," rather than made up of an increase in COVID-19 cases, is characterized by the "rising rates of mental health and substance use disorders."

These rising rates of mental health and substance use disorders can be attributed to a myriad of misfortunes. People who have lost a loved one during this pandemic are at risk in many additional ways. While they are necessary, social distancing and quarantine measures have escalated the emotional turmoil experienced by the families and friends in mourning. In fact, the emphasis on isolation has changed the way we as a nation, as well as individuals and communities, cope with tragedy.

The normal grieving process that people go through when they lose a loved one has changed in the face of all of these restrictions. The pandemic is limiting people's interactions with their loved ones on their deathbed as well as their ability to see their body after they pass away. Like the semi-common practice of open casket funerals, viewing the body of a deceased loved one can help some people through the mourning process.
Rising rates
For those left untouched by the virus, an increase in suicidal ideation and suicide attempts could stem from financial issues, decreased in-person support, constant consumption of news and social distancing - which can evoke feelings of loneliness.

The overall feeling that the current state of the world invokes is sadness.

During the week of June 24 to 30 of this year, 40% of U.S. adults reported struggling with mental health or substance use according to a study conducted by the Centers for Disease Control and Prevention. As a result, younger adults, minorities, essential workers and unpaid adult caregivers were concluded to have significantly worse mental health, increased substance use and increased suicidal ideation.

Although there are no U.S. statistics yet that directly tie an increase in suicides and COVID-19 in general populations, other countries are starting to note an increase.

In September, the Malawi police service reported a 57% increase in suicide rates to that point in 2020 compared with the same period in 2019, with some proposing it's due to economic stresses of the coronavirus pandemic.

On Oct. 12, Japan's National Police agency revealed that suicides increased 8.6% in comparison to the same time of year in 2019.

Even though there is no way to procure accurate quantitative evidence right now, several researchers predict that COVID-19 will severely affect suicide rates today as well as moving forward.

Limited social interaction contributes to feelings of loneliness, emptiness and possible issues with mental health, but this does not mean that social distancing guidelines should be bent in favor of a better mental state. This does not mean we should break social distancing guidelines to surround ourselves with our community or make ourselves happier. And this does not mean that these social distancing guidelines are directly responsible for a recent increase in people struggling with mental health and substance use.

Outside environmental factors - such as stress levels, relationships, loss and hardships - contribute to a person's risk of developing a mental illness or considering suicide. However, a person's genetics, brain chemistry and physical health can affect their mental health just as much or even more.
Prevention
Not only are there many factors that contribute to mental illness and suicidal ideation, but suicide rates were already increasing even before the coronavirus pandemic entered the picture.

A study conducted by the National Center for Health Statistics showed that suicide rates in the U.S. increased by 35% between 1999 and 2018 despite efforts to increase intervention and prevention efforts and lower suicide rates.

Even back in June, the CDC advocated for increased intervention and prevention efforts addressing mental health. One way we can support change is through increased education on wellness, mental illnesses and substance use.

"A public health/community strategy is critical to protect the health care system from becoming overwhelmed," an article published in the medical journal JAMA said.

Although changes in how the U.S. runs public health strategies are few and far between, clinicians can aid in preventing this "second wave" of mental illness and substance abuse from taking over our lives. When someone experiences a loss in the family, primary care physicians can use screening tools like the PTSD checklist for post-traumatic stress symptoms to identify a person's risk. In addition, they can use the Patient Health Questionnaire 9 to identify the symptoms of depression a person is showing.

Unfortunately, in many situations, it is up to friends, family and loved ones to notice if an individual is struggling with depression or any other form of mental illness. While the blame should not be put on the loved ones of someone who is struggling with mental illness, they can try their best to identify symptoms of mental illness and steer them in the direction to find the help they need.

The Diagnostic and Statistical Manual of Mental Disorders, or the DSM-5, is a taxonomic and diagnostic text used by professionals and researchers to identify the characterizations, symptoms and treatment options for various mental illnesses. With all of the different diagnoses filling up that encyclopedic book, there is no way to summarize all the signs that you or a loved one is dealing with mental illness.

Because researchers are anticipating a rise in suicidal ideation due to COVID-19, here are a few common warning signs that someone is considering suicide according to the Suicide Awareness Voices of Education website:

Talking about wanting to die or kill oneself

Talking about feeling hopeless

Increased use of alcohol or drugs

Talking about feeling trapped

Withdrawing from social groups or isolating themselves

Displaying extreme mood swings

Sleeping too little or too much

However, these are not limited to symptoms of suicidal ideation. They could also be a sign of another form of mental illness as well as an increase in stressors. If you notice someone showing any of these signs, reach out to a medical professional or someone of authority who could help them.

All of these signs, as well as prevention efforts apply, at all times, not just in the middle of a pandemic. But it is good to take note of them and consider them in your day-to-day life because you will never know who in your life may be struggling with mental illness.

Without invalidating the struggles caused by either tragedy, we should acknowledge the connection between COVID-19 and diminishing mental health - including suicidal ideation - as well as their effect on ourselves and each other.

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Recognize how COVID-19, suicide rates connect

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Editor's note: This editorial explores the risks of suicide. If you or a loved one are at risk, please stop here and contact the U.S. National Suicide Prevention Lifeline at 800-273-8255 or text TALK to 741741. In the midst of a pandemic as well as a non-stop parade of breaking news, the year 2020 is feeling more like a waking nightmare each day.

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The message from National Suicide Prevention Awareness Week is especially important this year.

Mental health issues have increased considerably during the coronavirus pandemic, according to a recent report released by the Centers for Disease Control and Prevention, and young adults and racial minorities are among those disproportionately affected.

"This pandemic has created not only the fear of the virus and so much grief and loss, surrounding us with the death and illness of so many people in the United States and around the world, but also the isolation that happens with quarantine," Sarah Harte, a clinical social worker, told the Daily News. She's also director of The Dorm, a treatment community for young adults in New York and Washington.

In a survey of 5,412 adults in late June, 40.9% reported at least one adverse mental or behavioral health condition, the CDC said in its Morbidity and Mortality Weekly Report released Aug. 14.

Those conditions include symptoms of anxiety, depression and "increased substance use to cope with stress or emotions related to COVID-19."

Nearly 11% reported having seriously considered suicide in the 30 days before completing the survey compared with about 4% in a 2018 survey who said they'd considered suicide in the past 12 months.

National Suicide Prevention Awareness Week, which began Sunday, seeks to inform and engage people about prevention and the warning signs of suicide.

"In the era of COVID-19, as we all try to protect our mental health and cope with uncertainty, it's more important than ever that we be there for each other and take steps to prevent suicide," the American Foundation for Suicide Prevention said in a statement.

The worrying CDC data found that certain groups were shown to be even more susceptible to suicide: 25.5% of young adults, aged 18 to 24; 30.7% of self-reported unpaid caregivers for adults; 21.7% of essential workers; as well as racial minorities -18.6% of Hispanic respondents and 15.1% of Black respondents.

Even before the pandemic hit, suicide has been a growing concern among health professionals in the U.S.

According to the American Foundation for Suicide Prevention, there were an estimated 1.4 million suicide attempts in the U.S. in 2018, which included 48,344 deaths - or an average of 132 per day.

Some experts see the silver lining in the current crisis.

Dr. Isaiah Pickens, a Los Angeles-based clinical psychologist and author, told The News the pandemic can help with the stigma surrounding suicide by normalizing conversations about mental health.

"Given that all of us have dealt with such a difficult and even, for many, traumatic, issues over the course of this past year, part of what we've seen is an uptick in people reaching out and seeking mental health services," which is something that helps with suicide prevention, he said.

The pandemic has created social distancing, isolation and an increase in unemployment - all contributing factors to suicide ideation.

"But also, on the flip side of it, there's just so many people who said, 'You know, this is a lot,' and 'it's OK if I need to get some help,'" said Pickens.

"This moment has actually opened up a new space for us to talk about mental health," he added.
If you or someone you know is going through a crisis, call the National Suicide Prevention Lifeline at (800) 273-TALK (8255). LGBT youth are encouraged to call TrevorLifeline at (866) 488-7386, or text 'START' to 678-678.

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Suicide Prevention Week highlights link between COVID-19 and alarming increase of people who 'seriously considered suicide'

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The message from National Suicide Prevention Awareness Week is especially important this year. Mental health issues have increased considerably during the coronavirus pandemic, according to a recent report released by the Centers for Disease Control and Prevention, and young adults and racial minorities are among those disproportionately affected.

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CDC Survey June 2020 - SI On the Rise During Covid

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CDC Survey June 2020 - SI On the Rise During Covid

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Centers for Disease Control and Prevention

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Please note:. This report has been corrected. An erratum will be published.
Mark É. Czeisler ¹,2; Rashon I. Lane, MA ³; Emiko Petrosky, MD ³; Joshua F. Wiley, PhD ¹; Aleta Christensen, MPH ³; Rashid Njai, PhD ³; Matthew D. Weaver, PhD ¹,4,5; Rebecca Robbins, PhD ⁴,5; Elise R. Facer-Childs, PhD ¹; Laura K. Barger, PhD ⁴,5; Charles A. Czeisler, MD, PhD ¹,4,5; Mark E. Howard, MBBS, PhD ¹,2,6; Shantha M.W. Rajaratnam, PhD ¹,4,5 ( View author affiliations)

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Summary
What is already known about this topic?
Communities have faced mental health challenges related to COVID-19-associated morbidity, mortality, and mitigation activities.
What is added by this report?
During June 24-30, 2020, U.S. adults reported considerably elevated adverse mental health conditions associated with COVID-19. Younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers reported having experienced disproportionately worse mental health outcomes, increased substance use, and elevated suicidal ideation.
What are the implications for public health practice?
The public health response to the COVID-19 pandemic should increase intervention and prevention efforts to address associated mental health conditions. Community-level efforts, including health communication strategies, should prioritize young adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers.

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The coronavirus disease 2019 (COVID-19) pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders.* Symptoms of anxiety disorder and depressive disorder increased considerably in the United States during April-June of 2020, compared with the same period in 2019 ( 1, 2). To assess mental health, substance use, and suicidal ideation during the pandemic, representative panel surveys were conducted among adults aged ≥18 years across the United States during June 24-30, 2020. Overall, 40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder (TSRD) related to the pandemic † (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%). The percentage of respondents who reported having seriously considered suicide in the 30 days before completing the survey (10.7%) was significantly higher among respondents aged 18-24 years (25.5%), minority racial/ethnic groups (Hispanic respondents [18.6%], non-Hispanic black [black] respondents [15.1%]), self-reported unpaid caregivers for adults § (30.7%), and essential workers ¶ (21.7%). Community-level intervention and prevention efforts, including health communication strategies, designed to reach these groups could help address various mental health conditions associated with the COVID-19 pandemic.

During June 24-30, 2020, a total of 5,412 (54.7%) of 9,896 eligible invited adults** completed web-based surveys †† administered by Qualtrics. §§ The Monash University Human Research Ethics Committee of Monash University (Melbourne, Australia) reviewed and approved the study protocol on human subjects research. Respondents were informed of the study purposes and provided electronic consent before commencement, and investigators received anonymized responses. Participants included 3,683 (68.1%) first-time respondents and 1,729 (31.9%) respondents who had completed a related survey during April 2-8, May 5-12, 2020, or both intervals; 1,497 (27.7%) respondents participated during all three intervals ( 2, 3). Quota sampling and survey weighting were employed to improve cohort representativeness of the U.S. population by gender, age, and race/ethnicity. ¶¶ Symptoms of anxiety disorder and depressive disorder were assessed using the four-item Patient Health Questionnaire*** ( 4), and symptoms of a COVID-19-related TSRD were assessed using the six-item Impact of Event Scale ††† ( 5). Respondents also reported whether they had started or increased substance use to cope with stress or emotions related to COVID-19 or seriously considered suicide in the 30 days preceding the survey. §§§

Analyses were stratified by gender, age, race/ethnicity, employment status, essential worker status, unpaid adult caregiver status, rural-urban residence classification, ¶¶¶ whether the respondent knew someone who had positive test results for SARS-CoV-2, the virus that causes COVID-19, or who had died from COVID-19, and whether the respondent was receiving treatment for diagnosed anxiety, depression, or posttraumatic stress disorder (PTSD) at the time of the survey. Comparisons within subgroups were evaluated using Poisson regressions with robust standard errors to calculate prevalence ratios, 95% confidence intervals (CIs), and p-values to evaluate statistical significance (α = 0.005 to account for multiple comparisons). Among the 1,497 respondents who completed all three surveys, longitudinal analyses of the odds of incidence**** of symptoms of adverse mental or behavioral health conditions by essential worker and unpaid adult caregiver status were conducted on unweighted responses using logistic regressions to calculate unadjusted and adjusted †††† odds ratios (ORs), 95% CI, and p-values (α = 0.05). The statsmodels package in Python (version 3.7.8; Python Software Foundation) was used to conduct all analyses.

Overall, 40.9% of 5,470 respondents who completed surveys during June reported an adverse mental or behavioral health condition, including those who reported symptoms of anxiety disorder or depressive disorder (30.9%), those with TSRD symptoms related to COVID-19 (26.3%), those who reported having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%), and those who reported having seriously considered suicide in the preceding 30 days (10.7%) ( Table 1). At least one adverse mental or behavioral health symptom was reported by more than one half of respondents who were aged 18-24 years (74.9%) and 25-44 years (51.9%), of Hispanic ethnicity (52.1%), and who held less than a high school diploma (66.2%), as well as those who were essential workers (54.0%), unpaid caregivers for adults (66.6%), and who reported treatment for diagnosed anxiety (72.7%), depression (68.8%), or PTSD (88.0%) at the time of the survey.

Prevalences of symptoms of adverse mental or behavioral health conditions varied significantly among subgroups ( Table 2). Suicidal ideation was more prevalent among males than among females. Symptoms of anxiety disorder or depressive disorder, COVID-19-related TSRD, initiation of or increase in substance use to cope with COVID-19-associated stress, and serious suicidal ideation in the previous 30 days were most commonly reported by persons aged 18-24 years; prevalence decreased progressively with age. Hispanic respondents reported higher prevalences of symptoms of anxiety disorder or depressive disorder, COVID-19-related TSRD, increased substance use, and suicidal ideation than did non-Hispanic whites (whites) or non-Hispanic Asian (Asian) respondents. Black respondents reported increased substance use and past 30-day serious consideration of suicide in the previous 30 days more commonly than did white and Asian respondents. Respondents who reported treatment for diagnosed anxiety, depression, or PTSD at the time of the survey reported higher prevalences of symptoms of adverse mental and behavioral health conditions compared with those who did not. Symptoms of a COVID-19-related TSRD, increased substance use, and suicidal ideation were more prevalent among employed than unemployed respondents, and among essential workers than nonessential workers. Adverse conditions also were more prevalent among unpaid caregivers for adults than among those who were not, with particularly large differences in increased substance use (32.9% versus 6.3%) and suicidal ideation (30.7% versus 3.6%) in this group.

Longitudinal analysis of responses of 1,497 persons who completed all three surveys revealed that unpaid caregivers for adults had a significantly higher odds of incidence of adverse mental health conditions compared with others ( Table 3). Among those who did not report having started or increased substance use to cope with stress or emotions related to COVID-19 in May, unpaid caregivers for adults had 3.33 times the odds of reporting this behavior in June (adjusted OR 95% CI = 1.75-6.31; p<0.001). Similarly, among those who did not report having seriously considered suicide in the previous 30 days in May, unpaid caregivers for adults had 3.03 times the odds of reporting suicidal ideation in June (adjusted OR 95% CI = 1.20-7.63; p = 0.019).

Discussion

Elevated levels of adverse mental health conditions, substance use, and suicidal ideation were reported by adults in the United States in June 2020. The prevalence of symptoms of anxiety disorder was approximately three times those reported in the second quarter of 2019 (25.5% versus 8.1%), and prevalence of depressive disorder was approximately four times that reported in the second quarter of 2019 (24.3% versus 6.5%) ( 2). However, given the methodological differences and potential unknown biases in survey designs, this analysis might not be directly comparable with data reported on anxiety and depression disorders in 2019 ( 2). Approximately one quarter of respondents reported symptoms of a TSRD related to the pandemic, and approximately one in 10 reported that they started or increased substance use because of COVID-19. Suicidal ideation was also elevated; approximately twice as many respondents reported serious consideration of suicide in the previous 30 days than did adults in the United States in 2018, referring to the previous 12 months (10.7% versus 4.3%) ( 6).

Mental health conditions are disproportionately affecting specific populations, especially young adults, Hispanic persons, black persons, essential workers, unpaid caregivers for adults, and those receiving treatment for preexisting psychiatric conditions. Unpaid caregivers for adults, many of whom are currently providing critical aid to persons at increased risk for severe illness from COVID-19, had a higher incidence of adverse mental and behavioral health conditions compared with others. Although unpaid caregivers of children were not evaluated in this study, approximately 39% of unpaid caregivers for adults shared a household with children (compared with 27% of other respondents). Caregiver workload, especially in multigenerational caregivers, should be considered for future assessment of mental health, given the findings of this report and hardships potentially faced by caregivers.

The findings in this report are subject to at least four limitations. First, a diagnostic evaluation for anxiety disorder or depressive disorder was not conducted; however, clinically validated screening instruments were used to assess symptoms. Second, the trauma- and stressor-related symptoms assessed were common to multiple TSRDs, precluding distinction among them; however, the findings highlight the importance of including COVID-19-specific trauma measures to gain insights into peri- and posttraumatic impacts of the COVID-19 pandemic ( 7). Third, substance use behavior was self-reported; therefore, responses might be subject to recall, response, and social desirability biases. Finally, given that the web-based survey might not be fully representative of the United States population, findings might have limited generalizability. However, standardized quality and data inclusion screening procedures, including algorithmic analysis of click-through behavior, removal of duplicate responses and scrubbing methods for web-based panel quality were applied. Further the prevalence of symptoms of anxiety disorder and depressive disorder were largely consistent with findings from the Household Pulse Survey during June ( 1).

Markedly elevated prevalences of reported adverse mental and behavioral health conditions associated with the COVID-19 pandemic highlight the broad impact of the pandemic and the need to prevent and treat these conditions. Identification of populations at increased risk for psychological distress and unhealthy coping can inform policies to address health inequity, including increasing access to resources for clinical diagnoses and treatment options. Expanded use of telehealth, an effective means of delivering treatment for mental health conditions, including depression, substance use disorder, and suicidal ideation ( 8), might reduce COVID-19-related mental health consequences. Future studies should identify drivers of adverse mental and behavioral health during the COVID-19 pandemic and whether factors such as social isolation, absence of school structure, unemployment and other financial worries, and various forms of violence (e.g., physical, emotional, mental, or sexual abuse) serve as additional stressors. Community-level intervention and prevention efforts should include strengthening economic supports to reduce financial strain, addressing stress from experienced racial discrimination, promoting social connectedness, and supporting persons at risk for suicide ( 9). Communication strategies should focus on promotion of health services §§§§,¶¶¶¶,***** and culturally and linguistically tailored prevention messaging regarding practices to improve emotional well-being. Development and implementation of COVID-19-specific screening instruments for early identification of COVID-19-related TSRD symptoms would allow for early clinical interventions that might prevent progression from acute to chronic TSRDs. To reduce potential harms of increased substance use related to COVID-19, resources, including social support, comprehensive treatment options, and harm reduction services, are essential and should remain accessible. Periodic assessment of mental health, substance use, and suicidal ideation should evaluate the prevalence of psychological distress over time. Addressing mental health disparities and preparing support systems to mitigate mental health consequences as the pandemic evolves will continue to be needed urgently.

Acknowledgments

Survey respondents; Kristen Holland, Emily Kiernan, Meg Watson, CDC COVID-19 Response Team; Mallory Colys, Sneha Baste, Daniel Chong, Rebecca Toll, Qualtrics, LLC; Alexandra Drane, Sarah Stephens Winnay, Archangels; Emily Capodilupo, Whoop, Inc.; The Kinghorn Foundation; Australian-American Fulbright Commission.

Corresponding author: Rashon Lane for the CDC COVID-19 Response Team, Rlane@cdc.gov.

¹Turner Institute for Brain and Mental Health, Monash University, Melbourne, Australia; ²Austin Health, Melbourne, Australia; ³CDC COVID-19 Response Team; ⁴Brigham and Women's Hospital, Boston, Massachusetts; ⁵Harvard Medical School, Boston, Massachusetts; ⁶ University of Melbourne, Melbourne, Australia.

References

1. CDC, National Center for Health Statistics. Indicators of anxiety or depression based on reported frequency of symptoms during the last 7 days. Household Pulse Survey. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2020. https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm

2. CDC, National Center for Health Statistics. Early release of selected mental health estimates based on data from the January-June 2019 National Health Interview Survey. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Health Statistics; 2020. https://www.cdc.gov/nchs/data/nhis/earlyrelease/ERmentalhealth-508.pdfpdf icon

3. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2018 National Survey on Drug Use and Health. Rockville, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; 2018. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdfpdf icon external icon

4. Stone D, Holland K, Bartholow B, Crosby A, Davis S, Wilkins N. Preventing suicide: a technical package of policy, programs, and practices. Atlanta, GA: US Department of Health and Human Services, CDC, National Center for Injury Prevention and Control; 2017. https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdfpdf icon

Characteristic

All respondents who completed surveys during June 24-30, 2020 weighted* no. (%)

Weighted %*

Conditions

Started or increased substance use to cope with pandemic-related stress or emotions¶

Seriously considered suicide in past 30 days

≥1 adverse mental or behavioral health symptom

Anxiety disorder†

Depressive disorder†

Anxiety or depressive disorder†

COVID-19-related TSRD§

All respondents 5,470 (100)25.5 24.3 30.9 26.3 13.3 10.7 40.9

Characteristic

Prevalence ratio¶ (95% CI¶)

Symptoms of anxiety disorder or depressive disorder†

Symptoms of a TSRD related to COVID-19§

Started or increased substance use to cope with stress or emotions related to COVID-19

Serious consideration of suicide in past 30 days

Symptom or behavior

Essential worker† vs. all other employment statuses (nonessential worker, unemployed, retired)

Unpaid caregiver for adults§ vs. not unpaid caregiver

Unadjusted

Adjusted¶

Unadjusted

Adjusted**

OR (95% CI)††

p-value††

OR (95% CI)††

p-value††

OR (95% CI)††

p-value††

OR (95% CI)††

p-value††

Symptoms of anxiety disorder §§

1.92 (1.29-2.87)

0.001

1.63 (0.99-2.69)

0.056

1.97 (1.25-3.11)

0.004

1.81 (1.14-2.87)

0.012

Symptoms of depressive disorder §§

1.49 (1.00-2.22)

0.052

1.13 (0.70-1.82)

0.606

2.29 (1.50-3.50)

<0.001

2.22 (1.45-3.41)

<0.001

Symptoms of anxiety disorder or depressive disorder §§

1.67 (1.14-2.46)

0.008

1.26 (0.79-2.00)

0.326

1.84 (1.19-2.85)

0.006

1.73 (1.11-2.70)

0.015

Symptoms of a TSRD related to
COVID-19 ¶¶

1.55 (0.86-2.81)

0.146

1.27 (0.63-2.56)

0.512

1.88 (0.99-3.56)

0.054

1.79 (0.94-3.42)

0.076

Suggested citation for this article: Czeisler MÉ , Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic - United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049-1057. DOI: http://dx.doi.org/10.15585/mmwr.mm6932a1external icon .

MMWR and Morbidity and Mortality Weekly Report are service marks of the U.S. Department of Health and Human Services.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
References to non-CDC sites on the Internet are provided as a service toMMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed inMMWR were current as of the date of publication. All HTML versions of MMWR articles are generated from final proofs through an automated process. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (https://www.cdc.gov/mmwr) and/or the originalMMWR paper copy for printable versions of official text, figures, and tables. Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov.

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increased substance use associated with covid-19

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adverse mental health effects and covid-19

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increased suicidal ideation during covid-19 pandemic

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Mental Health, Substance Use, and Suicidal Ideation During the ...

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This report describes mental health challenges faced by communities during the COVID-19 pandemic.

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📹SI On Rise For College Students - Aug 2020

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📹SI On Rise For College Students - Aug 2020

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One in four people aged 18 to 24 seriously contemplated suicide in June, according to new research from the Centers for Disease Control and Prevention.

The data are the latest in a series of reports highlighting increases in anxiety, depression and suicidal ideation since the COVID-19 pandemic began.

The data do not have a breakdown for college students, but they do break responses down by age groups. People who are in the traditional age group for college students seem to be especially vulnerable to mental health issues, compared to other age groups, and experts believe colleges should be investing more in mental health services during this time. With the ongoing recession, though, some worry that counseling and other services will be on the chopping block.

"I think mental health services are an 'easy' thing, in some people's minds, to cut," said Nadine Kaslow, professor of psychiatry and behavioral sciences at Emory University and past president of the American Psychological Association. "I'm very worried."

If you or someone you know is thinking of suicide, call the 24-7 National Suicide Prevention Lifeline at 1-800-273-8255 or text TALK to the Crisis Text Line at 741-741.

The CDC surveyed about 5,400 people in the last week of June on how their mental health has been during the pandemic. About 41 percent reported at least one negative mental health issue, including symptoms of anxiety or depression, or increased substance use to cope with stress.

Over all, about 11 percent of respondents said they had seriously considered suicide over the past 30 days. Those aged 18 to 24 were significantly more likely to report this, with 25.5 percent saying they had seriously considered suicide. Minority groups and essential workers were also much more likely to report considering suicide.

Rashon Lane, a behavioral scientist at the CDC who authored the study, said it's important to recognize that these identities can intersect across different populations.

"It's important to think through how we can provide mental health services to be more culturally appropriate," she said.

Lane recommends using social support strategies to help young adults feel more social connectedness, as well as offering more comprehensive treatment options for students, like harm reduction services.

"Collectively, we're seeing some troubling or concerning patterns," she said.

Of those aged 18 to 24, about one-quarter also said they had increased their substance use to cope with the pandemic, and about three-quarters reported facing at least one adverse mental health symptom.

Alongside the CDC data, other reports predict the pandemic and recession will lead to a rise in suicides. The Well Being Trust predicts there will be as many at 75,000 "deaths of despair" from the pandemic, stemming from substance misuse or suicide. Other research has shown the relationship between unemployment and suicide rates.

"It's almost as if everybody is psychologically carrying a heavy load of packages," said Victor Schwartz, chief medical officer at the Jed Foundation, a nonprofit that advocates for the mental health of teens and young adults, and clinical associate professor of psychiatry at New York University. "If you were in a hot place carrying a bunch of bags uphill and not knowing how long you had to go, that would cause physical stress and symptoms."

This is the psychological equivalent, Schwartz said.

He worries that colleges are going to slash their budgets, including those for mental health services, due to the recession.

"Colleges will have more mental health demands than ever," he said.

Higher education has, for the most part, improved services and increased young people's comfort with seeking help, Schwartz said. But there's too much demand, so colleges are going to have to think creatively about serving students with an array of issues with an array of solutions, not just traditional counseling, he said.

They'll also have to be nimble, at least for the coming academic year.

"Everybody is going to have to constantly be working with two or three plans," he said. "Everybody's going to have to become improvisers."

Kaslow emphasized the need for colleges to train people to be gatekeepers, who are people in the community who can recognize the warning signs that someone is depressed or suicidal. This will be more difficult, as it's harder to gather cues and clues when people are wearing masks or on Zoom, she said.

People will also have to take what college students say seriously. If they say they feel hopeless, people can't respond by saying that everyone feels that way, Kaslow said.

"So many college students are saying things like, 'This is the worst year of my life,'" she said. "All of the developmental things that come with the transition to young adulthood are being impacted by this."

Colleges also need to maintain services, and Kaslow recommends they start doing universal screenings of students' mental health.

College leaders need to be prioritizing mental health, said Sarah Ketchen Lipson, an assistant professor of health law and policy at Boston University.

"They're in a position right now to make a lot of decisions about what they're investing in," she said. "In a lot of cases, there are a lot of complicated decisions to make related to finances in higher education right now."

Colleges need to maintain their virtual mental health services during this time and continue promoting them, she said. They also need to normalize mental health for students and raise awareness of how mental health and academic performance are linked. Students should also be part of the conversation of how best to support their mental health, she added.

Continuing telehealth options for counseling will be important as the pandemic continues, said Andrew Lee, president of the American College Counseling Association.

"It is clear that these unprecedented times have irrevocably changed our profession. What was once considered a more fringe or novel way of service delivery has now become an essential mode of service provision," Lee said in an emailed response. "While it is unlikely that all students will only desire to receive services via technology, this shift has legitimized the use of remote telehealth sessions."

Seeing budget cuts and furloughs at colleges across the nation has been disappointing, said Katherine Wolfe-Lyga, director of the Counseling Services Center at the State University of New York at Oswego and secretary of the Association of College Counseling Center Directors. But she recognizes the economic issues colleges are facing.

Oswego won a grant to support infrastructure for suicide prevention, which she said could not have come at a better time.

"The financial difficulties that institutions and our students are facing are worrisome. We have seen many college administrators prioritize mental health support systems on campus and hopefully they will maintain that level of commitment as we collectively struggle through this," Wolfe-Lyga said in an emailed response.

It's especially essential given the mental health impacts of financial pressures on students.

"Financial concerns are an important factor that can exacerbate pre-existing mental health concerns or bring students in for treatment," Lee said. "As these issues will likely continue or worsen, it is likely that the need for mental health services on college campuses will continue to rise."

Faculty need to use compassionate flexibility, as well, said David Palmiter, a full professor of psychology at Marywood University.

"Sometimes people say that might mean a lowering of academic standards, but I don't think so," he said.

Marywood found support groups to be successful in the spring. Creating programs outside of traditional counseling can help serve students who may not yet be comfortable with the idea of sitting down one on one with a therapist, Palmiter said.

"Most people who can benefit from counseling do not get it," he said, adding that he hopes one good thing that comes out of this crisis is a better societal understanding of mental health.

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Suicidal ideation on the rise for college-aged adults due to COVID-19 pandemic

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One in four people aged 18 to 24 seriously contemplated suicide in June, according to new research from the Centers for Disease Control and Prevention. The data are the latest in a series of reports highlighting increases in anxiety, depression and suicidal ideation since the COVID-19 pandemic began.

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Mental Helath Apps for Black, Latinx, Asian, LGBTQ

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Mental Helath Apps for Black, Latinx, Asian, LGBTQ

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Mental Health Apps For Black, Latinx, Asian, and LGBT Communities

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Fortunately, there are many out there doing the work to make sure our communities can find the support they need, something that's especially crucial now. Ahead, we highlight some of the mental health apps and platforms that cater to specific marginalized communities, gaining insight on their unique offerings and the founders who created them.

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Everything changed on October 16, 2006, when Tina's 13-year-old daughter, Megan Taylor Meier, took her own life after being cyberbullied by an adult neighbor posing as a fictitious boy named "Josh Evans" on MySpace.

Tina made it her mission to prevent such tragedies and to help children and families affected by bullying and cyberbullying. In December of 2007, Tina's Aunt Vicki gave her the first $100.00 to open up the Megan Meier Foundation's bank account and apply for 501(c)(3) status.

Tina's first school presentation on behalf of the Megan Meier Foundation was on December 20, 2007 to over 900 middle school students. Tina's passion is stronger than ever and with the support of staff members, volunteers, her family and close friends, the Foundation has reached over 350,000 students, parents, educators, and professionals across the United States.

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About Tina Meier - Megan Meier Foundation

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Everything changed on October 16, 2006, when Tina's 13-year-old daughter, Megan Taylor Meier, took her own life after being cyberbullied by an adult neighbor posing as a fictitious boy named "Josh Evans" on MySpace. Tina made it her mission to prevent such tragedies and to help children and families affected by bullying and cyberbullying.

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The shuttering of the American education system has cut off young people from school staff members who helped them navigate the pressures of adolescence and cope with trauma.

Jael Hernandez, right, is a single mother of three children, including her eldest, Jizelle, left. The pressure of working two jobs remotely, on top of helping with her children's online learning, has left Ms. Hernandez with little time to handle their emotional needs. Credit... Jim Wilson/The New York Times

The email, written by an eighth grader and with the subject line "Wellness Check," landed in her school counselor's inbox nearly three weeks after schools had closed in Libby, Mont., a remote town of 2,700 cradled by snow-topped mountains.

"I would like you to call me," the student wrote. "This whole pandemic has really been frightening and I hate to say it, but I miss going to school. I hate being home all day."

The counselor, Brittany Katzer, was alarmed. The student had long struggled with depression and was considered high-risk for harming herself. Ms. Katzer called the girl several times, but the number she tried was out of service. She sent emails and left a message on the girl's mother's phone.

Neither the girl nor her mother returned the messages. The student has not contacted any of her teachers or submitted any assignments since the school district shifted to distance learning, Ms. Katzer said.

"I worry about her safety and mental health, but what else can I do?" asked Ms. Katzer, who said a staff member had dropped off lunches at the house and had spoken with the girl's sister, a third grader, who confirmed her older sister was home, though she has not completed any assignments.

Pre-pandemic, on a typical school day, Ms. Katzer said she spoke with about 100 students, either individually or in group sessions. "The face-to-face connections that I make with kids are irreplaceable. Now, who knows what's happening with them?"

The shuttering of the American education system severed students from more than just classrooms, friends and extracurricular activities. It has also cut off an estimated 55 million children and teenagers from school staff members whose open doors and compassionate advice helped them build self-esteem, navigate the pressures of adolescence and cope with trauma.

Desperate to safeguard students' emotional well-being amid the isolation and financial turmoil of the coronavirus pandemic, teachers are checking in during video classes, counselors are posting mindfulness videos on Facebook and school psychologists are holding therapy sessions over the phone.

"I'm hearing a lot of grief and loss," said Lauren Hunter, a counselor who works in two public schools in Los Angeles as part of the Cedars-Sinai Share & Care program, which provides mental health services to at-risk students in 30 county schools.

But the challenges hard-wired into online learning present daunting obstacles for the remote guidance counselor's office, particularly among students from low-income families who have lost jobs or lack internet access at home. And mental health experts worry about the psychological toll on a younger generation that was already experiencing soaring rates of depression, anxiety and suicide before the pandemic.

"Not every kid can be online and have a confidential conversation about how things are going at home with parents in earshot," said Seth Pollak, director of the Child Emotion Lab at the University of Wisconsin-Madison.

Until the coronavirus outbreak, Maellen Johnson, 16, a sophomore at Libby High School, had visited her guidance counselor's office nearly every school day since the seventh grade, when the counselor pulled her aside after hearing she was having suicidal tendencies. Their relationship, Maellen said, helped her overcome those feelings, and the office became her refuge from the stress of classes and family drama.

"It was just a peaceful place," Maellen said. "She always offered comfort and safety."

Now, Maellen texts her counselor at least once a week, usually to vent about the struggles of being stuck at home with her brother, her mother, her mother's fiancé and his two children in the house they have shared since November. The communication has helped her cope, she said, but texting is hardly a good substitute. "It's just easier to let out all those anxieties when you're actually talking face to face," she said.

Some educators, dissatisfied with the limitations of technology, have found ways to visit students during the pandemic.

Emily Fox, a social emotional specialist at a primary school in Chillicothe, Ohio, uses Zoom to meet with her students. Many of the children are being raised by grandparents, she said, while some have been traumatized by family addiction. She said she worried about suicidal ideation and attempts by students as young as kindergartners, a problem even before school closed.

Desperate to check up on her students, Ms. Fox regularly delivers lunch to those from more underprivileged families, and she recently devoted an afternoon to driving to a dozen houses, where she talked to students from a safe distance outside.

"It gave me comfort just seeing their smiling faces," she said.

During the outbreak, Jael Hernandez, a single mother of three, including an autistic son, has been homebound in their apartment in Oakland, Calif., because of her compromised immune system.

Though the school delivers some meals, and her children's grandmother does the food shopping, the pressure of working two jobs remotely, on top of helping her children with their online learning, has left Ms. Hernandez with little time to handle their emotional needs.

"I'm dealing with so much that I forget to really check on how they're feeling," said Ms. Hernandez, 38, admitting that she often erupts at her children because of the stress.

For Ms. Hernandez's elder child, Jizelle, 14, an eighth grader, the loss of school and friends has been compounded by her isolation. Allowed outside only to walk their pug around the building's backyard, she said she often cried because she was so overwhelmed.

"I feel alone," she said, "and like so many things are happening at once - I can't really process it."

Before the pandemic, Jo'Vianni Smith was a talented 15-year-old athlete who played on her high school's varsity softball team in Stockton, Calif. Music and sports were her passions, said her mother, Danielle Hunt, who proudly recounted how Jo'Vianni, a sophomore, had competed in the junior Olympic track and field championships last year.

But once her school and softball season shut down in March, so, too, did her active daily routine. Unable to hang out with her friends while isolating at home with her mother and grandparents, Jo'Vianni spent her days learning remotely, browsing social media and hitting balls at a local park until that, too, was closed.

"I feel like she was bored out of her mind," Ms. Hunt said.

Without any warning, Jo'Vianni died by suicide in her bedroom on April 4. Her mother was working downstairs and her grandmother, an essential worker, discovered her body when she returned home.

In the weeks since, Ms. Hunt has searched for clues that might shed light on why her daughter took her life. Jo'Vianni left no note, and the police found nothing suspicious in her phone or on social media accounts, so Ms. Hunt begged Jo'Vianni's friends for information. "I'm like, 'She's gone, no more teenage secrets, you can tell me now,'" she said, but they were just as mystified.

Amid the lockdown, Ms. Hunt organized a small viewing at their church, with only a few visitors allowed inside at a time. Now home, and with little to do but mourn, Ms. Hunt is wracked by grief and confusion.

She cannot square the act with the ambitious daughter she thought she knew so well. Still, she feels certain that the stress of the pandemic played a role in her daughter's tragic end.

"The world is so upside down, and nothing is right," she said.
If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK) or go to SpeakingOfSuicide.com/resources for a list of additional resources. Here's what you can do when a loved one is severely depressed.

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In a World 'So Upside Down,' the Virus Is Taking a Toll on Young People's Mental Health (Published 2020)

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The shuttering of the American education system has cut off young people from school staff members who helped them navigate the pressures of adolescence and cope with trauma. The email, written by an eighth grader and with the subject line "Wellness Check," landed in her school counselor's inbox nearly three weeks after schools had closed in Libby, Mont., a remote town of 2,700 cradled by snow-topped mountains.

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Wisconsin High School Sports | Wisconsin Sports Network | WisSports.net

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Results from a much-anticipated research study led by Dr. Tim McGuine, a UW health researcher and member of the WIAA Sports Medical Advisory Committee, have been made public, painting a more complete picture of the impact of the school closures and sports shutdowns resulting from the coronavirus pandemic.

With a stated objective of, "To identify how COVID-19 related school closures and sport cancellations in Wisconsin have impacted the health of adolescent athletes", the research study consisted of a short online survey of 3,243 adolescent athletes in Wisconsin, from 71 of the 72 counties in the state, regarding their feelings, emotions, and responses to the sport shutdown.

The findings show significant mental health, anxiety, and depression issues in the high school-aged population, and further emphasize the need for leaders at the state, local, and school levels to consider these issues when determining when and how to return to classroom instruction and extracurricular activities.

Of the more than 3000 participants, 65% reported anxiety symptoms, with 25% suffering moderate or severe anxiety.

Using historical data obtained from past research studies, the group determined that the rate of mild to severe depression increased from 31% to 68%. In the past 68% of respondents reported minimal or no depression, compared to just 32% in May of 2020.

Physical activity was down 50% in May of 2020 compared to past results. In scores around quality of life, the physical health score decreased from 91.7 to 82.6, the psychosocial health decreased from 90.4 to 76.2, and overall health decreased from 90.9 to 78.4.

The study estimates that 66,000 Wisconsin adolescent athletes are at risk for depression, with short-term effects of mental health disorders impacting students use of drugs and alcohol, staying in school, engaging with peers, and graduating from high school. Long term concerns of the mental health disorder increase can include impacting whether individuals go to college, extensive use of drugs and/or alcohol, and the ability to form meaningful relationships.

The study concludes, "Previous studies have demonstrated that prolonged quarantines can negatively impact mental health. Schools play an important role in providing access to mental health services for disadvantaged students. Medical providers, parents, and policy-makers must recognize the mental health strain the current pandemic is placing on adolescent athletes."

The WIAA will hold a video conference presentation for school superintendents and select media members with Dr. McGuine and possibly other members of the WIAA's Sports Medical Advisory Committee on Tuesday to discuss the findings.

The full research study can be viewed below. Other researchers participating in the study include Kevin Biese MA, Scott B Hetzel MS, Stephanie Kliethermes PhD, Claudia L. Reardon MD, David Bell PhD, M. Alison Brooks MD & Andrew Watson MD.

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UW Health research study results show significant and alarming mental health impacts on school closures and sport cancellations

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Results from a much-anticipated research study led by Dr. Tim McGuine, a UW health researcher and member of the WIAA Sports Medical Advisory Committee, have been made public, painting a more complete picture of the impact of the school closures and sports shutdowns resulting from the coronavirus pan

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At its foundation, TikTok is supposed to be a fun and silly app with lip syncs, challenges, dances and funny videos. But, as with most social media, there is an underlying dark side to the platform that parents and fans of the app should be aware of.

The line "I had pasta tonight" is not a new viral craze, but rather a call for help.

What the statement often means is that the person in the video is feeling depressed, anxious or experiencing suicidal thoughts.

According to data from the CDC, Gen Z is the most at-risk generation for mental illness. Business Insider reports that the suicide rate for people aged 10 to 24 has increased by 56 percent between 2007 and 2017.

Social media also can contribute to depression. Statistically, Gen Z is more likely to be on social media than not, and a study by Guildford Press concluded that there is a link between social media and poor mental and emotional health.

saw a tiktok about a girl saying her mom just made her favorite pasta.... not knowing what it's about, i went to the comment section & its everyone giving her reasons to stay. one comment said "have you heard your child's laugh yet?"....

- Amber

(@x_amberlynne) June 25, 2020

Other captions like "I finished my shampoo and conditioner at the same time" serve as codes for help. Mental health is still a stigmatized issue that many find very hard to openly admit or talk about, so these phrases act as a way to raise a red flag without feeling too vulnerable online.

A Reddit user believes that the phrases come from a Wattpad post titled, "Don't kill yourself today." One point says to "finish your shampoo and conditioner at the same time" and another says to "tell someone your best pasta recipe."

What's powerful about "I had pasta tonight" is the comments. Those who are aware of the meaning behind the phrase know to reach out to the person or reply with kind words.

One TikTok captioned "Told my mom about my favorite pasta recipe and she made it for dinner tonight" received over 3 million views and 60,000 comments - all of which can be summed up by one user's comment: "This comment section is my new therapy. Thank you."

"You're so loved," one person replied.

"You haven't come this far to only come this far," another posted.

"I love you all so much it's beyond words," the poster commented. "Thank you so much."
If you or someone you know is contemplating suicide, call the To read more about mental health, read this profile on More from In The Know: New Jersey woman provides book bags, mental health classes and "light" to kids in the Dominican Republic 11 kitchen gadgets that can make healthy eating easier Nordstrom launches first gender inclusive collection These $1 extenders will help relieve pain while wearing face masks Dimple Patel, who's on a mission to raise awareness within the South Asian community. National Suicide Prevention Lifeline at 1-800-273-8255. to learn about the warning signs of suicide.
The post The deeper meaning behind TikTok's 'I had pasta tonight' caption appeared first on In The Know.

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TikTokers are using the secret code 'I had pasta tonight' and it has nothing to do with dinner

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At its foundation, TikTok is supposed to be a fun and silly app with lip syncs, challenges, dances and funny videos. But, as with most social media, there is an underlying dark side to the platform that parents and fans of the app should be aware of.

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Rejection: The Crisis of Belonging for LGBTQ 

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Rejection: The Crisis of Belonging for LGBTQ 

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Rejection: the Crisis of Belonging - LGBT Youth

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From STARR Commonwealth

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By Dr. Caelan Soma, PsyD, LMSW

Dr. Caelan Soma, PsyD, LMSW, Chief Clinical Officer, provides oversight for all clinical operations and research at Starr Commonwealth. Dr. Soma provides trauma assessment and trauma informed, resilience focused intervention for youth utilizing evidence-based practices, including TLC's SITCAP® model programs.

About Starr Commonwealth

Starr Commonwealth is dedicated to the mission to lead with courage to create positive experiences so that all children, families, and communities flourish. We specialize in residential, community-based, educational, and professional training programs that build on the strengths of children, adults, and families in communities around the world. To schedule a training or consultation, please contact info@starr.org or call 800-837-5591.

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Rejection: The Crisis of Belonging - Starr Commonwealth

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The power and influence of positive human relationships in fostering resilience cannot be overstated. Urie Bronfenbrenner, a developmental psychologist renowned for his ecological systems theory of child development, once stated that "every child needs at least one adult who is irrationally crazy about him or her."

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ASCA POSITION STATEMENT ON SUICIDE ASSESSMENTS - Coming Soon

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ASCA POSITION STATEMENT ON SUICIDE ASSESSMENTS - Coming Soon

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The National Child Traumatic Stress Network

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Helps educators understand how they might address the interplay of race and trauma and its effects on students in the classroom. The guide outlines recommendations for educators and offers a list of supplemental resources. It should be implemented in accordance with individual school policies and procedures.

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Addressing Race and Trauma in the Classroom: A Resource for Educators

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Helps educators understand how they might address the interplay of race and trauma and its effects on students in the classroom. The guide outlines recommendations for educators and offers a list of supplemental resources. It should be implemented in accordance with individual school policies and procedures.

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Student-led group of increasing compassion through service to others. Created by a school counselor.

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Who are we? After four suicides at a local high school in 2004-05, the B.I.O.N.I.C. Team was started to empower young people to reach out to students going through similar tough times to let them know they are "seen," "valued," and "cared for" in hopes of preventing them from spiraling down into more serious issues including suicide.

Through simple outreaches we reach out to our peers through - New Student Breakfasts for peers who are new, get well packets for students who are sick, care packages for those who lose loved ones, outreaches to those who are bullied, and posters of support for schools that experience tragedy. We also reach out to the elderly and veterans.

We are impacting individuals, schools, and communities by changing the atmosphere in schools to a more caring climate where peers are looking out for each other. Click in this box to hear why over 950 schools (elementary through college) worldwide have inquired about starting a B.I.O.N.I.C. Team, plus even businesses and places of worship.

Sign up to keep informed on everything that is happening with B.I.O.N.I.C.

On September 9 th, 2020 - what we call " 9-9 - I Care Day " - what would the world look like in one day if every person in every school and community worldwide reached out to make a difference in 9 people's lives - one person each hour for 9 hours - thanking a store clerk, buying coffee for a teacher, texting "I love you" to a parent, calling your Grandma, giving a flower to a secretary?

Check back often and subscribe for more details in how schools, businesses, churches, organizations, and others can get involved in 9-9 - I Care Day!

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# data[].attributes.attachment_link.description
B.I.O.N.I.C. TeamB.I.O.N.I.C. Helping people say 'Believe it or not i care'with their lives!{'@context': 'http://schema.org','@type': 'VideoObject','name': 'BIONIC_FINAL_B_version','description': 'This video contains BIONIC_FINAL_B_version','thumbnailUrl': 'https://embed.vidello.com/83/c6ea28kqg6fck9ig/video/splash.jpg','uploadDate': '2019-03-07T06:30:56.000Z','duration': 115.49}How T​​​​​o Get InvolvedThere Is An Opportunity For Everyone To Contribute WHO?Who are we? After four suicides at a local high school in 2004-05, the B.I.O.N.I.C.

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Created by a school counselor, this is the Believe It Or Not, I Care = peer led group of building compassion into schools and saving lives.

# data[].attributes.attachment_link.readable_text
Who are we? After four suicides at a local high school in 2004-05, the B.I.O.N.I.C. Team was started to empower young people to reach out to students going through similar tough times to let them know they are "seen," "valued," and "cared for" in hopes of preventing them from spiraling down into more serious issues including suicide.

Through simple outreaches we reach out to our peers through - New Student Breakfasts for peers who are new, get well packets for students who are sick, care packages for those who lose loved ones, outreaches to those who are bullied, and posters of support for schools that experience tragedy. We also reach out to the elderly and veterans.

We are impacting individuals, schools, and communities by changing the atmosphere in schools to a more caring climate where peers are looking out for each other. Click in this box to hear why over 950 schools (elementary through college) worldwide have inquired about starting a B.I.O.N.I.C. Team, plus even businesses and places of worship.

Sign up to keep informed on everything that is happening with B.I.O.N.I.C.

On September 9 th, 2020 - what we call " 9-9 - I Care Day " - what would the world look like in one day if every person in every school and community worldwide reached out to make a difference in 9 people's lives - one person each hour for 9 hours - thanking a store clerk, buying coffee for a teacher, texting "I love you" to a parent, calling your Grandma, giving a flower to a secretary?

Check back often and subscribe for more details in how schools, businesses, churches, organizations, and others can get involved in 9-9 - I Care Day!

This is the Final Subheading on the Page

Here, we can ask visitors to connect or share on social media.

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Nulla tincidunt fermentum arcu a bibendum. Nunc finibus turpis congue lectus dignissim, eu tempus lectus pellentesque. Nunc facilisis at eros vel consectetur.

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# data[].attributes.attachment_link.description
B.I.O.N.I.C. TeamB.I.O.N.I.C. Helping people say 'Believe it or not i care'with their lives!{'@context': 'http://schema.org','@type': 'VideoObject','name': 'BIONIC_FINAL_B_version','description': 'This video contains BIONIC_FINAL_B_version','thumbnailUrl': 'https://embed.vidello.com/83/c6ea28kqg6fck9ig/video/splash.jpg','uploadDate': '2019-03-07T06:30:56.000Z','duration': 115.49}How T​​​​​o Get InvolvedThere Is An Opportunity For Everyone To Contribute WHO?Who are we? After four suicides at a local high school in 2004-05, the B.I.O.N.I.C.

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How Educators Can Address Trauma During Closure

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How Educators Can Address Trauma During Closure

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JED Foundation - Comprehensive Prevention Approach

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JED Foundation - Comprehensive Prevention Approach

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It Will Be Crucial for Schools to Address Mental Health Needs In the Fall 

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It Will Be Crucial for Schools to Address Mental Health Needs In the Fall 

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It will be crucial for schools to address mental health needs in the fall

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How are you doing today? That is what schools should be asking every student regularly when classes restart in the fall, however school looks. It's also...

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The Toll That Isolation Takese on Kids During the Coronavirus Era

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The Toll That Isolation Takese on Kids During the Coronavirus Era

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After six weeks of lockdown due to Covid-19, Cari Marshall was getting concerned about her 11-year-old daughter Chloe. The child missed seeing her friends in person and was becoming frustrated communicating with them solely via FaceTime, TikTok and the gaming app Roblox.

"It laid bare how important her personal relationships are to her daily happiness," says Ms. Marshall, a political volunteer organizer in Austin, Texas. "She is all about her friendships."

Copyright ©2023 Dow Jones & Company, Inc. All Rights Reserved. 87990cbe856818d5eddac44c7b1cdeb8

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The Toll That Isolation Takes on Kids During the Coronavirus Era

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After six weeks of lockdown due to Covid-19, Cari Marshall was getting concerned about her 11-year-old daughter Chloe. The child missed seeing her friends in person and was becoming frustrated communicating with them solely via FaceTime, TikTok and the gaming app Roblox.

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Children Process Grief and Loss Through Play 

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Children Process Grief and Loss Through Play 

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Soon after the Oklahoma City bombing, in 1995, children in a nearby kindergarten started playing dead. Over and over, they toppled towers of blocks and lay motionless on the floor. When their teacher asked them to tell her about what was happening in their play, the students informed her that they had all been killed by terrorists.

The play continued in this vein for some time-smashed towers, splayed-out children-until their teacher asked if they might be interested in building a hospital. "She went in with stethoscopes, masks, and bandages, and helped kids move towards a phase that was focused on care and healing," says Nancy Carlsson-Paige, a professor emerita at Lesley University in Cambridge, Massachusetts, and an expert on the ways young children process trauma through play.

That expertly handled transition-recognizing that the children were stuck and might need a nudge-demonstrates a few important principles about play, according to Carlsson-Paige. First, the teacher did not judge the children's play or let her own anxieties about the situation seep through. For young children, she understood, play is the only way to work through everything they wrestle with, from everyday challenges to anxiety, fear, and even loss and death. Second, while the teacher left plenty of room for discovery, she stepped in when the play turned obsessive, redirecting her students in a way that was both well-timed and developmentally appropriate.

As the world confronts the novel coronavirus pandemic, an economic depression, and global protests about racism and systemic inequalities, children are being exposed to painful and often scary ideas-and their play will reflect their efforts to make sense of what they see and hear.

Why Children Play Through Grief and Loss

The late Vivian Gussin Paley, a kindergarten teacher, recipient of the MacArthur "genius" grant, and author of dozens of books on children's play lives, put it this way: "The young child wants to play. He wants to play because intuitively he understands that through play he will understand more about who he is than in any other format."

Seth Aronson, a psychologist and the Director of Curriculum, Training and Supervising Analyst at the William Alanson White Institute of Psychiatry, Psychoanalysis, and Psychology in New York City, extends that line of thinking into play that involves the processing of fear, anxiety, or loss.

"One of the functions that play serves for kids is it allows them to approach something that might be frightening in a way that makes it less frightening and more understandable," he says. Through play, children "control the tempo and the pace and the content" of a situation and gain the ability to anticipate what happens next-all of which can take the sting out of scary situations. "Whenever there's any kind of scary or traumatic situation, play really allows the child the displacement and the space to play out some of those things," he says. "If it's happening to a doll, it's not really happening to me."

In other words, imaginative play not only enables children to better understand reality-by helping them to inhabit the perspectives of, say, both a doll patient and a stuffed animal doctor-but also to quickly change the narrative when the reality becomes too much to bear. (In the past two months, I've seen this with a three-year-old I've spent a lot of time with, who repeatedly declares dolls dead before bringing them back to life.) Psychologists call these processes denial and undoing, and they're essential to maintaining a child's sense of safety and control.

"Play has the power to make something un-happen, to correct something that's overwhelming," Aronson explains. For instance, a child whose grandmother recently died might say that she saw Grandma in her room, or that she played with her. "It's totally normal," Dr. Aronson says. "It's undoing the event in a way that's comforting and soothing and helps the child deal with the loss."

How Grown-ups Can Set the Stage

Erika Christakis, a former faculty member at the Yale Child Study Center and the author of The Importance of Being Little: What Young Children Really Need from Grownups, says that the play impulse is evolutionarily hardwired in humans and "can't be short-circuited." Nevertheless, she says, adults play a key role in setting the groundwork for what psychologists call "productive play"-which actively helps children process their experiences and acquire emotional and cognitive skills-while watching for signs of unproductive play, which represent and amplify feelings of distress.

The P.A.C.E. approach: Christakis says that the acronym P.A.C.E. -which stands for playfulness, acceptance, curiosity, and empathy-is a useful guide for helping adults interact with young children. Adults should recognize that children are navigating a tension within themselves: they want to feel powerful and independent, while also yearning to feel protected and cared for. Given this, adults should empower children with age-appropriate choices: asking them what song to sing, what to have for a snack-or what they want to play.

Generally speaking, adults shouldn't be overly worried that children will lead themselves down roads they aren't prepared to navigate: the very instinct to explore a subject in play likely means that the child is ready-and perhaps needs-to do so. "Children are really good at getting what they need through the tools that they have," she says. She adds, "Kids can tolerate a lot as long as they know that their feelings are not creepy or wrong."

Don't shame: Sometimes children's play can inspire uncomfortable feelings in adults, which is perfectly fine, as long as adults don't convey to children that their play is shameful or wrong. Play is highly personal: Nancy Carlsson-Paige, the professor, says it contains "the whole child: emotions and thoughts and physical being and social self." As such, children tend to interpret criticism or dismissal of their play as criticism or dismissal of themselves.

"The healthiest, most nurturing thing we can do for children is to join them in their feelings," Christakis says. She encourages adults to communicate that "there's nothing you could say to me that would be too weird, too annoying."

Create the conditions for imaginative exploration: To encourage children to play out what's on their minds, experts recommend providing children with "multi-use" toys-generic objects like blocks and wooden dolls, onto which children can project what they need to project. When children have a Superman action figure, they tend to play out Superman storylines; but when they have a faceless figure, they engage with their own thoughts and emotions, what they find exciting, troubling, or confusing. It's these scenarios that are most conducive to productive play, which reflects some aspects of a child's experience or imagination.

Watch for unproductive play: In rare situations, play-or a lack thereof-can be a cause for concern. Generally speaking, adults should not intervene in children's play. However, "if the child's play makes the child anxious, when it's too literal for the child, or when it's obsessive and repetitive-that's a sign that the play isn't serving its purpose," says Aronson, the New York psychologist. In these situations, adults can gently introduce new elements or coax the narrative in a new direction, as the teacher in Oklahoma did when her kindergarteners repeatedly revisited the terrorist attack.

"I always look for some kind of change in play," says Carlsson-Paige. If that change doesn't occur-if the same troubling event is rehashed over and over, with the same outcome each time-intervention, or psychological attention, may be merited.

However, what may be most concerning is the absence of play. When Carlsson-Paige spent time in El Salvador in the early 1990s, during the country's civil war, the children she encountered there were so traumatized they didn't play at all. When she returned the next year, after the war's conclusion, play had returned.

"Children need to have a certain sense of safety to go into an imaginary play zone," she asserts. Adults can provide that safe space at this tumultuous and historic moment-being careful to strike the right balance between the freedom children need to explore difficult subject matter on their own, and the periodic need to step in when kids get stuck.

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How Children Process Grief and Loss Through Play

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Soon after the Oklahoma City bombing, in 1995, children in a nearby kindergarten started playing dead. Over and over, they toppled towers of blocks and lay motionless on the floor. When their teacher asked them to tell her about what was happening in their play, the students informed her that they had all been killed by terrorists.

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The pandemic makes it clear: it's time to finally address the mental health crisis in America

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The pandemic makes it clear: it's time to finally address the mental health crisis in America

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The pandemic has not only weighed on the physical health of Americans, but their mental health too.

And the US was already facing a mental health crisis, even before COVID-19 hit.

Congress can help address the crisis and we can all work to improve the country's collective mental health.

Patrick J. Kennedy is a former US Representative, author, and founder of the Kennedy Forum.

Norm Gorin is vice president of MindWise Innovations.

This is an opinion column. The thoughts expressed are those of the author.

Visit Business Insider's homepage for more stories.

Never has there been a time in our history when people talked as openly about anxiety, depression, or feelings of hopelessness as they are during the pandemic. Crisis lines are no longer taking calls purely about the symptoms of COVID-19 or how to get tested, but instead are inundated with people asking for help to fight feelings of high anxiety and stress.

Business leaders know this is an unavoidable component to the immediate health of employees, with many now searching for ways to support the behavioral health of their workforce. Before the pandemic, depression alone was estimated to cost the American economy $210 billion annually, with 50% of that cost shouldered by employers. The World Economic Forum projected that mental health disorders will cost nations $16.3 trillion between 2011 and 2030, which represents a staggering loss in economic output.

Experts believe the pandemic is likely to produce a tsunami of behavioral health challenges and "deaths of despair" as tens of millions of Americans are added to the unemployment bench with many more expected to join their ranks. We know from experience with the construction industry, which tops the chart for suicide deaths, that economic insecurity is a leading factor in suicide deaths.

A systematic review of the research suggests the burden of post-traumatic stress disorder (PTSD) among persons exposed to human-made and natural disasters is substantial. Large-scale disasters are almost always accompanied by increases in depression, PTSD, substance use disorders, and other mental health conditions, as well as domestic violence, and child abuse.

Despite the grim statistics, there is a reason to be optimistic about the mental health of our country. With everyone so greatly impacted by this global pandemic, stigma seems to be a thing of the past. People are finally talking openly about their anxiety or depression. The question is no longer if you're struggling, but how badly you're struggling.

This unfortunate new normal could ultimately open doors for millions, increasing awareness and utilization of behavioral health resources and treatment options like never before. But we have much work to do as a nation to improve our infrastructure of care and eliminate the roadblocks that currently deter many with mental health and addiction challenges.

Given that the US was already in the midst of a behavioral health crisis long before the pandemic hit - with nearly 45,000 people dying by suicide each year and over 67,000 from drug overdoses - we need urgent action.

State and federal leaders must allocate adequate and sustained funding for mental health and addiction care. Half of the nation's counties have no behavioral health providers. Even where there are providers, far too many don't accept insurance due to low reimbursement rates. In fact, in the US, most psychiatrists practice out-of-network, which makes treatment expensive and out of reach for many. Nearly 60% of adults with a mental illness did not receive mental health services in the past year well before the pandemic altered our lives forever. This is unacceptable.

Three ways Congress can address the issue

Three initiatives are currently being considered by Congress - all are crucial.

The first, the bipartisan STANDUP Act of 2019, is designed to encourage states and tribes to implement and expand evidence-based suicide prevention training This would help ensure more states are making annual suicide training of students a priority and the law of the land, a recommendation of suicide experts for over a decade.

The second, the Behavioral Health Coverage Transparency Act would strengthen enforcement of existing behavioral health parity laws, which require insurers to cover treatment for mental health and substance use disorders no more restrictively than treatment for illnesses of the body, such as diabetes or cancer.

The legislation would increase mandatory federal audits of health plans, require insurance companies to disclose how they make decisions on behavioral health care coverage, and establish a Consumer Parity Portal - a one-stop shop where consumers could learn about their rights and submit complaints about potentially illegal denials of coverage.

The third, the Mental Health Parity and Addiction Equity Act of 2008 (Federal Parity Law) must be enforced along with corresponding state parity laws. These require insurers to cover treatment for mental health and substance use disorders no more restrictively than treatment for illnesses of the body, such as diabetes and cancer. Now, more than ever, discriminatory insurance practices cannot be tolerated.

Our leaders can no longer wait to make these necessary changes. It's time to reset our approach to behavioral health care. We need to commit future rounds of funding to provide resources that prioritize suicide prevention and support the range of mental health challenges - including addiction - that have been unleashed by today's pandemic. It seems only prudent to prepare for the full spectrum of this storm's implications. Incremental progress isn't enough when thousands are dying daily, millions are out of work, and a tsunami of suicides and overdoses is at our doorstep.

And to those who say it's not the right time to wage this war, we argue that not addressing mental health and addiction now will only prolong the impact of the COVID-19 pandemic and ultimately cost more lives. The most hard-fought battles in life are often the ones where we have the most to lose.
Patrick J. Kennedy is a former US Representative where he was the lead author of the Mental Health Parity and Addiction Equity Act (Federal Parity Law). In 2013, he founded The Kennedy Forum, a nonprofit that unites advocates, business leaders, and government agencies to advance evidence-based practices, policies, and programming in mental health and addiction. Norm Gorin is Vice President of MindWise Innovations (Mindwise.org). Powered by Riverside Community Care, a non-profit leader in behavioral health and human services, MindWise offers a comprehensive approach to mental health, substance misuse, and suicide prevention.

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The pandemic makes it clear: it's time to finally address the mental health crisis in America

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The pandemic has not only weighed on the physical health of Americans, but their mental health too. And the US was already facing a mental health crisis, even before COVID-19 hit. Congress can help address the crisis and we can all work to improve the country's collective mental health. Patrick J.

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ASCA Position Statement: Suicide Prevention 

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ASCA Position Statement: Suicide Prevention 

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See Your Strength Decals - Video for Youth: You Are Enough

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See Your Strength Decals - Video for Youth: You Are Enough

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The recent spike in calls to the Hopeline hotline for Filipinos feeling depressed has come as no surprise to Jean Goulbourn.

The coronavirus threat has spurred a near 200% increase in calls in the past month, a reflection of fear, anger and disappointment at unfulfilled government promises for relief assistance, says Goulbourn, the hotline's founder.

"We're getting calls that we never did before - 70 to 85% are high anxiety. We had a 13-year-old who called to ask, 'Do you think my family will get the virus? We are very poor,'" Goulbourn said.

If the threat of the coronavirus spread hasn't scared people, the government's messaging about it may also be stoking mental health conditions.

White coffins have been positioned around Metro-Manila to enforce the government's shut-in order. "Stay at home or stay inside", with an arrow pointing to an image of a coffin, is the message attached to each box.

To be sure, Filipinos were struggling with depression long before the threat of the coronavirus shut them in their homes or stranded them abroad.

In a country of more than 100 million people, Goulbourn says there are fewer than 5,000 licensed psychiatrists, psychologists and guidance counselors available for anyone feeling lost or wanting to self-harm.

Hopeline founder Jean Goulbourn in a file photo. Image: Natasha Goulbourn Foundation

Last year, Goulbourn says that around five to seven attempted suicides per day were rushed to hospitals in Metro-Manila alone, according to information shared with her by medical professionals.

It's an estimate, she stresses, as there are few hard statistics and even fewer current ones on suicides, largely because shame and stigma lead families to plead with doctors to record the cause of death as something else - a heart ailment, an accident, anything but suicide.

Goulbourn and her family did not try to hide their truth. Instead, they took the pain of their youngest daughter's death by suicide in 2001 and learned all they could about depression, mental health and wellness.

Then they established the Natasha Goulbourn Foundation in 2007 with a team of doctors as trustees and advisers.

Together they launched campaigns and programs to educate Filipinos on how to recognize and treat depression and, above all, to remove the shame attached to it.

Nine years ago, the Foundation set up "Hopeline 24/7 emotional crisis line" with a small crew of people answering phone calls and linking what could be high-risk callers to psychiatrists and therapists.

When Goulbourn, a fashion designer known in the Philippines for her Silk Cocoon atelier, was approached last year by a few companies with condo buildings and shopping malls, she sensed a breakthrough on her long-running campaign for investment against despair.

Generic image of a Filipino youth in Metro-Manila. Photo: Facebook

The property managers were concerned about the high number of people jumping to their deaths from their buildings and asked if her foundation would train their security guards and desk managers to recognize signs of depression.

"Each one of us can do something," she says, emphasizing corporations as much as the central government, churches and city mayors. Investment in services are needed as much as a cultural change in attitude towards both depression and the self-harm it can cause.

Although the Philippines tends to rank moderately well in the United Nations' World Happiness Report, moving from 71st in 2018 to 69th in 2019, suicide in the country is a hidden, harsh reality, says Goulbourn.

How much of a reality is hard to tell from the Philippine Department of Health website. It only references global or 15-year-old statistics that indicate an increase in suicides two decades ago.

It also cites a 2011 World Health Organization's Global School-Based Health Survey that reported 16% of students aged 13-15 had at some time seriously considered suicide, while 13% had "actually attempted suicide one or more times during the past year."

"Why are Filipinos too poor and yet too happy?" Josephus Jimenez wrote in the Philippine Star newspaper citing the World Happiness Report.

He also noted that the country had ranked in the top five on a global optimism index.

"That means that the Filipinos are full of hopes that this year and the next will bring better times for us all," he wrote. He attributed the smiles and positive outlook to faith, family and a lot of Facebook.

That's clearly not true for all Filipinos, particularly now with many trapped and at risk of losing their livelihoods by the government's virus-containing "enhanced community quarantine" measures.

A young girl wearing a mask amid the coronavirus scare as she sits outside her home in Manila. Photo: AFP/Maria Tan

Hopeline has heard from many elderly widows now living on their own and struggling with isolation because a family member died from the virus or they live in another town or overseas.

"Most don't know how to do Zoom or work with digital gadgets," Goulbourn says, which deepens their isolation.

With a phone number recently added to help Filipino workers stranded outside of the country cope with the isolation, calls are now coming in from non-Filipinos, she says.

The helpline is available to all subscribers of the Globe mobile telephone service, which has supported Hopeline since its inception.

Not only is the coronavirus increasing anxiety and thus callers, Goulbourn worries it's also threatening the financial life support of such services as Hopeline and other groups dedicated to mental health awareness and suicide prevention in the Philippines.

Despite being confined to her home, Goulbourn continues campaigning for funding to sustain the hotline as well as expand services and the number of mental health responders.

Her foundation, which changed its name to NGF Mindstrong in September 2019 and became a representative of the International Association of Suicide Prevention, is now urging local government units to begin building a counseling system within health centers.

In June, or when schools finally resume, the Wellness Emotional Resilience Program is slated to roll out nationally with the Department of Education to provide homeroom guidance as part of the curriculum for grades 4 to 12 to "build students' self-esteem and ability to better cope with problems," says Goulbourn.

A woman wears a mask as a precautionary measure against the spread of Covid-19 in Manila on March 13, 2020. Photo: AFP/Maria Tan

And NGF Mindstrong is promoting what it calls a "movement" among student leaders at five universities with proactive mental health activities, such as peer counselling, to work towards "zero suicides."

Goulbourn says she wants to be prepared for the aftermath of when the threat of the coronavirus has been contained.

"By June, July, August we'll see if resilience is strong or if the economic problems will cause high-risk depression and bring up suicides," she says. "I don't want to think of it. I want to be wrong. But I also want our Foundation to be prepared."

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A viral call for help from suicidal Filipinos

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The recent spike in calls to the Hopeline hotline for Filipinos feeling depressed has come as no surprise to Jean Goulbourn. The coronavirus threat has spurred a near 200% increase in calls in the past month, a reflection of fear, anger and disappointment at unfulfilled government promises for relief assistance, says Goulbourn, the hotline's founder.

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At Bark, we know first-hand just how urgent it is to offer support and guidance to help prevent suicide. The issue can seem difficult to grasp, but every statistic represents real people who need help:

In 2019, Bark detected more than 1,800 instances of imminent suicide.

In the first 8 months of 2020, Bark detected 35,000+ instances of severe self-harm and/or suicidal ideation.

As of August 31, Bark has alerted families to an average of 5 instances of imminent suicide every day this year.

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Suicide Awareness and Prevention Resources for Parents

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At Bark, we know first-hand just how urgent it is to offer support and guidance to help prevent suicide. The issue can seem difficult to grasp, but every statistic represents real people who need help: In 2019, Bark detected more than 1,800 instances of imminent suicide.

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Bob Filbin, Chief Data Scientist and Co-Founder

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COVID:19 Mental Health Data | Crisis Text Line

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Corona virus is top of minda across the world—and for our texters. We’re seeing a rise in anxiety as the virus hits America.

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Ring the Alarm - Task Force - Resources 

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Ring the Alarm - Task Force - Resources 

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Ring the Alarm: Crisis of Black Youth Suicide in America - DOCUMENT 

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Ring the Alarm: Crisis of Black Youth Suicide in America - DOCUMENT 

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THE CONGRESSIONAL BLACK CAUCUS

EMERGENCY TASK FORCE ON BLACK YOUTH SUICIDE & MENTAL HEALTH

CHAIR, REP. BONNIE WATSON COLEMAN

Over the last several years, data has emerged indicating an alarming increase in the suicide rates for Black children and teenagers over the past generation. While research has also shown climbing rates for youth from other racial and ethnic groups, this trend in Black youth runs counter to historical data showing lower rates of suicide among Black Americans. The narrowing racial gap in suicide rates tells us that this emergent issue among Black youth warrants attention now. A cadre of Black researchers from across the United States has been ringing the alarm to raise awareness about this disturbing trend. On April 30, 2019, U.S. Representative Bonnie Watson Coleman established he Congressional Black Caucus (CBC) Emergency Taskforce on Black Youth Suicide and Mental Health, simultaneously empowering a working group, led by Dr. Michael Lindsey, PhD, MSW, MPH, Executive Director of the NYU McSilver Institute for Poverty Policy and Research, of experts composed of the country's leading Black academic, advocacy and practicing experts in this space. Over the past 8 months, the taskforce and working group have held hearings, forums, events and listening sessions to identify both the causes and potential solutions to this burgeoning crisis. On December 17, the taskforce released a report, and simultaneously introduced legislation aimed at closing the mental health care gap for black youth.

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Emergency Task Force On Black Youth Suicide & Mental Health

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THE CONGRESSIONAL BLACK CAUCUS EMERGENCY TASK FORCE ON BLACK YOUTH SUICIDE & MENTAL HEALTH CHAIR, REP. BONNIE WATSON COLEMAN Over the last several years, data has emerged indicating an alarming increase in the suicide rates for Black children and teenagers over the past generation.

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The suicide rate for black youth is rising faster than for any other racial and ethnic group, now making it the second-leading cause of death for black children aged 10 to 19, according to a congressional report released this week.

The 38-page report, Ring the Alarm: The Crisis of Black Youth Suicide in America, was conducted by a task force of the Congressional Black Caucus and found a sharp rise in the rate of suicides and attempts among black youth.

The report also found that suicide attempts rose 73 percent from 1991 to 2017 for black adolescents of both sexes, and injuries from attempted suicides rose 122 percent for black boys inthe same time period.

"The suicide rate for black youth has been increasing faster than any other group, and that is very concerning to us," said Rep. Bonnie Coleman Watson,D-N.J., who chaired the caucus's task force , and took questions about it this week upon its release on a call with reporters.

"However, the good news is there are indeed solutions, there are evidence-based programs, there are ways of supporting the opportunities to do the research to understand the particularities of our community and the traumas associated with our children and their mental health well being," she said.

Coleman Watson announced pending legislation aimed at addressing youth mental health in communities of color. Among the proposals in the Pursuing Mental Health Act of 2019 are:

Increase the amount of research relating to the mental health of black youth and suicide through the National Institutes of Health and the National Institute of Mental Health, particularly by minority researchers;

Promote training of students, parents, teachers and other school staff members to identify and screen for signs of trauma, mental health disorders and risk of suicide;

Increase funding for the National Institute on Minority Health and Health Disparities to study mental health disparities in racial and ethnic minority groups;

Prohibit federal funds from being used for conversion therapy and prohibits the awarding of federal grants to states that continue to allow it.

"The bottom line is this: Black youth suicide and suicidal behavior are rising, defying historic trends. The gap is narrowing between black and white youth, and we must get at the bottom of why," said Dr. Michael A. Lindsey, executive director of the NYU McSilver Institute for Poverty Policy and Research, who led the working group that conducted the report and joined Coleman Watson on the conference call.

"The signs of suicide in black youth are too often overlooked and not well understood," Lindsey said, "and so we must have more research that helps in finding answers to this growing epidemic in the black community."

Lindsey added that while "completed suicides are still highest among white youth, the gap is narrowing at a fast pace when you look at the fact that over the last decade suicide gaps have raised by 60 percent for black adolescent boys and over 100 percent for black adolescent females."

"That is a sign," Lindsey said, "an indication that we need to be ringing the alarm."

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Suicide rate rising fast for black youth, report finds

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The suicide rate for black youth is rising faster than for any other racial and ethnic group, now making it the second-leading cause of death for black children aged 10 to 19, according to a congressional report released this week.

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Black Kids and Suicide - Why are the rates so high and ignored? 

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Black Kids and Suicide - Why are the rates so high and ignored? 

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Teen suicide rates among black youth are increasing. In 2016 and again in 2018, national data revealed that among children age 5-11, black children had the highest rate of death by suicide. For the years 2008 to 2012, 59 black youth died by suicide, up from 54 in the years 2003-2007.

Also, the 2015 Centers for Disease Control and Prevention's biennial Youth Risk Behavior Survey reported that, compared to non-Hispanic white boys, black high-school age boys are more likely to have made serious suicide attempts that require medical attention.

I am a professor of psychology and also director of the culture, risk and resilience research laboratory at the University of Houston, and I recently co-authored a study that suggests that new risk profiles may be needed for better suicide prediction in African Americans in particular.

Comprehensive suicide awareness

Suicide has become a leading cause of death in the U.S. among all age groups, but particularly in youth and young adults. It is the second leading cause of death among 10- to 34-year-olds. Parents, teachers and professionals must be able to both talk about it and understand the risks for vulnerable children of any race. But those of us who work with black youth may also need to address some myths about suicide in the African American community.

For example, one such myth has its start almost three decades ago, Kevin Early and Ronald Akers' interviews with African American pastors concluded that suicide is a "white thing" and that black people are accustomed to struggling through life challenges without succumbing to suicide. those authors concluded that black people see suicide as a "white thing" but it is a myth that black people do not die by suicide.

Based on anecdotal conversations that many others and I have heard in day-to-day conversations and that sometimes emerge in popular media, this opinion about suicide in the black community has shifted relatively little.

More importantly, black youth at risk may even be more difficult to identify than non-black youth. One study referred to college age racial/ethnic minority people, including African Americans, as "hidden ideators" who are less likely than other youth to disclose thoughts of suicide. Because suicide is occurring and at shockingly young ages, comprehensive efforts are needed to address this public health problem.

Studies suggest that stigma about mental illness and the feeling that one will be outcast further or ignored may keep black youth from sharing their thoughts. Also, public health and mental health experts may be unaware that suicide risk factors could show up differently depending on ethnic group.

Simply put, a one-size-fits-all approach does not work for identifying suicide risk. And little or no action has been taken to address the increasing crisis. As an African American psychologist, I find this frustrating when children's lives are lost - lives that could be saved.

Unique needs in African American mental health

Most mental health services are not designed with cultural and social nuances in mind. My research team has found consistently that the challenges that black kids face in navigating dual cultural contexts may increase their risk of suicidal thoughts.

In research on adults, we found that black men and women who used more Eurocentric or individualist approaches that was more self-focused rather than managing stress via the belief in a Higher Power were more likely to consider suicide. This was not true for those who used more culturally meaningful, spiritual coping.

When there are cultural differences, therapists must be willing to "think outside of the box" to fully evaluate risk for suicide. As an example, the racism that black Americans encounter increases stress for many. Thus, their stressors and mental health issues will need different solutions and approaches than treatments that work for white people.

In another study published in Comprehensive Psychiatry, we observed different patterns of risk for black adults compared to white adults who were admitted for psychiatric care. We examined sleep-related problems, which are elevated among black Americans, and suicide because sleep issues are a serious but understudied risk factor for suicide crisis. It turns out that inadequate sleep can escalate an emotional crisis. Our research found that problems staying awake for activities such as driving or engaging in social activities, which reveal inadequate sleep, were associated with a four-fold greater risk for suicide crisis compared to non-suicide crisis in black adults who were admitted for psychiatric treatment.

We have also found that experiencing racism is associated with thoughts about suicide for black youth and adults.

How to find help

Caring adults are a child's first line of defense. If a child discloses that he is thinking about dying, it is important to ask him to share more about his ideas and if he knows he might die. If a child has a suicide plan, it is time to get professional help. The Crisis Text Line at 741741 could be an option for teens who need help to cool down in a crisis.

When it comes to finding a mental health professional, parents need an expansive list of referral options, including university-affiliated mental health clinics that offer evidence-based services on a sliding scale and federally qualified health centers for the uninsured. Regardless of the setting, a well-trained therapist may be of a different race.

Parents and caregivers must be willing to sit, listen and try to fully understand what is most upsetting for a child who is experiencing a difficult situation and a lot of emotions.

For those who believe that the alarming statistics will eventually reverse course without any action, this may be true. In the meantime, saving one life is worth the effort.

Thoughts of suicide do not mean that a child or teen needs to be hospitalized. It means they are in emotional pain and want the pain to end. Adults can investigate the problem and remove it or help the child deal with it. Online resources such as Stopbullying.gov include interactive videos that are useful to parents, educators and youth. Suggesting to a child that she "get over it" is less than helpful. A child who is already in a vulnerable state cannot problem-solve without meaningful support from the caring adults in charge.
If you are having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). The website is National Suicide Prevention Lifeline.
[ Deep knowledge, daily. Sign up for The Conversation's newsletter. ]

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Black kids and suicide: Why are rates so high, and so ignored?

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Teen suicide rates among black youth are increasing. In 2016 and again in 2018, national data revealed that among children age 5-11, black children had the highest rate of death by suicide. For the years 2008 to 2012, 59 black youth died by suicide, up from 54 in the years 2003-2007.

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Between 1991 and 2017, suicide attempts among black adolescents increased by 73%, while attempts among white youth decreased, according to an analysis of more than 198,000 high school students nationwide (Lindsey, M.A., et al., Pediatrics, Vol. 144, No. 5, 2019). Other studies have shown an elevated risk of suicide among African American boys ages 5 to 11 (Bridge, J.A., et al., JAMA Pediatrics, Vol. 172, No. 7, 2018).

In response to these startling findings, psychologists are boosting their efforts to address suicide by diagnosing and treating its precursors - such as trauma, depression and anxiety - and raising awareness of the crisis.

"When we have people of the same racial or ethnic group experiencing a disparity for something as tragic and awful as suicide, everybody should be concerned," says Alfiee Breland-Noble, PhD, founder and board president of the African American Knowledge Optimized for Mindfully Health Adolescents Project, a research and outreach nonprofit based in Arlington, Virginia.

Psychologists are taking action by designing interventions for schools and faith-based communities, crafting messages to encourage help-seeking and training community leaders to recognize signs of mental illness in children and teens. And in 2018, Breland-Noble and other psychologists joined a working group alongside the Emergency Taskforce on Black Youth Suicide and Mental Health, commissioned by U.S. Rep. Bonnie Watson Coleman (D-N.J.) and the Congressional Black Caucus, to probe the worrying trend.

The working group identified major gaps in research, service providers and prevention programs focused on mental health and suicidality among black youth, as well as a lack of funding for future efforts ( Ring the Alarm: The Crisis of Black Youth Suicide in America [PDF, 1.5MB], 2019). In response to the group's findings, Watson Coleman introduced the Pursuing Equity in Mental Health Act of 2019 (PDF, 362KB) in December, which proposes more than a billion dollars for research, treatment and prevention efforts.

"It's a watershed moment because in the 23 years that I've been doing this work, very few people will name and attend to the unique mental health needs of black children," Breland-Noble says.

Risks for black youth

Across the board, mental health problems such as depression, anxiety and post-traumatic stress disorder put youth at risk for suicidal thoughts and attempts. But many African American children and adolescents face additional challenges, including exposure to violence and racial discrimination, that may further increase their risk, says Sherry Molock, PhD, associate professor of psychology at The George Washington University in the District of Columbia and a member of the working group.

Black youth are also less likely than their white peers to receive care for depression - and when they do enter treatment, it's often through the juvenile justice system. Breland-Noble says that white children with behavioral problems such as irritability and belligerence are often diagnosed with mood disorders, while black children exhibiting the same behaviors are seen as disruptive and requiring discipline.

"Where we fall down as a field is that we look at the same types of behaviors in white and African American children but diagnose them differently," she says.

To address such gaps in diagnosis and service utilization, Molock created Helping Alleviate Valley Experiences Now (HAVEN), a suicide prevention approach for faith-based communities (Suicide and Life-Threatening Behavior, Vol. 38, No. 3, 2008). The program trains congregants to recognize warning signs of depression and anxiety; works with clergy members to incorporate messages about mental health and help-seeking into Bible study lessons, Sunday school classes and sermons; and aids churches in developing mental health resource directories. Molock has even helped several churches establish on-site counseling centers staffed by licensed mental health professionals.

Others are studying barriers to mental health services in black communities that prevent suicidal youth from getting the support they need. Concrete barriers, such as the cost of care, lack of health insurance, unreliable transportation and a dearth of providers are a big part of the problem, says Inger Burnett-Zeigler, PhD, clinical psychologist and associate professor of psychiatry and behavioral sciences at Northwestern University's Feinberg School of Medicine.

But psychological factors - including mistrust of the mental health-care system, doubt about the effectiveness of medical treatment and shame around help-seeking - also play a role (The Journal of Behavioral Health Science & Research, Vol. 45, No. 1, 2018; International Journal of Geriatric Psychiatry, Vol. 29, No. 2, 2014). To overcome some of these barriers, Burnett-Zeigler leads "Mental Health 101" training seminars in black communities. She helps teachers, youth leaders and other community members learn to recognize signs of depression and trauma and the benefits of turning to mental health professionals in such circumstances.

"Black youth will touch hands with many, many people before they get to a mental health provider," she says. "It's critical that these folks have the information they need to do a warm handoff."

Psychologists are hopeful that the proposed Pursuing Equity in Mental Health Act of 2019 (PDF, 362KB), the first national bill to address mental health in black youth, will garner attention for the growing crisis and stimulate progress in research, prevention and treatment. The bill aims to allocate $650 million for research on health disparities, $100 million for patient and community-based research and $250 million to improve culturally competent mental health care in schools. It would also increase the authorized funding level for the APA Minority Fellowship Program. Additional funds are intended to improve cultural competence and diversity among providers, who are still primarily white ( APA Center for Workforce Studies, 2018).

APA endorsed the measure, and future APA efforts will involve advocacy for specific provisions and attempts to gain bipartisan support for the bill in both houses of Congress. These activities will become part of a comprehensive health equity advocacy strategy that APA's Advocacy Office is crafting.

"In all the years I've been doing this research, I've never seen legislation like this," Molock says. "It's refreshing that the Congressional Black Caucus is not only bringing attention to the topic - but also putting action behind it."

Further Reading

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Sounding the alarm on black youth suicide

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Between 1991 and 2017, suicide attempts among black adolescents increased by 73%, while attempts among white youth decreased, according to an analysis of more than 198,000 high school students nationwide (Lindsey, M.A., et al., Pediatrics , Vol. 144, No. 5, 2019).

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Johns Hopkins Resources / Warning Signs 

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Johns Hopkins Resources / Warning Signs 

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What is teen suicide?

Suicide is when a teen causes his or her own death on purpose. Before attempting to take his or her own life, a teen may have thoughts of wanting to die. This is called suicidal ideation. He or she may also have suicidal behavior. That's when a teen is focused on doing things that cause his or her own death.

Suicide is the third leading cause of death in young people ages 15 to 24. The CDC reports that:

Boys are 4 times more likely to die from suicide than girls.

Girls are more likely to attempt suicide than boys.

Guns are used in more than half of youth suicides.

What causes a teen to attempt suicide?

The teen years are a stressful time. They are filled with major changes. These include body changes, changes in thoughts, and changes in feelings. Strong feelings of stress, confusion, fear, and doubt may influence a teen's problem-solving and decision-making. He or she may also feel a pressure to succeed.

For some teens, normal developmental changes can be very unsettling when combined with other events, such as:

Changes in their families, such as divorce or moving to a new town

Changes in friendships

Problems in school

Other losses

These problems may seem too hard or embarrassing to overcome. For some, suicide may seem like a solution.

Which teens are at risk for suicide?

A teen's risk for suicide varies with age, gender, and cultural and social influences. Risk factors may change over time. They are:

One or more mental health conditions, including substance use disorder

Impulsive behaviors

Undesirable life events or recent losses, such as the death of a parent

Family history of mental or substance use disorder

Family history of suicide

Family violence, including physical, sexual, or verbal or emotional abuse

Past suicide attempt

Gun in the home

Imprisonment

Exposure to the suicidal behavior of others, such as from family or peers, in the news, or in fiction stories

What are the warning signs of teen suicide?

Many of the warning signs of suicide are also symptoms of depression. They are:

Changes in eating and sleeping habits

Loss of interest in usual activities

Withdrawal from friends and family members

Acting-out behaviors and running away

Alcohol and drug use

Neglecting one's personal appearance

Unnecessary risk-taking

Obsession with death and dying

More physical complaints often linked to emotional distress, such as stomachaches, headaches, and extreme tiredness (fatigue)

Loss of interest in school or schoolwork

Feeling bored

Problems focusing

Feeling he or she wants to die

Lack of response to praise

Another warning sign is making plans or efforts toward committing suicide:

Says "I want to kill myself," or "I'm going to commit suicide."

Gives verbal hints, such as "I won't be a problem much longer," or "If anything happens to me, I want you to know ...."

Gives away favorite possessions or throws away important belongings

Becomes suddenly cheerful after a period of depression

May express weird thoughts

Writes 1 or more suicide notes

These signs may look like other health problems. Make sure your teen sees his or her healthcare provider for a diagnosis.

How is a teen diagnosed as being suicidal?

Threats of suicide are a cry for help. Always take such statements, thoughts, behaviors, or plans very seriously. Any teen who expresses thoughts of suicide should be evaluated right away. Talk with your teen's healthcare provider.

Any teen who has tried to commit suicide needs a physical checkup first to rule out life-threatening health problems. He or she should then get a mental health evaluation and treatment until he or she is stable. This often will take place at an inpatient facility to make sure of the child's safety.

How is a teen treated for suicidal behavior?

Treatment will depend on your child's symptoms, age, and general health. It will also depend on how severe the condition is.

Treatment starts with a detailed evaluation of events in your teen's life during the 2 to 3 days before the suicidal behaviors. Treatment may include:

Individual therapy

Family therapy. Parents play a vital role in treatment.

An extended hospital stay, if needed. This gives the child a supervised and safe environment.

How can I help prevent my teen from attempting suicide?

Learning the warning signs of teen suicide can prevent an attempt. Keeping open communication with your teen and his or her friends gives you an opportunity to help when needed. Also take these steps:

Keep medicines and guns away from children and teens.

Get your teen help for any mental or substance use problems.

Support your teen. Listen, try not to offer undue criticism, and stay connected.

Become informed about teen suicide. Resources include the public library, local support group, and the internet.

Know the warning signs for depression:

Feelings of sadness, hopelessness, or loneliness

Declining school performance

Loss of interest in social and sports activities

Sleeping too little or too much

Changes in weight or appetite

Nervousness, agitation, or irritability

Teens can take these steps to help prevent suicide if they see warning signs in a friend:

Take their friend's behavior and talk of suicide seriously.

Encourage their friend to seek expert help. Go with the friend, if needed.

Talk with an adult they trust about their friend.

When should I call my teen's healthcare provider?

Call your teen's healthcare provider right away if your teen:

Feels extreme depression, fear, anxiety, or anger toward him or herself or others

Feels out of control

Hears voices that others don't hear

Sees things that others don't see

Can't sleep or eat for 3 days in a row

Shows behavior that concerns friends, family, or teachers, and others express concern about this behavior and ask you to seek help

Call 911 if your teen has suicidal thoughts, a suicide plan, and the means to carry out the plan.

Key points about teen suicide

Suicide is when a teen causes his or her own death on purpose.

Suicidal ideation is when a teen has thoughts of wanting to die.

Suicidal behavior is when a teen is focused on doing things that cause his or her own death.

Normal developmental changes combined with stressful life events may cause a teen to think about suicide.

Many of the warning signs of suicide are also symptoms of depression.

Any teen who expresses suicidal thoughts should be evaluated right away.

Next steps

Tips to help you get the most from a visit to your child's healthcare provider:

Know the reason for the visit and what you want to happen.

Before your visit, write down questions you want answered.

At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.

Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.

Ask if your child's condition can be treated in other ways.

Know why a test or procedure is recommended and what the results could mean.

Know what to expect if your child does not take the medicine or have the test or procedure.

If your child has a follow-up appointment, write down the date, time, and purpose for that visit.

Know how you can contact your child's provider after office hours. This is important if your child becomes ill and you have questions or need advice.

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Suicide is when a teen causes their own death on purpose. Before attempting to take their own life, a teen may have thoughts of wanting to die. This is called suicidal ideation. They may also have suicidal behavior. That's when a teen is focused on doing things that cause their own death.

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Youth Suicide Related to Covid- Focus on the Family 

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Youth Suicide Related to Covid- Focus on the Family 

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Youth Suicide Related to the COVID-19 Crisis

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Youth Suicide Related to Covid - Focus on the Family

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Youth Suicide Related to Covid - Focus on the Family

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Youth Suicide Related to the COVID-19 Crisis

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May 2020

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During this time of COVID-19, parents are finding themselves suddenly in the role of a teacher, but they may also be on the frontline for supporting their children with mental-health issues or suicide risk.

As schools engage in virtual teaching, many school counselors, social workers, and psychologists are offering availability through telehealth, but it might be more difficult for those professionals to observe children and adolescents who are struggling emotionally. Teachers may see their children online, but it can a challenge to notice behavioral changes on these platforms. Thus, it is important that parents know the warning signs of suicide and how to help their child, particularly as suicide is the second leading cause of death for youth ages 15 to 24 and the third leading cause of death for kids ages 10 to 14.

Warning signs for suicide are often hidden and are best detected by those who know the child well, especially a parent. Warning signs might include children appearing depressed, withdrawn, lacking energy, feeling hopeless about the future, or displaying overwhelming emotional distress. They may talk about suicide and death or have difficulty finding reasons why life is worth living. Children and teens may demonstrate anger or hostility that is out of character or out of context and may have increased agitation or irritability. Warning signs of particular concern include feeling like a burden to others, using drugs or alcohol, making a suicide plan, or seeking suicide means, such as a firearm or medication.

As children are on technology much of the day during this stay-at-home order, they may indicate feelings of suicidal ideation on social media that need to be explored. Ensure that children are educated on warning signs, as well, and know to report concerns immediately. This is not a matter of tattling, but rather of saving the life of a friend. Children should not bear the weight of this burden themselves, nor should they think they can help a peer who needs professional treatment. Children are encouraged to tell a parent or a trusted adult if they are concerned about a friend or peer.

How parents can help

It may be hard to distinguish between a child who is really struggling and one who is having a normal reaction to this COVID-19 pandemic. It is more important than ever to openly talk to your children about how they are feeling and to ask questions directly such as "are you OK?" or "you seem depressed, have you had thoughts of suicide?" Asking about suicide does not give a child the idea to do it. Opening up a conversation lets children know you are willing to discuss whatever they are feeling, no matter how difficult that talk might be. Be sure to listen attentively and without judgment, even if what they tell you hurts, angers, or surprises you.

Thank your children for their honesty and courage in talking to you about their pain. Let your children know they have been heard. The best way to do this is by engaging in follow-up conversations, assuring them that you will get them help, if needed, and finding resources to help them.

It can sometimes be difficult for children to talk to their own parents. Try not to take this personally. Encourage your children to use other supports that are available 24/7, such as calling the National Suicide Lifeline at 800-273-8255 or using the Crisis Textline by texting HELP to 741-741. For further resources, parents can contact the Pennsylvania Center for Community Resources Support and Referral Helpline at 855-284-2494.

Many therapists are offering telehealth during COVID-19. Check with your insurance carrier to see which agencies are covered under your policy or consult with your child's pediatrician. You can also use these sites to find treatment providers: locator.apa.org/ or https://findtreatment.samhsa.gov.

It takes a village to keep children safe, especially during these unprecedented circumstances, so do not be afraid to reach out for help. Your child does not need to go through this alone, and neither do you.
Terri Erbacher is a clinical associate professor at Philadelphia College of Osteopathic Medicine and school psychologist for the Delaware County Intermediate Unit. She is co-author of the text "Suicide in Schools: A Practitioner's Guide to Multi-level Prevention, Assessment, Intervention, and Postvention."

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Youth suicide risk during COVID-19: How parents can help | Expert Opinion

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During this time of COVID-19, parents are finding themselves suddenly in the role of a teacher, but they may also be on the frontline for supporting their children with mental-health issues or suicide risk.

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Act Now to Get Ahead of Mental Health Crisis 

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Act Now to Get Ahead of Mental Health Crisis 

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Mental health specialists are working now to bolster the resilience of Americans who are suffering from feelings of despair - in hopes of preventing increases insuicides among people who are under increased pressure during the coronavirus pandemic.

Time is of the essence, public health researchers say. Experience with past natural disasters, such as earthquakes and hurricanes, shows that a rise in suicide often happens in the months after the immediate physical dangers of the disaster have passed.

A report jointly published last week by two foundationsthat support mental health issues estimates that, unless steps are taken now, the increase in "deaths of despair" from alcohol, drugs and suicide could increase by 75,000 as a result of COVID-19.

"Undeniably, policymakers must place a large focus on mitigating the effects of COVID," says Benjamin F. Miller, chief strategy officer of the Well Being Trust, which published the report in conjunction with the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. "However, if the country continues to ignore the collateral damage - specifically our nation's mental health - we will not come out of this stronger."

Fortunately, there are ways to mitigate those risks now, say psychologists and suicide survivors. For example, they urge elected leaders to make it easier for people who are suffering to get access to mental health care - whether or not they are employed.

The National Action Alliance for Suicide Prevention, for example, is now coordinating with other groups in a " National Response to COVID-19." The campaign, co-led by the head of the National Institute of Mental Health and former Rep. Patrick J. Kennedy, aims to better coordinate and publicize mental health resources for those who are particularly vulnerable right now.

J, for example, is a 33-year-old wife, mother and social worker for whom mysterious illness is a trigger for suicidal thinking. A decade ago, a rare hormonal disease ravaged her body, and she spent years misdiagnosed. That experience nearly broke her emotionally, and she attempted suicide twice.

The pandemic made that trauma vivid again when she came down with symptoms of COVID-19 but couldn't get access to testing or care.

"We're in rural Montana, so there's basically one place I can go," says J. But it was Good Friday, so the clinic was closed, and she wasn't sure where to get tested.

J was already laden with anxiety; she worried her hours as a social worker might be cut, leaving her counseling clients without help. (For professional reasons, J asked that NPR use only her first initial.)

"I'm dealing with all these new stressors, and there it is: For the first time in years now, I'm feeling suicidal myself."

J slept, letting the horrible, familiar feelings recede. She later reached out to friends - a formula that works for her. Eventually, she tested negative for the virus.

But for many other people, the pandemic has changed some of their usual coping mechanisms.

"The normal avenues of help aren't necessarily there," says Dese'Rae Stage, a Philadelphia writer, photographer and suicide-prevention activist. Stage is looking for a new therapist after hers stopped practicing recently but is finding that many aren't taking new patients. "It's already hard to find a therapist who does sliding scale payments or takes insurance," but the pandemic has made it even harder to find one, she says.

So Stage and other survivors have other recommendations for people looking for help:

Connect online: See friends and family by Zoom or phone. Feelingunderstood and sharing feelings of pain can help alleviate it.

Adjust your medications if necessary: Make sure you're on the right medication and the right amount. Many psychiatrists are taking advantage of relaxed rules from insurersregarding telemedicine, so they are still able to meet remotely with patients and can adjust medication as needed during those appointments.

Seek teletherapy or group therapy: Teletherapy has seen massive growth for those who can find providers. Also, support groups like Alcoholics Anonymous are meeting online.

Make a safety plan: Discuss with family or partners what works for you - specific measures they can take or not take when you're in crisis. Lock up any guns; store ammunition in a separate place. "I have friends who struggle with suicidal thoughts but who are generally pretty solid who are saying, 'I've had to put my guns away. I never have to put my guns away, but my guns are in a safe right now,' " Stage says.

Develop a new routine: Quarantine has disrupted daily life, so developing new patterns that foster good sleep, healthy eating and exercise are helpful. This brings focus to the day and is helpfully distracting from thoughts of hopelessness and anxiety.

Seek financial help: If you've lost a job or you're worried about paying bills, do what you can to address that. See if you qualify for things like unemployment benefits, which have been increased by $600 a week for those who lost jobs because of the pandemic. Some banks and landlords are giving breaks on late mortgages and rent; lenders will sometimes renegotiate terms of your loans.

Averting the public health crisis of increased suicide attempts is a big and complex challenge. The pandemic has touched off many risk factors all at once, including joblessness, addiction and profound isolation. Suicide experts have studied the effects of trauma, from hurricanes Katrina and Ike to the Great Recession, but this pandemic - with its global geographic and psychosocial reach - could be particularly sweeping, they say.

"The two most replicated, robust factors linked to suicide are economic change - downturn - and social disconnection," says Dr. Roger McIntyre, professor of psychiatry at the University of Toronto. Those two factors are major hallmarks, he notes, of the COVID-19 pandemic.

McIntyre and his team this week published online in the journal World Psychiatry their research estimate of how the current pandemic and its economic constraints could affect some people.

"If, in fact, the unemployment rate is 10 to 20 percent, we came out at a staggering statistic of over 8,000 additional suicides over and above what would have been expected if COVID never came into our lives," McIntyre told NPR.

And of course that rate had already been climbing in recent years.

So prevention advocates are doubling down. But addressing suicide is no simple task - it has complex roots.

During the housing crisis and Great Recession a dozen years ago, suicides spiked, for example, but not for a single reason, says Dr. Joshua Gordon, director of the National Institute of Mental Health. Though taking one's own life is often linked to depression or other mental illness, that's not always the case.

In looking at data about suicide attempts from those days, Gordon says, "You can see that it's not just about the eviction. It's not just about the foreclosure. Most of them have a range of five to 10 other significant adverse events in their lives - many of them financial, but also personal and social - that raise one's risk."

Whether you're grieving the recent loss of someone or dealing with difficulties at home, call someone and talk to that person about what you're feeling, Gordon and other mental health experts advise. Even small steps like texting someone you know can have a positive impact.

Anja Burcak, who is 25 and lives in Mobile, Ala., says she has been able to manage her bipolar disorder through the pandemic by leaning on her online circle of friends. Many have survived suicide attempts themselves and are helping each other now.

"People unite more," she says. "I know physically we literally cannot do that, but they might be calling people they haven't called in years."

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Act Now To Get Ahead Of A Mental Health Crisis, Specialists Advise U.S.

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Mental health specialists are working now to bolster the resilience of Americans who are suffering from feelings of despair - in hopes of preventing increases insuicides among people who are under increased pressure during the coronavirus pandemic. Time is of the essence, public health researchers say.

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Opinion | There Is No Vaccine for Teenage Despair (Published 2020)

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Being shut in has a way of bringing out our dark thoughts. But it’s also a chance for honest conversation.

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How to Keep Children's Stress From Turning Into Trauma 

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How to Keep Children's Stress From Turning Into Trauma 

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Parents can help children use the stress of coronavirus shutdowns as an opportunity for growth, experts say.

Credit... Elva Etienne/Getty Images

Children may be processing the disruptions in their lives right now in ways the adults around them do not expect: acting out, regressing, retreating or even seeming surprisingly content. Parents need to know that all of this is normal, experts say, and there are some things we can do to help.

"Our natural response to scary things is biologically to release stress hormones," said Dr. Nadine Burke Harris, a pediatrician and surgeon general of the state of California, and the author of " The Deepest Well: Healing the Long-Term Effects of Childhood Adversity. " The release of stress hormones activates our fight or flight response. Our bodies, in responding with the release of stress hormones, are doing exactly what they should be doing.

But in some cases, exposure to stressful events - which right now might include the absence of routines, a parent's job loss and economic hardship, or the serious illness or death of someone a child cares about - can leave children feeling traumatized.

Dr. Burke Harris said the Covid-19 pandemic is a "perfect storm" for this stress to negatively impact children's mental and physical health and behavior. But at a time when there are so many unknowns, tools are available to help mitigate the harms that children experience. Instead of fearing stress, she said, we need to tune in to our kids, assess their needs and help them turn stressful situations into opportunities for growth.

Here are some ways that parents can help kids work through stress without it becoming toxic to their emotional and physical well-being.

When we see a child acting in a manner that we think is inappropriate, we need to consider that the child is outside her window of tolerance for stress, explained Corinne Edwards, a therapist in private practice with over 15 years of experience working with children with histories of trauma. "Children's brains are wired for survival, and given this, it's important to look at their behaviors from the lens of considering what need the behavior is attempting to meet during this difficult time."

For some children, temper tantrums and bed-wetting - stages they had seemed to outgrow months or years ago - might be the only sign that they are facing an internal struggle.

"Reactions that seem unwarranted for a given circumstance, or different than a child's typical demeanor, can be cues of underlying distress," said Joy Gabrielli, a psychologist and assistant professor in the University of Florida's Department of Clinical and Health Psychology.

If you are not sure whether the stress response you're seeing is normal, you may want to seek counseling for your child. Often, your child's regular health care provider can point you toward mental health resources that may be accessed through telemedicine while you are under stay-at-home orders.

While many kids are experiencing a stressful situation right now, those who have been exposed to other adverse events in childhood are at an increased risk of struggling during and after this crisis.

A tally of adverse childhood experiences, known as an ACE score, can be used as an indicator of a person's risk for later health problems, so having a high ACE score is like a warning light. ACEs include " aspects of the child's environment that can undermine their sense of safety, stability and bonding " - traumatic events like experiencing violence, abuse, neglect or substance abuse in the home. Covid-19 presents unique challenges to kids who have experienced a significant number of adverse events, said Dr. Burke Harris.

"An ACE score is not the be-all and end-all," Dr. Burke Harris said. Instead, she compares it to a thermometer. You can be sick and not have a fever. But if you have a fever, it is an indicator to everyone that you are sick, and that we need to pay close attention.

"When we can predict, hopefully we can prevent," Dr. Burke Harris said. By knowing who is most at risk to suffer toxic stress from Covid-19, policymakers can deliver community resources to those who are expected to need them most.

Yo Jackson, a psychology professor at Pennsylvania State University, who also serves as the associate director of the Child Maltreatment Solutions Network, stressed that it would be overly simplistic to say that children from homes with greaterrisk factors are suffering more right now. "Dose matters," she said, "but it is much more nuanced than that. We can't just 'check the boxes' to decide how Covid-19 will affect a particular child."

Dr. Burke Harris agreed. "The same stressor won't elicit the same response in everyone," she said. Kids who were not at risk before Covid-19 may face new risks because the safety nets parents relied on in the past have disappeared, and those who relied on support networks in the past may be overwhelmed with the lack of resources currently available.

Adults must recognize that for some kids, the newfound solitude brought on by Covid-19 feels like a gift. While we may be struggling with schools being closed, kids could be rejoicing in it. We might assume our kids miss their friends, but they may appreciate having more time with us. And some who were dealing with bullying or social challenges at school may be relieved not to have to see other kids.

When we think of adversity in childhood, the key, Dr. Burke Harris said, is to think about what kids can do, and what we are able to offer, in the face of that stress.

The Coronavirus Pandemic: Key Things to Know

"While dose matters, buffering matters, too," she said. Buffers help us deal with stress and allow us to process it in healthier ways. Along with positive relationships, Dr. Burke Harris explained that sleep, exercise and nutrition also can help kids keep stress under control.

Dr. Burke Harris recommends that parents help kids avoid the harmful effects of stress by first talking with them about the pandemic. She advises parents to help kids understand that there are things they can do to help others - like staying home whenever possible and wearing a mask when they go out. Kids feel good when they know they are helping solve a problem.

Dr. Burke Harris also encourages parents to keep kids connected with friends and family, which can be done through video chats, phone calls and letter writing. Lastly, she recommends families create and stick to a routine that gives kids structure, making time for play, hygiene and when able to be done safely, physical activity.

Some children will struggle more than others during the pandemic, and these kids may need even greater support in the months to come.

"As difficult as it is to see children in distress, we want to interact with them from a place of support," Ms. Edwards said. These moments are opportunities for connection, and we can help kids grow by helping them learn how to process their strong feelings and reminding them that they are not alone.

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How to Keep Children's Stress From Turning Into Trauma (Published 2020)

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Parents can help children use the stress of coronavirus shutdowns as an opportunity for growth, experts say. Children may be processing the disruptions in their lives right now in ways the adults around them do not expect: acting out, regressing, retreating or even seeming surprisingly content.

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As the country deals with the ongoing stress and uncertainty around the current COVID-19 pandemic, it's important to remember that we all have a role to play in promoting connectedness, belonging, resiliency, and prevention. Many Americans are dealing with stress and feelings of despair related to physical distancing, health concerns, job loss, and financial uncertainty. Today, it's more important than ever before that we reach out and #BeThere for each other, and share stories of hope and human connection. To help support your messaging efforts, the Action Alliance and its partners have compiled a list of resources because we are all in this together.

COVID-19 Mental Health and Suicide Prevention Key Messages - Provides some key messages related to mental health and suicide prevention in the wake of the pandemic

guidance and tools that can be used by anyone who develops and disseminates suicide-related content.

#BeThe1To - The National Suicide Prevention Lifeline's campaign empowers individuals with tools to start a conversation with someone they are concerned about.

#RealConvo - The American Foundation for Suicide Prevention's campaign encourages individuals to have real conversations about mental health with the people in their lives.

#Take5 - The National Council for Suicide Prevention's campaign empowers individuals to learn the five action steps everyone can take to save a life.

Faith.Hope.Life Campaign - Provides resources to help faith leaders and faith communities celebrate reasons for living and to support individuals in their community struggling with mental health and suicide.
Family Members with Children Family Members of Older Adults Health Care Providers/Clinicians Youth/Young Adults
Additional COVID-19 Mental Health Support

VA - The U.S. Department of Veterans Affairs has compiled information and resources specific to veterans and the COVID-19 pandemic.
If you or someone you know is in crisis, please call 800-273-TALK (8255) or text 'HOME' to 741741.

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As the country deals with the ongoing stress and uncertainty around the current COVID-19 pandemic, it's important to remember that we all have a role to play in promoting connectedness, belonging, resiliency, and prevention. Many Americans are dealing with stress and feelings of despair related to physical distancing, health concerns, job loss, and financial uncertainty.

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250 mental health organizations bound together to identify supports for mental health during and after the pandemic.

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Bringing together public and private sectors to lead a coordinated, national mental health and suicide prevention response

According to a recent CDC survey, more than 40% of U.S. adults surveyed during a one week period in June 2020 reported struggling with pandemic-related behavioral health issues; nearly 31% of them reported anxiety or depression; and over one in ten adults seriously considered suicide. Further, a recent Harris Poll survey found more than 80% of U.S. adults say that, as a result of the pandemic, it is more important than ever to make suicide prevention a national priority; and 73% are more aware of the importance of taking care of their own mental health.

While we don't know yet the full impact this historic public health and economic crisis will have on the country's mental health, the time to act is now.

As a national convener, the National Action Alliance for Suicide Prevention (Action Alliance)-the nation's public-private partnership-mobilized diverse sectors to lead the coordinated Mental Health & Suicide Prevention National Response to COVID-19 (National Response). Together, we can make mental health a priority like never before- both during the pandemic and long after-ensuring a lasting legacy of mental health and suicide prevention transformation.

By acting now and uniting together-across sectors and agencies-we can accelerate actionable solutions and emerge stronger than we were going into this pandemic. From adversity comes a unique opportunity for the National Response to ensure we change the trajectory of our country's mental health and suicide prevention efforts.

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Bringing together public and private sectors to lead a coordinated, national mental health and suicide prevention response According to a recent CDC survey, more than 40% of U.S. adults surveyed during a one week period in June 2020 reported struggling with pandemic-related behavioral health issues; nearly 31% of them reported anxiety or depression; and over one in ten adults seriously considered suicide.

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Pandemic Pushing America into Mental Health Crisis 

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Pandemic Pushing America into Mental Health Crisis 

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Isolation and economic upheaval caused by the coronavirus pandemic are already resulting in a sharp spike in people seeking mental health help. (Amanda Andrade-Rhoades for The Washington Post)

Three months into the coronavirus pandemic, the country is on the verge of another health crisis, with daily doses of death, isolation and fear generating widespread psychological trauma.

Federal agencies and experts warn that a historic wave of mental-health problems is approaching: depression, substance abuse, post-traumatic stress disorder and suicide.

Just as the initial outbreak of the novel coronavirus caught hospitals unprepared, the United States' mental-health system - vastly underfunded, fragmented and difficult to access before the pandemic - is even less prepared to handle this coming surge.

"That's what is keeping me up at night," said Susan Borja, who leads the traumatic stress research program at the National Institute of Mental Health. "I worry about the people the system just won't absorb or won't reach. I worry about the suffering that's going to go untreated on such a large scale."

Data shows depression and anxiety already roiling the nation.

Nearly half of Americans report the coronavirus crisis is harming their mental health, according to a Kaiser Family Foundation poll. A federal emergency hotline for people in emotional distress registered a more than 1,000 percent increase in April compared with the same time last year. Last month, roughly 20,000 people texted that hotline, run by the Substance Abuse and Mental Health Services Administration.

Online therapy company Talkspace reported a 65 percent jump in clients since mid-February. Text messages and transcribed therapy sessions collected anonymously by the company show coronavirus-related anxiety dominating patients' concerns.

"People are really afraid," Talkspace co-founder and CEO Oren Frank said. The increasing demand for services, he said, follows almost exactly the geographic march of the virus across the United States. "What's shocking to me is how little leaders are talking about this. There are no White House briefings about it. There is no plan."

The suicides of two New York health-care workers highlight the risks, especially to those combating the pandemic. Lorna Breen, a top New York emergency room doctor, had spent weeks contending with coronavirus patients flooding her hospital and sometimes dying before they could be removed from ambulances. She had no history of mental illness, her relatives have said in interviews, but struggled increasingly with the emotional weight of the outbreak before she died. Days later, reports emerged that a Bronx emergency medical technician also killed himself.

Have you had trouble accessing mental health services because of the coronavirus pandemic? We want to hear from you.

Researchers have created models - based on data collected after natural disasters, terrorist attacks and economic downturns - that show a likely increase in suicides, overdose deaths and substance use disorders.

And yet, out of the trillions of dollars Congress passed in emergency coronavirus funding, only a tiny portion is allocated for mental health. At the same time, therapists have struggled to bring their practices online and to reach vulnerable groups because of restrictions on licensing and reimbursement. Community behavioral health centers - which treat populations most at risk - are struggling to stay financially solvent and have begun closing programs.

"If we don't do something about it now, people are going to be suffering from these mental-health impacts for years to come," said Paul Gionfriddo, president of the advocacy group Mental Health America. That could further harm the economy as stress and anxiety debilitate some workers and further strain the medical system as people go to emergency rooms with panic attacks, overdoses and depression, he said.

Just as the country took drastic steps to prevent hospitals from being overwhelmed by infections, experts say, it needs to brace for the coming wave of behavioral health needs by providing widespread mental health screenings, better access to services through telehealth, and a sizable infusion of federal dollars.

Dire warnings in data

When diseases strike, experts say, they cast a shadow pandemic of psychological and societal injuries. The shadow often trails the disease by weeks, months, even years. And it receives scant attention compared with the disease, even though it, too, wreaks carnage, devastates families, harms and kills.

Mental-health experts are especially worried about the ongoing economic devastation. Research has established a strong link between economic upheaval and suicide and substance use. A study of the Great Recession that began in late 2007 found that for every percentage point increase in the unemployment rate, there was about a 1.6 percent increase in the suicide rate.

Has your child tested positive for the coronavirus? Share your experiences with The Post.

Using such estimations, a Texas nonprofit - Meadows Mental Health Policy Institute - created models that suggest if unemployment amid the coronavirus pandemic ends up rising 5 percentage points to a level similar to the Great Recession, an additional 4,000 people could die of suicide and an additional 4,800 from drug overdoses.

But if unemployment rises by 20 percentage points - to levels recorded during the 1930s Great Depression - suicides could increase by 18,000 and overdose deaths by more than 22,000, according to Meadows.

"These projections are not intended to question the necessity of virus mitigation efforts," cautioned authors of the Meadows report, "but rather to inform health system planning."

Suicide experts and prevention groups have deliberately refrained from discussing too widely death projections such as those from the Meadows Institute. Experts say reporting excessively or sensationally on suicide can lead to increases in suicide attempts, an effect known as contagion. And the factors involved in any suicide are often complex, they point out.

"Could the numbers go up? Yes, but it isn't inevitable. We know suicide is preventable," said Christine Moutier, chief medical officer for the American Foundation for Suicide Prevention.

Research has shown interventions make a marked difference, such as limiting access to guns and lethal drugs, screening patients for suicidal thoughts, treating underlying mental conditions and ensuring access to therapy and crisis lines to call and text. "That's why we need to act now," Moutier said.

On Wednesday, a coalition representing more than 250 mental-health groups announced it was convening a national response to the problem of pandemic suicide - an effort that will include at least one federal agency, the National Institute for Mental Health.

'Poisonous fire hydrant'

Front-line workers - health-care providers, grocery store workers, delivery people - are especially vulnerable to the coming storm of mental health problems.

"We're used to dealing with sick people and seeing terrible things, but what's devastating with covid is the sheer volume. It's like drinking from a poisonous fire hydrant," said Flavia Nobay, an emergency room doctor.

As infections soared in March in New York, Nobay took leave from her duties at the University of Rochester Medical Center to volunteer as an ER doctor in Queens.

Weeks later, the experience still haunts her: Watching families crumple in the ambulance bay knowing they may never see relatives again. Hearing the relentless alerts every few minutes of crashing patients and respiratory arrest. Sending patients home because they weren't quite sick enough, knowing they may be coming right back. Or even worse, the chance they may not make it back.

"It chips away at your soul," Nobay said. "You have to hold on to the positive and how you're helping in the ways you can. That hope is like medicine. It's as important and tangible as Tylenol."

Data from Crisis Text Line shows social isolation, unemployment and forced quarantines are having a significant effect on people's mental health. (Video: Luis Velarde/The Washington Post)

A study of 1,257 doctors and nurses in China during that country's coronavirus peak found that half reported depression, 45 percent anxiety and 34 percent insomnia.

Before the pandemic, doctors and nurses were already acutely prone to burnout, research shows, because of the workload, pressure, chaos and increasingly dysfunctional health-care system.

"We're now hitting a period of uncertainty where a lot of people are asking themselves how long they can keep it up," said Liselotte Dyrbye, a Mayo Clinic doctor and leading researcher on burnout. "The teapot can only boil for so long."

Could therapy ease your coronavirus stress? How to decide, what to expect and where to find it.

A broken system when it's needed the most

This approaching wave of mental injuries will be met in coming months by a severely broken system.

In the United States, 1 in 5 adults endure the consequences of mental illness each year. Yet less than half receive treatment, federal statistics show. As suicide rates have fallen around the world, the rate in the United States has climbed every year since 1999, increasing 33 percent in the past two decades.

Part of the problem, experts say, is the markedly different way the United States treats mental illness compared with physical illness.

In normal times, a heart attack patient rarely has trouble securing a cardiologist, operating table and hospital bed. But patients in mental crises, studies show, consistently struggle to get their insurance to pay for care. Even with insurance, they struggle to find therapists and psychiatrists willing to take that payment. Those who can afford it often end up paying out of pocket.

Experts warn that such parity and access problems may only worsen with the pandemic, which has upended the functions of hospitals, insurance companies and mental health centers.

In a joint letter Wednesday, leaders in mental health and substance abuse treatment pleaded for the Trump administration's help. The letter - signed by the American Psychological Association, the American Psychiatric Association, the National Alliance on Mental Illness and 12 other organizations - asked federal officials to save community mental health centers facing financial collapse.

The letter also asked the government to lift reimbursement restrictions that have prevented therapists from using phone calls to treat patients. On Thursday, the Trump administration indicated it would do so.

A survey of local mental health and drug addiction centers showed the pandemic has already left many on the brink of financial collapse, preventing them from providing services that generate much of their reimbursement revenue. More than 60 percent said they would run out of funding in less than three months and had already closed some programs.

In a letter to Congress in early April, mental health organizations estimated that $38.5 billion is needed to save treatment providers and centers and that $10 billion more is needed to respond to the coronavirus pandemic. On Friday, the federal substance abuse and mental health agency said it had been allocated less than 1 percent of the amount advocated by mental health groups - $425 million in emergency funding - and has awarded $375 million to states and local organizations.

While Congress recently authorized $100 billion in emergency funds for hospitals and medical providers, very little will go to mental health and addiction service providers because they mainly receive funding through Medicaid. And most of the emergency provider money is being distributed through Medicare.

"We are facing the loss of mental health centers and programs at a time when we are going to need them more than ever," said Chuck Ingoglia, president of the National Council for Behavioral Health, which represents 3,326 treatment organizations.

Glimmers of hope

There are glimmers of hope, experts say, amid the gloomy outlook.

The sudden push into telemedicine could make services more accessible in years to come. And the national mental health crisis could spark reforms and movement toward better treatment.

And while almost everyone is experiencing increased stress, the effect for many will be transient - trouble sleeping, shorter fuses.

The difficulty is identifying and treating those who develop deeper, worrisome mental problems such as post-traumatic stress disorder and severe depression.

"To control the virus, it's all about testing, testing, testing. And for the mental health problems ahead, it's going to be all about screening, screening, screening," said Gionfriddo of Mental Health America.

For years, Gionfriddo's nonprofit has offered questionnaires on its website - widely used in medicine - to help people screen themselves for mental-health problems. Since the pandemic began, those daily screenings have jumped 60 to 70 percent. And since February, the number of people screening positive for moderate to severe anxiety and depression has jumped by an additional 18,000 people compared with January.

Speaking from her parents' home in Pittsburgh, Ananya Cleetus said she has felt the increased strain.

First came the closure of her school, the University of Illinois at Urbana-Champaign, bringing to an end her ambitious plans for the semester in computer engineering. Then came the loss of her therapist, forbidden by licensing rules from treating her across state lines. And social media didn't help - all those posts of people baking bread and living their best #quarantinelife, making hers feel all the more pitiful.

It was getting increasingly hard to get out of bed, said Cleetus, 23, who has bipolar disorder and helps lead a student advocacy group.

"It took me a few weeks and talking to friends to finally realize this wasn't just something wrong with me," Cleetus said. Since then, she has poured her energies into creating a daily routine and an online guide for fellow students struggling with the pandemic and mental health.

"This virus is messing with everyone. The anxiety, isolation, uncertainty," she said. "Everyone's struggling with it in one way or another."
If you or someone you know needs help, call the National Suicide Prevention Lifeline at 800-273-TALK (8255). Crisis Text Line also provides free, 24/7, confidential support via text message to people in crisis when they text to 741741.
Coronavirus: What you need to know

Where do things stand? Covid-19 remains one of the leading causes of death in the United States, tied to about 250 deaths daily, on average, mostly among the old and immunocompromised. See the latest covid numbers in the U.S. and across the world.
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The latest on coronavirus boosters: The FDA cleared the way for people who are at least 65 or immune-compromised to receive a second updated booster shot for the coronavirus. Here's who should get the second covid booster and when.

New covid variant: A new coronavirus subvariant, XBB. 1.16, has been designated as a "variant under monitoring" by the World Health Organization. The latest omicron offshoot is particularly prevalent in India. Here's what you need to know about Arcturus.

The state of public health: Conservative and libertarian forces have defanged much of the nation's public health system through legislation and litigation as the world staggers into the fourth year of covid.

Would we shut down again? What will the United States do the next time a deadly virus comes knocking on the door?

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The coronavirus pandemic is pushing America into a mental health crisis

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Three months into the coronavirus pandemic, the country is on the verge of another health crisis, with daily doses of death, isolation and fear generating widespread psychological trauma. Federal agencies and experts warn that a historic wave of mental-health problems is approaching: depression, substance abuse, post-traumatic stress disorder and suicide.

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New Mental Health Data Offers First Glimpse of COVID-19's Psychological Toll

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In late April, more than one in four American adults met the criteria that psychologists use to diagnose serious mental distress and illness.

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1/3 of Americans Clinically Depressed or Anxious 

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1/3 of Americans Clinically Depressed or Anxious 

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Student Trauma Won't Just Disappear When Return to School 

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Student Trauma Won't Just Disappear When Return to School 

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When Lee Starck read about a recent 45 percent drop in reported cases of child abuse and neglect in Montana, he was skeptical.

"I think the opposite may be true," said Starck, a K-4 school counselor in Stevensville, Montana. "When you think about the chronic stress of this time, the economic hardship, I doubt that's an accurate picture of what's going on."

A new study suggests Starck is probably right. Three researchers found that reported cases of child maltreatment in Florida was 27 percent lower that it usually is this time of year. This drop is, in their words, "counterfactual" and is likely being mirrored across the country. School closures due to the COVID-19 pandemic, the researchers write, have severed the "link between child maltreatment victims and the number one source of reported maltreatment allegations - school personnel."

School counselors and school psychologists, as part of their jobs, are mandated reporters of child abuse and neglect. These incidents, Starck fears, may be increasing due to the chronic stress - economic or health-related - some households are experiencing during this crisis.

Other students are just having difficulty coping with social isolation and the pressures of online learning. Whatever the challenge, the coronavirus has robbed many students of the valuable face-to-face guidance and support of their school counselors.

"School provides a routine and a sense of normalcy. The current situation is anything but routine and normal," says Kathy Reamy, a school counselor in La Plata, Maryland, and chair of the NEA School Counselor Caucus. "In the absence of seeing our students at school in person, it's really difficult to get a sense of how they are doing."

Like all the classroom teachers who transitioned practically overnight to online instruction, counselors have adjusted, tapping into their resourcefulness to reach their students and their families.

There are obvious challenges. When kids are outside the safety - and privacy - of his office at school, "It can be difficult sensing their comfort level and overall sense of security," says Starck.

Emily Klein, a school psychologist at Skyline Middle School in Wilmington, Delaware, has prioritized maintaining her relationships with students until the fall when, hopefully, she can meet with them face-to-face. "Remote conversations aren't really conducive to problem-solving or skills-building, the things we usually like to work on. So I'm focusing on staying in touch and keeping our bond strong."

'They Need to Know I'm Always Here'

Schools are a collaborative environment. Educators, regardless of their job title, draw from each other's experience and expertise to serve the best interest of students.

Starck misses the interaction and consultation with teachers at Stevensville. "They're extremely intuitive," he says. "They know their students. They can pick up on red flags in the classroom and they let me know if something is wrong."

Heidi Murray, a school counselor in Warren County, Ohio, didn't really appreciate until school closed the value of informal interactions with students. "You pass by them in the hallway. You sense their demeanor, what kind of day they're having. You get a pulse on where they are emotionally."

Over the past two months, counselors have been staying at home, one hand on their laptop, the other holding their phone, using email, text, Google Voice, Zoom, - whatever takes to reconnect with students.

"It can be draining just to finally get them or their parents on the phone or on a video call," admits Starck. "But when it happens, students seem happy to reconnect. Their faces light up. There's joy and that keeps my fires lit as well."

"Our caseloads are going to be overwhelming because students are likely to have some serious mental health issues when we reopen." - Emily Klein, school psychologist

"It really helps to hear each other's voices, even if it's just over the phone," adds Murray. "We're communicating."

Kathy Reamy sends out a weekly video message via email to her students and their parents just to to check in or provide information and updates about the things they may be interested in, like graduation and prom. She also includes tips for reducing stress and anxiety with mindfulness activities, exercise, and stressing the the importance of staying in touch with friends.

For those students she's particularly concerned about, Reamy reaches out to them individually by phone, email or text.

Some students, however, can't be reached. "They aren't responding to any of my attempts to contact them, and neither are their parents. At least when they are coming to school there are multiple staff members who lay eyes on them on a daily basis. Now with some of them, despite all of our efforts, we have no idea how they're doing."

Emily Klein continues to email parents every week, even if she hasn't heard back in a while. "They need to know that I'm always here."

Zoom Has Its Limits

Most students at Stevensville have a Google account associated with the school, which Starck has used to initiate contact with students and heir parents. Once that contact has been established, and the student agrees, Starck schedules a video call over Zoom.

Talking to their counselor over video in their own homes with parents and siblings nearby, even in the same room, can be tricky. "The success of the session really depends on how comfortable the student is in that environment," says Starck.

While acknowledging Zoom or some other platform is the the only viable option during this time, Klein has misgivings about the lack of student privacy.

"There may be someone else in the room that dampens the students' ability to be candid or forthright," she explains. "So sometimes the session ends up with me getting a video tour of the house or saying hello to the family cat."

The deficiencies around video are especially evident in Klein's work with special education eligibility. Student evaluations are due around this time of year. Klein can't properly carry out this task, at least with some of her students, without spending time with them. In addition, Klein and her colleagues often need more information to adequately plan for the student's needs, and that requires testing.

"The tests we use haven't been normed, validated or standardized to administer them remotely," she says. "As far as I'm concerned, it's not really an option."

Those evaluations will need to completed when she returns, ensuring that a major backlog of work awaits her in the Fall. "We haven't received a whole lot of guidance. We're just told to wait until we get back."

The problem with that, Klein adds, "is that our caseloads are going to be overwhelming because students are likely to have some serious mental health issues when we reopen."

'This Pandemic Will Change People Forever'

Over the past two months, student emotions have ping-ponged between anxiety and grief, says Starck. "Initially, they were worried about their health, their family's health, and the closures were so sudden. When it was clear school was not going to reopen in the spring, they grieved. It was a huge loss."

"Now, as we begin to think about reopening, we're back to fear and anxiety. They're wondering, What will school be like? Will it ever be the same?"

Starck worries about the emotional state of many students - especially those from unstable home environments - when they return to school.

"We don't really know what the intensity of the anxiety and trauma has been. We don't yet have the full picture of what many students have been experiencing. That's unsettling to me."

According to the American School Counselor Association, a school should have no more than 250 students per student counselor. The good news is that this ratio has narrowed to its lowest margin since 1986 - 430 to 1, but obviously it's still well above the recommended ratio.

As the pandemic and school closures have exacerbated student mental health needs, however, potential massive budget cuts loom on the horizon. That would be unacceptable, says NEA President Lily Eskelsen García.

"When school buildings are reopened, it must be an all-hands-on-deck approach," Eskelsen García said. "Threatening furloughs and layoffs mean class sizes will balloon - all while we need to maintain social distancing for public safety - and already overworked counselors will be stretched even thinner as kids grapple with mental health issues worsened by the coronavirus pandemic." NEA has been tirelessly pushing the U.S. Senate to pass the HEROES Act, which would help fill critical K-12 funding gaps as the economic crisis worsens. (Tell your U.S. Senator to pass the Heroes Act)

There's no guarantee yet that students and educators in Kathy Reamy's district will even be returning to school in the fall. They're not alone. But whether remote learning continues or school doors reopen, student progress will depend on how we support their emotional and mental health.

"This pandemic will change people forever," Reamy says. "We will need more counselors in schools, more clubs and activities that address social/emotional health, and more training for the staff to help them recognize and address the difficult emotions experienced by both students and staff. In the absence of things in place to better serve the emotional needs of our school communities, our students' education will suffer."

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Student Trauma Won't Just Disappear In the Fall, Counselors Warn | NEA

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When Lee Starck read about a recent 45 percent drop in reported cases of child abuse and neglect in Montana, he was skeptical. "I think the opposite may be true," said Starck, a K-4 school counselor in Stevensville, Montana.

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Peer to Peer Suicide Prevention

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TRUSTED BY LEADING SUICIDE PREVENTION EXPERTS

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Hope Squad | Youth Suicide Prevention for Schools

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Hope Squad is a student-led, peer-to-peer support program that harnesses school connectedness to reduce the risk of suicide in elementary and secondary schools. We train trusted adults on campus (Advisors) who then empower students (Members) to recognize warning signs and connect their peers to a trusted adult.

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Yellow Ribbon Suicide Prevention Program : Home

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Privacy Policy What Information Do We Collect? When you visit our website you may provide us with two types of information: personal information you knowingly choose to disclose that is collected on an individual basis and website use information collected on an aggregate basis as you and others browse our website.

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Higher Hope relates to less violence and weapon carrying at school Higher hope is a better predictor of academic success than IQ Hope is teachable Hopeful Minds shows promise to reduce anxiety, increase hope and improve emotional regulation skills in youth #Hope #TimeToAct #HopefulMinds

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Safer Care for Those at Risk of Suicide

Zero Suicide is a Transformational Framework for Health and Behavioral Health Care Systems

The foundational belief of Zero Suicide is that suicide deaths for individuals under the care of health and behavioral health systems are preventable. For systems dedicated to improving patient safety, Zero Suicide presents an aspirational challenge and practical framework for system-wide transformation toward safer suicide care.

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Safer Care for Those at Risk of Suicide The foundational belief of Zero Suicide is that suicide deaths for individuals under the care of health and behavioral health systems are preventable. For systems dedicated to improving patient safety, Zero Suicide presents an aspirational challenge and practical framework for system-wide transformation toward safer suicide care.

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Mental health specialists are working now to bolster the resilience of Americans who are suffering from feelings of despair - in hopes of preventing increases insuicides among people who are under increased pressure during the coronavirus pandemic.

Time is of the essence, public health researchers say. Experience with past natural disasters, such as earthquakes and hurricanes, shows that a rise in suicide often happens in the months after the immediate physical dangers of the disaster have passed.

A report jointly published last week by two foundationsthat support mental health issues estimates that, unless steps are taken now, the increase in "deaths of despair" from alcohol, drugs and suicide could increase by 75,000 as a result of COVID-19.

"Undeniably, policymakers must place a large focus on mitigating the effects of COVID," says Benjamin F. Miller, chief strategy officer of the Well Being Trust, which published the report in conjunction with the Robert Graham Center for Policy Studies in Family Medicine and Primary Care. "However, if the country continues to ignore the collateral damage - specifically our nation's mental health - we will not come out of this stronger."

Fortunately, there are ways to mitigate those risks now, say psychologists and suicide survivors. For example, they urge elected leaders to make it easier for people who are suffering to get access to mental health care - whether or not they are employed.

The National Action Alliance for Suicide Prevention, for example, is now coordinating with other groups in a " National Response to COVID-19." The campaign, co-led by the head of the National Institute of Mental Health and former Rep. Patrick J. Kennedy, aims to better coordinate and publicize mental health resources for those who are particularly vulnerable right now.

J, for example, is a 33-year-old wife, mother and social worker for whom mysterious illness is a trigger for suicidal thinking. A decade ago, a rare hormonal disease ravaged her body, and she spent years misdiagnosed. That experience nearly broke her emotionally, and she attempted suicide twice.

The pandemic made that trauma vivid again when she came down with symptoms of COVID-19 but couldn't get access to testing or care.

"We're in rural Montana, so there's basically one place I can go," says J. But it was Good Friday, so the clinic was closed, and she wasn't sure where to get tested.

J was already laden with anxiety; she worried her hours as a social worker might be cut, leaving her counseling clients without help. (For professional reasons, J asked that NPR use only her first initial.)

"I'm dealing with all these new stressors, and there it is: For the first time in years now, I'm feeling suicidal myself."

J slept, letting the horrible, familiar feelings recede. She later reached out to friends - a formula that works for her. Eventually, she tested negative for the virus.

But for many other people, the pandemic has changed some of their usual coping mechanisms.

"The normal avenues of help aren't necessarily there," says Dese'Rae Stage, a Philadelphia writer, photographer and suicide-prevention activist. Stage is looking for a new therapist after hers stopped practicing recently but is finding that many aren't taking new patients. "It's already hard to find a therapist who does sliding scale payments or takes insurance," but the pandemic has made it even harder to find one, she says.

So Stage and other survivors have other recommendations for people looking for help:

Connect online: See friends and family by Zoom or phone. Feelingunderstood and sharing feelings of pain can help alleviate it.

Adjust your medications if necessary: Make sure you're on the right medication and the right amount. Many psychiatrists are taking advantage of relaxed rules from insurersregarding telemedicine, so they are still able to meet remotely with patients and can adjust medication as needed during those appointments.

Seek teletherapy or group therapy: Teletherapy has seen massive growth for those who can find providers. Also, support groups like Alcoholics Anonymous are meeting online.

Make a safety plan: Discuss with family or partners what works for you - specific measures they can take or not take when you're in crisis. Lock up any guns; store ammunition in a separate place. "I have friends who struggle with suicidal thoughts but who are generally pretty solid who are saying, 'I've had to put my guns away. I never have to put my guns away, but my guns are in a safe right now,' " Stage says.

Develop a new routine: Quarantine has disrupted daily life, so developing new patterns that foster good sleep, healthy eating and exercise are helpful. This brings focus to the day and is helpfully distracting from thoughts of hopelessness and anxiety.

Seek financial help: If you've lost a job or you're worried about paying bills, do what you can to address that. See if you qualify for things like unemployment benefits, which have been increased by $600 a week for those who lost jobs because of the pandemic. Some banks and landlords are giving breaks on late mortgages and rent; lenders will sometimes renegotiate terms of your loans.

Averting the public health crisis of increased suicide attempts is a big and complex challenge. The pandemic has touched off many risk factors all at once, including joblessness, addiction and profound isolation. Suicide experts have studied the effects of trauma, from hurricanes Katrina and Ike to the Great Recession, but this pandemic - with its global geographic and psychosocial reach - could be particularly sweeping, they say.

"The two most replicated, robust factors linked to suicide are economic change - downturn - and social disconnection," says Dr. Roger McIntyre, professor of psychiatry at the University of Toronto. Those two factors are major hallmarks, he notes, of the COVID-19 pandemic.

McIntyre and his team this week published online in the journal World Psychiatry their research estimate of how the current pandemic and its economic constraints could affect some people.

"If, in fact, the unemployment rate is 10 to 20 percent, we came out at a staggering statistic of over 8,000 additional suicides over and above what would have been expected if COVID never came into our lives," McIntyre told NPR.

And of course that rate had already been climbing in recent years.

So prevention advocates are doubling down. But addressing suicide is no simple task - it has complex roots.

During the housing crisis and Great Recession a dozen years ago, suicides spiked, for example, but not for a single reason, says Dr. Joshua Gordon, director of the National Institute of Mental Health. Though taking one's own life is often linked to depression or other mental illness, that's not always the case.

In looking at data about suicide attempts from those days, Gordon says, "You can see that it's not just about the eviction. It's not just about the foreclosure. Most of them have a range of five to 10 other significant adverse events in their lives - many of them financial, but also personal and social - that raise one's risk."

Whether you're grieving the recent loss of someone or dealing with difficulties at home, call someone and talk to that person about what you're feeling, Gordon and other mental health experts advise. Even small steps like texting someone you know can have a positive impact.

Anja Burcak, who is 25 and lives in Mobile, Ala., says she has been able to manage her bipolar disorder through the pandemic by leaning on her online circle of friends. Many have survived suicide attempts themselves and are helping each other now.

"People unite more," she says. "I know physically we literally cannot do that, but they might be calling people they haven't called in years."

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Act Now To Get Ahead Of A Mental Health Crisis, Specialists Advise U.S.

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Mental health specialists are working now to bolster the resilience of Americans who are suffering from feelings of despair - in hopes of preventing increases insuicides among people who are under increased pressure during the coronavirus pandemic. Time is of the essence, public health researchers say.

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Covid-19 Sent LGBTQ Students Back to Unsupportive Homes. That Raises the Risk They Won’t Return.

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Vulnerable students lost their affirming communities when they left campus. Professors and administrators are offering remote support.

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2018 ASCA Handout

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© 2021 Think Social Publishing, Inc.

We wish when we don't have a plan, but we hope when we think we can do something for ourselves. Let's help our social emotional learners tap into and develop the cognitive processes required to engage in hope-oriented thinking. In his book, The Hope Circuit (Seligman, 2018), Dr. Seligman describes our brains as having a "default circuit" which will lead us to feeling helpless if put in a situation that we feel is beyond our control. Contrary to popular belief, the brain does not learn to feel helpless; it naturally goes there if factors push it in that direction. Upon recognizing this in his lab, Dr. Steve Maier, a longtime colleague of Dr. Seligman, went in search of how the brain avoids the many problems associated with feeling helpless and he discovered what Dr. Seligman ultimately coined "The Hope Circuit." In a nutshell, our brains, when faced with a dilemma, seek to engage aspects of reasoning and thinking to figure out how to avoid the helplessness trap. While this sounds obvious in some ways, consider how many times we expect individuals with social emotional learning challenges to perform a set of behaviors for which they do not have the skill set to produce, creating in them a feeling of helplessness and hopelessness. How can we help them shift into using thinking and reasoning to create a pathway toward improved social competencies, rather than simply expecting them to know how to behave?

Metacognition Activates the Upstairs Brain for Social Emotional Learning

Dr. Siegel and Dr. Payne Bryson (The Whole-Brain Child, 2011) describe the brain as having an "upstairs" and a "downstairs." Clearly, the upstairs brain, also described by others as "higher cortical functioning" or "higher order reasoning," involves the hope circuit. The downstairs brain has many functions for life support but also involves sensing, feeling, and reacting, often impulsively, to what we have experienced, what we are experiencing, or what we worry we might experience in the future. Have you ever had a student cry for 45 minutes about schoolwork that he or she has not even begun to try to work on? While the downstairs brain is reactive, the upstairs brain is contemplative. Dr. Stephen Covey, in his book, The 7 Habits of Highly Effective People (Covey, 2013), discusses what he read by a psychologist whose name he cannot recall: "There is a space between stimulus and response." In short, this means that within this "space" we have moments to reflect and engage thinking and reasoning to figure out the best ways to proceed in a given situation. To manage that space is to use metacognition in our upstairs brain. Moreover, language is also a core member of the thinking and reasoning team.

Over the years, we have become convinced that to develop increasingly sophisticated social competencies, language is an essential component We know that the building block of perspective taking, also referred to as theory of mind, is co-dependent on the development of language (de Villiers, 2007). Language, perspective taking, and visual awareness of situational cues merge developmentally so that we grow in our ability to socially attend, interpret, problem solve, and respond to situations of all kinds. From the more basic-who to greet when walking down the hall-to the really complex, such as socially problem solving what to do during something as huge and complicated as the COVID-19 pandemic.

Self-Regulation Within a Group Requires Metacognition

While this sounds logical, if not easy, it's anything but when you think about it! Consider that we think of the use of language as having two dimensions, expressive and receptive, and we seek to measure these through standardized tests. Yet, there is another incredibly important dimension of language not often discussed when it comes to exploring academic performance, group work, and self-regulation: our use of language inside our mind for understanding the social world and how we can possibly navigate to regulate in that world through the use of our inner thought processes. For example,

How do I think about another's thinking and feelings?

How do I consider my own thinking and feeling?

How do I want people to read my intentions?

How could others possibly be reading my intentions in ways I hadn't considered?

What do I think that person is intending based on what they are doing and saying?

We use forms of language inside our minds to contemplate our own and others' thoughts, intentions, and feelings. We also problem solve to consider how to respond to the social situation based on our own desires, while also considering how others expect us to behave or how they will possibly feel and think about our response.

In reading this you might think this type of internal dialogue and direction relates to older children, teens, and adults, but consider that this is likely the type of reasoning we expect of three to four-year-old children when self-regulating in small groups. For example, when working with little ones, the teacher has a short time during the day called "circle time," a time in which children gather together with a shared purpose of following the teacher's lead and exploring a concept as a group. The teacher asks a question to all the children in the group, but only one child is chosen to answer it. Think about all the information that is being considered within the mind of each child who is actively participating at this time. What does active participation mean? For most, it means they are sitting quietly, considering the teacher's intentions, and thinking about the concept she has introduced. Many children know the answer to the teacher's question, but to work as part of a group, they also have to know not to say the answer if the teacher is calling on another student.

Now consider that most children in this scenario are purposefully not doing something: they are not saying the answer out loud, they are not running around the room, they are not facing away from the group. This is their upstairs brain at work: they are figuring out what the teacher is talking about, but they have also figured out how to be part of the group in a specific situation and are actively learning when to share and not share the information they have in their minds. This ability is what we depend on for individuals to cooperate and learn in social groups in all aspects of our society, home, school, vocation, and broader community. Yet, this internal language and reasoning, which helps guide our ability to problem solve how we are to respond to those around us defies standardized test measurement. The term associated with this mental process is social metacognition.

Cognitive Behavior Therapy and Metacognition

Metacognition most typically is described as our ability to reason and think about our own thinking and feelings. While most of us experience metacognitive thinking without being fully aware of it, counselors, psychologists, experts in mindfulness, and our Social Thinking Methodology process shine a spotlight on it. Helping us to develop awareness of our own internal conversations, or mind chatter, helps us to improve how we manage our internal messaging. One form of internal chatter can uplift or encourage us (inner coach voice), but more often this voice may sound demeaning (self-defeating voice). As we learn we can take control, even over our internal, judgmental thinking, and better understand the relationship this has to our feelings, the more we can learn to take control of our social mind and have hope for more positive outcomes in our life. And this helps switch on our neurologically based "hope circuit."

Developing a more robust understanding of ourselves and our internal thinking to help manage our thoughts is the basis of cognitive behavioral therapy (CBT). An adult client recently explained to me that one of the most important things his psychologist taught him was that "my thoughts are not necessarily true." CBT is a critical tool for helping individuals cope with chronic flooding of negative emotion, anxiety, social anxiety, and depression and its focus is to heighten awareness and acuity of their metacognitive abilities to help them feel better in their own skin.

However, our brain is not limited to only thinking and reasoning about self-regulating our inner feelings and thoughts-since we exist in the presence of others. Dr. Michael Tomasello, a cultural anthropologist, describes that beginning in infancy we develop a form of "self-otherness." He means we carry within our minds an ever-present knowledge that our existence is considered, felt, and thought about by those around us. Not only experienced by those with whom we are interacting, but also by those with whom we share space or co-exist.

Social Problem Solving Requires Social Metacognition

The term "social metacognition" is discussed by researchers and philosophers (Briñol & DeMarree, 2012) to explore how our minds consider the thoughts and feelings of one or many other minds as part of our own social metacognition. Recently, we asked an audience of about 400 people to estimate how many people they had to be aware of in the audience throughout the day, even when they had no plans to relate to most of the people that surrounded them. Most answered that they must consider the needs of all the people in the room for the conference day to seamlessly continue without confusion or disruption. Now consider this: how many minds must a student consider when sitting in a classroom of thirty other students and a teacher? Clearly, our social metacognitive abilities are not only focused on keeping ourselves calmer and more comfortable solely for the purpose of feeling better all by ourselves. Our social metacognitive mind doesn't get a lot of rest; it is supposed to be vigilant whenever we are in the presence of others, including many of our own or others' pets! For instance, a social metacognitive thought chain might look like this: Who are these people? What's their intention? What do I need to do based on their being here with me now? How do I want this dog to feel about me? How do I think the dog feels?

While language is an essential ingredient, our internal language and visual understanding of the social world fuel our ability to reason. Social reasoning is the doorway to social problem solving. Over the years we have noticed that a number of the individuals we work with have terrific science reasoning but limited social reasoning. They exhibit solid to strong test scores related to their receptive and expressive language and academic learning abilities, yet they are not strong in their social metacognitive reasoning. A 32-year-old engineer with a PhD went to a psychiatrist because he experienced chronic compelling anxiety and depression. Ultimately, she referred him to our clinic for what I came to observe as subtle but significant social issues. This man appears neurotypical, but I came to learn that he struggled tremendously in understanding other people. He asked me one day, "How can I be considered such a good problem solver as a computer engineer, but such a weak problem solver when it comes to figuring out people." A dilemma he experienced was why a person he knows from work group meetings, with whom he is not friends, would want to talk to him when standing in line for lunch? His not knowing how to handle the situation cranked up his anxiety and also contributed to his depression. When I was getting to know this individual, I explained how I understood where the anxiety came from, but asked him what this had to do with his depression. He exclaimed, "Think about it. If I am constantly anxious about people, that's pretty depressing!" One day I asked him to consider how he thought inside his mind. The next week he reported that in watching his thinking, he realized he "thought in pictures." I asked if he had ever heard of Temple Grandin or read her book, Thinking in Pictures, and he said he had not. As we worked on social problem solving, he used our treatment framework called Solving Problems Before They Become Problems. He found it really helpful and asked to take it home. What he discovered was that he could problem solve situations better if he thought with language and not just exclusively with pictures. He discovered that visual images will only get him so far, but it's language that drives us to explore differing points of view, feelings, possible reactions, and how we might verbally respond across a range of imagined social situations. Language-based reasoning is critical for social problem solving within our minds, in the same way that verbally expressed language is important for having discussions and conversations.

The Social Thinking Methodology® Provides Pathways to Hope

Teaching individuals to be more aware of their own and others' social thinking (social metacognition) launched when I accepted a position in a school district as the high school speech-language pathologist. Previously, I had worked with classically autistic teens and young adults who were non-verbal and minimally verbal and had frequent disruptive behaviors. I was mentored by the amazing Nancy Dalrymple, an autism educator, leader, and researcher, to develop and use compassionate behavioral teaching methods to externally motivate and teach simple concepts to those who could not effectively navigate the world with language-based learning. While I found compassionate behaviorism tremendously effective for those who needed external learning strategies, this type of teaching was no match for the grumpy and disenfranchised teens I was encountering when beginning my work at a high school in 1995. What I did not know at that time was that my students who had some levels of social self-awareness were likely experiencing their brain defaulting to a point of helplessness. They were actively rejecting social experiences, with peers and adults, given they had a history where they could not perform the social behaviors expected of them to blend in with their peers. They would do as much of their assigned schoolwork as they could, but refused to engage socially on any level. When some of my students were placed on behavior plans, they spent much of their energy trying to find the hole in the behavior plan, rather than seeking to do the social behaviors for which they would be rewarded. They appeared angry and demeaning to others. What was their problem? I realized it may have a lot to do with the fact that they struggled with understanding how the social world worked, making it difficult for them to work in the social world. My response to their anger was to recognize they didn't really dislike me, even though they said "I hate you." They didn't know me. I had to try something different with them, and since they were not willing to externally participate, I sought to reach them internally, to help them make sense of the social world, rather than expect them to "behave."

When I changed my approach from demanding performance of social expectations to being curious about how their brains processed and responded to social information, I began to learn how to help them. One question I posed to a group of high school boys was, "Do people have thoughts about you when you are not talking to them?" When they each responded, "No, people don't think about me if I am not talking," that led me to begin teaching explicitly with language to help them understand that we all have thoughts and feelings about those we share space with.

Social Emotional Learning Is a Carefully Scaffolded Process

Throughout the past 25 years, our Social Thinking Methodology continues to evolve only because we continue to learn from many different individuals what they find confusing about the social world. The information we have been developing taps into students' social metacognitive reasoning. We also have been learning that individuals of all types, those considered "neurotypical," those identified as being from low socio-economic backgrounds, those with ADHD, "behaviorally disordered," "emotionally disturbed," or "shy" can collectively benefit from social emotional coaching that helps to explain the social world and how to better learn to navigate and regulate within it. Many mainstream classrooms around the world have adopted our published materials. Whether children of four years old or adults in their senior years, it is through our internal reasoning that we make sense of each other and realize people are making sense of us. Our social mind, after all, is our meaning maker!

How the social world works, and how we work in the social world is synergistic, meaning endlessly layering on top of each other. Nevertheless, when the mind is purposefully learning (rather than intuitively learning), we can only teach people to focus their social attention and interpretation on one concept at a time. For that reason, any and all of the materials published by Think Social Publishing, will always begin by teaching students a concept or range of concepts prior to expecting them to learn to express new behaviors. To that extent, our teaching materials always start with priming students' social emotional learning with how the social world works, prior to guiding them in problem solving to figure out what behaviors to produce in the social world. Bottom line: If interventionists are doing well using our methodology, they will never begin by having a student change a behavior. Instead, we begin by helping students learn or affirm what they already know about how the social world works, to sharpen their social cognitive reasoning tools prior to expecting them to learn to self-regulate their own behavior.

The books You are a Social Detective! paired with Superflex®: A Superhero Social Thinking® Curriculum have helped many social learners, aged five to ten years old, learn about themselves as observers, interpreters, problem solvers, and ultimately self-regulators in the social world. What people describe as the "magic" of these story book-based teaching concepts, is in their social metacognitive teaching. The teaching comic book, You are a Social Detective! introduces the Social Thinking Vocabulary (e.g., social smarts, think with your eyes, body in the group, and more) while also introducing the Social Emotional Chain Reaction -how what each of us does or says, based on the situation, can provoke an emotional and behavioral reaction in others, which then affects the original doer of the source behavior. Through language and pictures, students are introduced to information and strategies for learning how to reason more actively about how we all impact each other, even when we are simply sharing space and not actively engaging in a conversation.

This information primes the pump for children to begin their exploration into their own ability to learn about how they use their social competencies, including problem solving and responding in the presence of others. Superflex®: A Superhero Social Thinking® Curriculum uses storytelling and fictional cartoon characters to help students recognize that each of us has a super flexible superhero in our mind to manage many of our mind's disrupters, described in the form of characters called the Unthinkables (Rock Brain, One-Sided Sid, Worry Wall, and many more). Between the visual imagery, direct teaching about how the social world works, and how each of us is learning to work in the social world, we see active engagement of children's minds, imagination, and, most importantly, their desire to learn about themselves, their brains, others' thinking, and their own impact on themselves and others through their behavior.

Social Metacognition Is a Ready Tool for Switching on the Hope Circuit

Learning to understand one's self in the social world is not only about our many successes but also about knowing when we are overwhelmed and why. If we can acknowledge when things are not going great for us, we can avoid feeling helpless and push toward hope as long as we also understand that what we are experiencing is temporary. A mother of a 9-year-old boy shared the following personal story with us:
My son has recently started learning about Superflex with his speech- language pathologist. It has given him vocabulary and a way of thinking about his challenges that help him to understand his own thoughts. Last night he was being really negative about everything...This is what he said about the encounter: "After being ambushed by Negasaurus Nix and Kenny Can't, I have fired all of my Thinkable guards. Rock Brain perforated Positive-saurus Fix's shield, so he quit, and Kenny Can retired. So that's it. I was just ambushed and I lost."
We avoid helplessness by acknowledging that things may be difficult in the moment, but not for the rest of our lives. If you think this all sounds a lot like learning to self-regulate you are right! If you think the hope circuit is related to goal-oriented thinking and, therefore, engages executive functions, you are correct again!

Another remarkable thing about fueling a student's social metacognitive learning is that when we teach a student to think, they carry their thinking out the door. Here a 19-year-old student at a four-year university and living away from home for the first time reflects on how his social learning sessions in high school are helping him in the young adult world of university life, including living in the dorms and going to the cafeteria every day.
Another challenge was forcing myself to sit with groups I knew, even though it was extremely easy to go to the bench seating and eat alone. To remedy this, I thought of how boring it would be to eat alone all the time, which always initially seemed to be a good idea. But as the school year progressed, my mindset became: "I prefer to eat with others for the most part because it's always more exciting to get to know others more." This let me realize that my high school lunch experience provided me with the practice, and now I was ready to take the [college] cafeteria head on.
This same student was a freshman in high school four years earlier. He began working with me by insisting, "I don't want to make a friend! I only want to learn how to cope with all the jerks...and believe me EVERYONE is a jerk!"

Language as a metacognitive teaching tool breaks the social world open to explore different perspectives, intentions, and feelings. It gives us different ways to think flexibly, critically, and with compassion for ourselves and others. It cracks a diamond into myriad facets. The more expressive we are with our metacognitive internal and external language, the more we can understand and respond to people in context. Whether the social emotional learner is 4, 14, 40, or 70 years old, language can explain, at differing levels of complexity, how all the cultures in the social world work to help people navigate to regulate within their social world.

Rather than take language for granted, let's view it as an essential tool for helping us reason and problem solve how to achieve the outcomes we seek for ourselves and others. The amazing social mind has to engage in organized, yet flexible thinking as part of our social metacognition. And when our minds can't figure it out, that's when we ask questions to learn from others' minds.

Think about it. At the core of our ability to live, learn, work, and enjoy being together is our ability to make sense of each other. To move from helplessness to hope is the job of the mind. Let's provide our social learners with the tools to actively engage their social metacognitive mindsets.

References:

Briñol, P., & DeMarree, K. G. (Eds.). (2012). Social metacognition. Psychology Press.

Covey, S. R. (2013). The 7 habits of highly effective people: Powerful lessons in personal change. Simon & Schuster.

de Villiers J. (2007). The interface of language and theory of mind. Lingua. International Review of General Linguistics, 117(11), 1858-1878. https://doi.org/10.1016/j.lingua.2006.11.006

Madrigal, S., & Winner, M. G. (2008). Superflex®: A superhero Social Thinking® curriculum. Think Social Publishing, Inc.

Seligman, M. E. P. (2018). The hope circuit: A psychologist's journey from helplessness to optimism. PublicAffairs.

Siegel, D. J., & Bryson, T. P. (2011). The whole-brain child: 12 revolutionary strategies to nurture your child's developing mind. Delacorte Press.

Winner, M. G., & Crooke, P. (2008). You are a social detective: Explaining social thinking to kids. Think Social Publishing, Inc.

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Social Metacognition: Using Social Emotional Learning to Defeat Helplessness and Engage Hope

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© 2021 Think Social Publishing, Inc. We wish when we don't have a plan, but we hope when we think we can do something for ourselves. Let's help our social emotional learners tap into and develop the cognitive processes required to engage in hope-oriented thinking.

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The burden of suicide has shifted increasingly towards younger aged individuals over the last half century (WHO, 2004), and suicide accounts for more deaths among young people ages 10 - 24 in the U.S. (approximately 10/100,000) than all natural causes combined (NCHS, 2007). The public health significance of the problem is most apparent when the high rates of non-lethal suicidal behavior are taken into account. Each year, between 5-9% of adolescents attempt suicide and nearly 700,000 of them require medical attention (CDC, 2008; Grunbaum et al., 2002). Adolescents who make a suicide attempt are at markedly increased risk: a prior suicide attempt is a robust risk factor for suicide across sex, age, and race/ethnic groups (Joiner et al., 2005; Shaffer et al., 1996). Due to recognition of this public health problem, reducing youth suicide is a major focus of the U.S. suicide prevention agenda (National Strategy for Suicide Prevention; US Public Health Service, 2001), and youth suicide prevention programming has increased dramatically in the past decade. However, there is minimal evidence that youth suicides are declining, and the US Health People 2010 goals of cutting suicide rates by one-half and reducing the 12-month medically serious suicide attempt rate for adolescents from 2.6% to 1% (CDC, 2006) are not close to being met.

Current youth suicide prevention programming is unlikely to have a broad population impact needed to meet federal and state goals of reducing youth suicide deaths. Expanding programming to include interventions that modify 'upstream' risk and protective processes has the potential to enhance suicide prevention impact significantly. To achieve this goal, new partnerships are needed among suicide prevention advocates, practitioners, policy makers and researcher to identify promising interventions and build an evidence base needed to promote broad population dissemination of effective programs.

Current Status of Youth Suicide Prevention Programming

To date, nearly all widely used youth suicide prevention programs apply different 'case identification' methods to expand recognition and referral for treatment services of individuals who are already suicidal or at high risk for suicide. Training for adult gatekeepers and direct screening of youth populations for mood, substance abuse, or suicidal problems are the two most widely used approaches. These strategies respond to evidence that most suicidal youth have mental health and/or behavioral problems, most frequently depression and substance abuse, and few are receiving mental health services (Gould et al., 2005; Shaffer & Craft, 1999). With the passage in 2004 of the Garrett Lee Smith Memorial Act (GLSMA), federal funding became widely available for the first time for states, tribal groups and colleges across the U.S. to implement community-based youth suicide prevention programs. Gatekeeper training and screening are the most common approaches employed by GLSMA-funded groups; over 100,000 gatekeepers were trained and 30,000 youth screened in the first two GLSMA grantee cohorts from 2005 - 2008 (Goldston et al., 2010).

Research evaluating screening, gatekeeper training, education curriculum and hybrid programs combining those elements has accelerated, and a small number of studies have used rigorous designs that involve randomization and control groups. Although no evidence is available to determine if those strategies reduce suicide deaths, changes in behaviors targeted directly by these programs may contribute to decreased suicides. For example, in addition to supporting the safety of administering questions about suicide through school-based screening (Gould et al., 2005), nearly three-quarters of students referred will utilize some mental health services (at least one mental health contact) after screening and a high level of case management (Gould et al, 2010; Husky et al., 2011). Gatekeeper training increases knowledge of warning signs and attitudes; however, a recent completed randomized trial of a widely-used school-based gatekeeper training program found limited impact on changing adult staff-student communication about suicide, which is a key intended outcome of this training (Wyman et al., 2008), and no overall effect in secondary schools on increasing identification of suicidal students (Brown et al., 2011). Evaluations of a second generation, hybrid program (Signs of Suicide) combining an educational curricula with direct screening scored by students themselves, found decreased short-term rates of suicide attempts (3-months after starting the intervention) but not by increasing use of treatment services (Aseltine & DeMartino, 2004; Aseltine et al., 2007). At present, minimal evidence has been reported to determine if referrals to usual mental health treatment services reduces suicide risk, which is an assumption underlying each case identification approach.

Limitations of Current Approaches and Potential Benefits of Modifying Upstream Risk/Protective Processes

Identifying youth who are already suicidal or highly at risk for suicide to link them with treatment services may save lives and reduce other adverse consequences from suicidal behavior. However, the potential for 'case identification and referral' approaches to significantly reduce suicide rates in the population is limited by several factors, some described in the Institute of Medicine's (2002) Reducing suicide: A national imperative. Several of these limiting factors are described below, along with the potential benefits from expanding the current suicide prevention agenda to include interventions that modify 'upstream' risk and protective processes:

1. Relying on existing mental health and other services (e.g., substance abuse treatment) will not meet the needs of many suicidal youth. In communities with the highest rates of youth suicides, reliance on referrals to the mental health system to address the needs of suicidal youth may not suit those communities' ability to provide accessible, effective services. In many rural areas, where youth suicide rates are above the national average (Brown et al., 2007), there is scarcity of, lack of acceptability and low accessibility to services (Hirsch, 2006). Suicides also disproportionately affect Native American and Alaska native youth, particularly males. Regarding services for Native American and Alaska Native youth, a recent U.S. Inspector General's report (2011) documented significant gaps in both mental health and substance abuse services in native communities.

2. The potential for large population reductions in suicide rates is greater for approaches that target more common, lower-risk conditions compared to approaches that target the highest risk conditions (IOM, 2002). Specifically, approaches targeting high-risk conditions will be limited in reducing suicides in the total population due to their relatively low occurrence (i.e., prevalence) (Brown, 2001). For example, although adolescents hospitalized for major depression are much more likely to die from suicide than non-hospitalized youth (i.e., a much higher relative risk), a prevention approach that reduces suicide risk in this group can only have a modest overall impact because hospitalization for major depression is relatively rare. In contrast, a much larger effect on reducing suicides is possible by reducing the occurrence of new instances of antisocial behavior problems or substance abuse, both of which increase risk for suicide at a lower level than hospitalization for depression but occur much more frequently in the population. To date, suicide prevention funding and policy has focused on reducing risk associated with the highest risk conditions, rather than conditions that have the potential for greatest population impact. Recent findings showing that the Good Behavior Game program implemented in 1st grade classrooms (Kellam et al., 2008) lowered suicidal behavior 15 years later in late adolescence (Watkins et al., 2008) demonstrates the potential suicide prevention impact from targeting early life aggressive-disruptive behaviors, which increase children's risk for a variety of mental health and substance abuse problems later in development.

3. The current focus on treatment of individual disorders also has limited potential for strengthening protective factors within social systems or promoting across large segments of the youth population individual strengths that promote effective coping for adolescents who experience mental health problems and acute stressors. Interventions that modify school settings and communities by increasing youth-adult connectedness (CDC, 2006) or that utilize peer opinion leaders to change coping norms among youth in their social networks (Wyman et al., 2010) are examples of interventions that may enhance the likelihood that depressed or distressed youth will seek and receive help and reduce the occurrence of new instance of suicidal behavior. Similarly, interventions that create positive school climate and reduce bullying (Olweus, 1996) may be cost effective in reducing suicidal behaviors. Among the approaches that can modify social settings and reach large groups are universal programs that target entire school communities or higher risk groups such as children in foster care. The potential impact of such interventions was underscored by a recent Institute of Medicine (2009) report on effective programs that prevent mental, emotional and behavioral disorders, which concluded that integration within natural settings such as schools increases the likelihood that programs will have enduring positive impact (O'Connell, Boat, et al., 2009). Changes in laws and policies that decrease children's access to weapons may also be cost effective in reducing suicide deaths. In addition, youth development programs targeting young children designed to increase emotional competencies and 'self-regulation' (e.g., PATHS, Greenberg et al., 1995) have shown positive impact on reducing 'distal' risk factors for suicide (e.g., internalizing and externalizing problems in school), although their potential impact on reducing risk for suicide has not yet been systematically examined.

Identifying Priorities and Overcoming Obstacles to Upstream Suicide Prevention

Suicide prevention researchers, practitioners and policy makers, including the IOM's (2002) report, have called for an expansion of youth suicide prevention approaches towards universal and selective strategies designed to move prevention 'upstream'. However, with a few exceptions, progress has been minimal in identifying which prevention strategies hold the greatest promise in having broad population impact in lowering suicide rates or in expanding funding and partnerships for new youth suicide prevention strategies. The following questions are designed to stimulate discussion towards actionable solutions.

1. How can partnerships be created from suicide prevention advocacy groups, prevention practitioners, researchers and policy makers to create a critical mass of interest in upstream youth suicide prevention?

2. What are the primary barriers that reduce enthusiasm and commitment to upstream prevention by key opinion leaders and groups - such as long time lapses between early prevention programming and outcomes - and what strategies may overcome those barriers?

3. How can partnerships be built between researchers and practitioners interested in suicide prevention and prevention scientists who have made progress in developing and disseminating programs in highly relevant areas such as antisocial behavior, depression, and substance abuse prevention,and in mental health promotion?

4. How can priority areas be identified for upstream suicide prevention with consensus among key stakeholders including funders necessary to expand implementation and identify the most promising approaches?

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'Upstream' Youth Suicide Prevention: Need for a National Commitment - SPTS

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The burden of suicide has shifted increasingly towards younger aged individuals over the last half century (WHO, 2004), and suicide accounts for more deaths among young people ages 10 - 24 in the U.S. (approximately 10/100,000) than all natural causes combined (NCHS, 2007). The public health significance of the problem is most apparent when the [...]

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Our bodies are chronically in “threat mode”—but being kind recalibrates our nervous system

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Being kind to others positively impacts your physical and mental health, according to this groundbreaking research by Stanford professor Dr. James Doty.

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Suicide Rates Increasing- What You Can Do

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Suicide Rates Increasing- What You Can Do

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Suicide Rates Are Increasing. Here’s How You Can Help Change That.

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A new CDC report contains some discouraging stats about deaths by suicide. That doesn’t mean all hope is lost.

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A study by The British Academy Of Sound Therapy shows that listening to music every day can greatly improve your mental health.

Your mental health is arguably one of the most important parts of your well-being. Listening to your favourite music is sometimes the best way to get through life's trials and tribulations.

I t turns out that listening to music every day helps to build a healthier lifestyle. It also helps to improve a person's wellbeing.

The British Academy Of Sound Therapy conducted a study of 7,500 people and the way they listen to and enjoy music. The study says that listening to 78 minutes of music per day greatly increases people's mental and physical wellbeing.

According to the study, a person's daily listening habits should be reflected in specified moods:

16 mins of 'calming' music

14 mins of 'uplifting' music

15 mins of 'motivating' music

16 mins of whatever helps to overcome sadness

17 mins of whatever helps to deal with anger

Lyz Cooper, who helped put the study together explained, that "There are certain properties of music that affect the mind and body. Dedicating time each day to listen to music that triggers different emotions can have a hugely beneficial impact on our well-being."

We can now argue that listening to Harry Styles and Rage Against the Machine in equal measure does, in fact, lead to a balanced and healthy mind.

Don't forget to consume your five moods and emotions a day.

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Study shows that listening to music every day improves mental health

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Your mental health is arguably one of the most important parts of your well-being. Listening to your favourite music is sometimes the best way to get through life's trials and tribulations. I t turns out that listening to music every day helps to build a healthier lifestyle.

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Ben n Jerry's: Mental Health in Schools 

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Ben n Jerry's: Mental Health in Schools 

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February 26, 2020

Just as they have throughout history, young people are working hard to make the world a better place-leading the movement to fight climate change, building pressure to enact common-sense gun reform, and so much more.

But as they're fighting to create the world we want to see, the world we at Ben & Jerry's have always believed in, they're also suffering from increasing levels of stress, anxiety, fear, and depression. One out of five American children experiences mental illness, but 80% of them won't get the help they need. One big reason why: Schools are hiring police and security officers instead of mental health professionals.

This year, Florida legislators have the chance to increase education funding and ensure that more mental-health professionals are hired to support students in their schools. We hope you'll join us in demanding that Florida lawmakers, and their counterparts all over the country, support young people. Here are some of the many reasons why we should all push to have more counselors in schools.

1. It's time to invest in services that truly make our kids safer

Despite the fact that many school districts continue to pour money into hiring police and security, there is no evidence that this makes kids safer. In fact, for students of color, the presence of police actually makes them less safe.

Black students are more likely to attend schools with police than white students, which helps explain why Black students are arrested 3 times more often than white students. And while Black and Latinx students make up only 40% of the U.S. public school population, they account for 58% of school arrests. Isn't it finally time to shut off the school-to-prison pipeline?

When students of color have early interactions with the criminal justice system, they are much more likely to be ensnared in that system throughout their lives. If schools had more counselors on staff, there would be more support and fewer arrests, leading to healthier outcomes for all students.

2. Young people in America are experiencing a mental-health crisis

This is a serious situation. Studies have produced some very troubling statistics:

* The suicide rate among children ages 10 to 17 has increased by 70% between 2006 and 2016, according to the Centers for Disease Control (CDC).

* Nearly 35 million children have experienced at least one event that could lead to childhood trauma. (About 72% of children will have experienced at least one traumatic event before the age of 18.)

Students carry all this with them when they come to school, which is a big reason why they are 21 times more likely to seek help from a professional at school than they are anywhere else. But what happens if there are no professionals there? Or if there aren't enough? ( 1.6 million kids attend a school that has a police officer but no counselor.) Police and security officers are not trained mental health professionals-in fact, only 12 states require special training for officers assigned to schools.

3. Mental health professionals really help students

The American School Counselor Association (ASCA) recommends a student to school counselor ratio of 250:1... and there are only three states in the country that meet the recommendation. The national average is twice that (Florida's is also right around 500:1-and rising).

Now, imagine trying to remember the names and personal details of 500 people who are depending on you to help them through some of the most challenging moments of their lives. Not so easy.

Research shows that having more counselors per student leads to a decrease in disciplinary problems at school, as well as an increase in academic achievement. If what we want is for students to feel safe and secure and go on to achieve success, then the answer is obvious: We need to hire more mental-health professionals for our schools.

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3 Reasons Investing in Mental Health Services for Schools Is Totally Worth It

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February 26, 2020 Just as they have throughout history, young people are working hard to make the world a better place-leading the movement to fight climate change, building pressure to enact common-sense gun reform, and so much more.

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The suicide rate increased 33 percent from 1999 through 2017, from 10.5 to 14 suicides per 100,000 people ( NCHS Data Brief No. 330, November 2018). Rates have increased more sharply since 2006. Suicide ranks as the fourth leading cause of death for people ages 35 to 54, and the second for 10- to 34-year-olds. It remains the 10th leading cause of death overall.

But it's a different story in other parts of the world. Over roughly the same period, other countries have seen rates fall, including Japan, China, Russia and most of Western Europe. What is going wrong on our shores-and what lessons can we import from elsewhere?

Suicide trends: Looking for clues

Pinpointing the reasons that suicide rates rise or fall is challenging in part because the causes of suicide are complex. Risk factors include health factors (such as depression, substance use problems, serious mental illness and serious physical health conditions including pain), environmental factors (such as access to lethal means and stressful life events including divorce, unemployment, relationship problems or financial crisis) and historical factors (including previous suicide attempts, a family history of suicide and a history of childhood abuse or trauma).

"At the individual level, there is never a single cause of suicide. There are always multiple risk factors," says Christine Moutier, MD, chief medical officer of the American Foundation for Suicide Prevention. "That confluence of multiple risk factors makes it a trickier business to explain a population-level rise."

And while the climbing rates are cause for concern, experts point out that they don't tell the whole story. In fact, the U.S. suicide rate is similar today to the rate of 30 years ago. Deaths by suicide fell markedly in the 1980s and 1990s before rising again at the turn of the century. What's more, while some countries, such as Russia, have seen dramatic declines in suicide rates since the 1990s, their rates are still well above those in the United States.

In other words, there is no obvious culprit for an increase in suicides-nor is there a single, easy solution we can import from other nations to turn the trend around. Yet there are clues.

Socioeconomic changes might be part of the puzzle. Globally, suicide rates have often fallen when living conditions have improved. And the reverse is also true. Princeton University economists Anne Case, PhD, and Angus Deaton, PhD, have shown that deaths from suicide, drugs and alcohol have risen steeply among white, middle-aged Americans since 2000 (, Vol. 112, No. 49, 2015). They argue these "deaths of despair" are linked to a deterioration of economic and social well-being among the white working class (Mortality and Morbidity in the 21st Century, Brookings Papers on Economic Activity, Spring 2017).

The CDC figures appear in line with that theory. From 2000 to 2016, the suicide rate for white Americans climbed from 11.29 to 15.7. For black Americans, it rose from 5.52 to 6.03 over the same period. What's more, suicides have increased most sharply in rural communities, where loss of farming and manufacturing jobs has led to economic declines over the past quarter century.

Meanwhile, people who are struggling often fail to receive interventions that could save their lives. "There is a lack of accessible, affordable, effective mental health care. And the health-care system hasn't been designed with suicide risk in mind," Moutier says.

Limiting legal means

While data from other countries can't explain the rising rate of American suicides, they may hold clues about how to prevent them. One takeaway from the data both at home and abroad: Limiting access to means of death can make a real difference.

When countries have made it harder to access a means of death, their suicide rates have declined. In England, people once could end their lives with carbon monoxide from toxic coal gas. When the country switched to less-toxic gas for heating and cooking, deaths from suicide dropped by 40 percent. In Asia, many countries saw suicide rates drop after making it more difficult to access toxic pesticides that are used in farming. Bridge barriers that prevent people from jumping have similar effects.

In the United States, more than half of all suicide deaths are the result of firearms. And there's evidence that when access to guns goes down, so do suicide deaths. During the 1990s, household gun ownership fell significantly. During those years, deaths from suicide by firearm also decreased, while suicide by other means stayed about the same. The result: a notable drop in the overall suicide rate, from more than 12 per 100,000 in 1990 to just under 10.5 in 1999.

A strategy for prevention

Another common element among many countries that have seen suicide rates fall: They have made suicide prevention a mission, through efforts such as improving access to mental health treatment, investing in community interventions, coordinating suicide prevention across health-care, social, education and employment services, and implementing workplace suicide prevention programs that train supervisors to identify and help those at risk. "Some of those countries, including Japan, have gotten impressively serious about investing in a national plan," Moutier says.

Japan has long had some of the highest suicide rates among industrialized countries. Rates there rose markedly in the late 1990s, a trend often attributed to the Asian financial crisis of 1997. Around the turn of the 21st century, a cultural shift occurred. Japanese citizens began to view suicide as a public health problem rather than as a personal problem to deal with in private. In 2006, the country passed legislation to fund suicide awareness and prevention campaigns and by 2012, the number of suicide deaths had fallen below 30,000 for the first time in more than a decade.

One element of Japan's plan that appears to have been helpful was a mandate requiring that detailed, municipal-level suicide statistics be released every month. That step allowed suicide prevention resources to be matched to communities with the greatest needs.

In the United States, timely suicide data that include details about risk factors and mechanisms of death have been hard to come by. The CDC's National Violent Death Reporting System, which collects such details, was only created in 2002, and it wasn't until 2018 that it was expanded to collect data on suicides and other violent deaths from all 50 states. "We haven't had a really good picture of the characteristics and life experience of suicide decedents across the U.S.," says Jane L. Pearson, PhD, chair of the Suicide Research Consortium at the National Institute of Mental Health.

The United States has also been slow to develop a national strategy. The country's first national plan to address suicide prevention was published in 2001, and it wasn't until 2010 that the National Action Alliance for Suicide Prevention was launched as a public-private partnership to advance and update the National Strategy for Suicide Prevention. That strategy, released by the U.S. Surgeon General and the Action Alliance in 2012, outlines goals and objectives for reducing deaths by suicide.

It's an encouraging step, Pearson says, but there's been a lag in moving from research to action to meet the National Strategy objectives. Accessible, affordable mental health services are still out of reach for many people with suicidal thoughts and behaviors. "We can't point to any single factor causing an individual to consider suicide, but we can point to health-care practices that can make a difference in suicide prevention. The three key areas are risk identification, intervention and follow-up," Pearson says. "We're making progress in understanding risk factors and how to intervene, but the rate keeps climbing because we're not fully implementing what we know."

One promising approach comes from a study by psychologist Edwin Boudreaux, PhD, at the University of Massachusetts Medical School, and colleagues. The multi-site trial explored universal suicide screening in hospital emergency departments. Study participants who were identified as being at risk received an intervention that involved an assessment, brief intervention, discharge resources and follow-up phone calls focused on reducing suicide risk. Patients who received the screening and intervention had 30 percent fewer total suicide attempts in the next year compared with patients who received treatment as usual (JAMA Psychiatry, Vol. 74, No. 6, 2017).

Such interventions are promising, but there's a lot of work to be done. Meanwhile, Pearson and other experts argue that psychologists should be doing more to help those at risk of dying by suicide. Many psychology training programs barely touch on the topic, Pearson says. "You'd think mental health professionals should be experts in helping suicidal people, but we aren't."

But it's never too late to get up to speed. "There's so much anxiety around treating suicidal people, but you shouldn't beat yourself up. If you trained more than five or 10 years ago, there wasn't a lot of science to inform what we should be doing clinically," Moutier says. "Now there are new standards to be aware of." She recommends mental health professionals, physicians and other clinicians familiarize themselves with the standard care recommendations published by the National Action Alliance for Suicide Prevention (Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe, 2018).

For professionals working in outpatient behavioral health settings, those recommendations include:

Assessing patients for suicide risk at intake and repeating the assessment periodically.

Completing a safety plan in collaboration with all patients at increased risk during the same visit.

Giving patients information on telephone crisis lines.

Taking steps to reduce access to lethal means, including asking family members to assist.

Reassessing risk and reviewing or updating the safety plan at each visit until the risk is reduced.

A key message, experts say, is that there is genuine hope for people considering suicide. "Suicide is about despair, and the only cure for despair is hope," says Joel Dvoskin, PhD, ABPP, a clinical and forensic psychologist in Arizona and New Mexico who has worked with jails to implement suicide prevention interventions among inmates. "Psychologists can prevent suicide by helping people to regain hope. If we're not about that, we should get out of the business."

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The suicide rate increased 33 percent from 1999 through 2017, from 10.5 to 14 suicides per 100,000 people ( NCHS Data Brief No. 330, November 2018). Rates have increased more sharply since 2006. Suicide ranks as the fourth leading cause of death for people ages 35 to 54, and the second for 10- to 34-year-olds.

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"Districts that are less resourced might be sharing one psychologist for the entire school district, or one psychologist who is responsible for 3,000 kids," said Kelly Vaillancourt Strobach, policy director for the National Association of School Psychologists (NASP). "When you have these shortage of these professionals, you're really only able to serve those kids who are in extreme crisis."

Absent a national blueprint for helping students cope with mental health conditions, states are scrambling to identify potential prototypes. The BRYT program, which was founded and pioneered in a Boston-area school in 2004 by the nonprofit Brookline Center for Community Mental Health, has emerged as a successful model for helping kids re-enter school after a mental health crisis.* The Brookline Center works with school districts to help them plan and implement BRYT programs, which are staffed by school employees. Although the center doesn't finance programs, it helps schools identify potential sources of funding.

Ninety percent of students in BRYT remain on track to graduate, and their attendance rates have increased from 52 percent before participation to above 80 percent after. The program itself is expanding. BRYT's director, Paul Hyry-Dermith, said 137 schools in Massachusetts now employ the program and pilots are starting to roll out in Rhode Island, New York and New Hampshire. Partnerships are also in the works with school districts in Washington state and Oregon.

At Cambridge Rindge & Latin, an ethnically diverse school that in 2018 sent 82 percent of its graduates to college, the BRYT classroom is tucked at the end of a quiet hallway. Blue parchment covers the fluorescent ceiling lights, showering the space in a balmy azure. A walnut-stained rocking chair with an embroidered cushion that reads "Be Kind" rests in one corner. In another corner, a noise machine beckons for attention before it's soon forgotten.

Eleven students spend one assigned period a day here, where they chat with counselors, prepare for and work on homework assignments with the program's academic liaison, or simply rest and relax. Students are also welcome in the room any time they feel overwhelmed.

"Many of the kids in our program are coming out of a psychiatric hospitalization," said Ashley Sitkin, BRYT clinician/program leader at Rindge & Latin. "Some of the kids haven't been hospitalized but they've missed a lot of school because they've gotten stuck in this avoidance cycle, which is really common for kids who struggle with anxiety and depression."

At Rindge & Latin, Sitkin and her colleague, academic coordinator Nkrumah Jones, disrupt that cycle with a three-to-four-month reintegration plan that includes emotional support and mental care coordination. That includes a clinical diagnosis of students before they enter the program, and constant contact with outside health providers who also provide each student with care. Sitkin and her staff also reach out to parents and keep them informed. Academic coordination is crucial, too. Both BRYT coordinators and teachers acknowledge it is unrealistic to expect students who miss weeks of school to make up all class work, so care coordinators serve as a liaison between student and teacher, indentifying key assignments and ironing out a make-up plan.

Eli, a trans student at Rindge & Latin, began to battle with depression in eighth grade, a condition that worsened the following year when he entered high school. By his sophomore year, therapy and medication proved fruitless. Eli stopped going to school. He checked into a psychiatric hospital, an experience that his mother said replenished Eli's hope and helped him kick his meds. But the thought of returning to school tormented Eli. Unable to walk into the building, he met Sitkin and Jones at the school door before being escorted to the safe space.

"I was dealing with pretty severe anxiety and depression. I would miss school, which would make me more stressed, which meant I would want to miss more school," said Eli. Before participating in BRYT, Eli, now a senior, would attend just three or four classes a day, he said. Gradually, with help from Sitkin, he returned to classes full time. "I was behind on school work before I left, so the academic coordination, having someone else deal with my teachers, was really, really helpful."

At Rindge & Latin, the mental health challenges students contend with have become more severe in recent years. Student suicide is a growing worry. Several students attempted suicide this semester, teachers and staff said. "I had a student today tell me she's feeling very suicidal," said Sitkin.

That's part of a national trend. The suicide rate for children and young adults, ages 10 to 24, rose by 56 percent from 2007 and 2017 and is now the second leading cause of death among teenagers, according to the Department of Health and Human Services. Some 3,000 high school students across the U.S. attempt suicide every day.

Duncan MacLaury, a history teacher in his fourth year at Rindge & Latin, said he often sees students struggling with depression and suicidal ideation. Ibrahim Dagher, who teaches Arabic at the school, also sees the symptoms, though often they are hard to detect.

"I have a student who has been through a very traumatic experience," said Dagher. "She attempted suicide this year, and I had no idea, meaning I saw no signs. She was present in class the day of, so that really shocked me."

Experts point to the increased use of smart phones and social media as the likely culprit for the spike in teen suicide over the last decade. New technology keeps kids in front of screens instead of interacting face-to-face with their peers, they say, which leads to increased isolation. It can also expose them to feelings of insecurity and to cyber harassment and bullying.

Social media helped exacerbate emotional problems for Tashin, 17, a junior at Rindge & Latin. She first started experiencing anxiety after exposure to family violence, but her slide into depression hastened when she was in eighth grade, after students began to bully her online. They would create group chats on Instagram mocking her and then send posts her way. The social bullying continued when Tashin was a sophomore at Rindge & Latin, and she began to miss school. Shortly afterward, she entered a hospital after she began to cut herself.

"That has stayed with me," said Tashin, now a junior and a BRYT alum, of the social media bullying. "A lot of people told me I wouldn't get anywhere in life."

Dorchester, just south of Boston, wallows in hardship. The per capita income is just $26,292, the second lowest in the Boston area, and almost more than $10,000 less than the city average. Just 14 percent of residents hold bachelor's degrees. The 460 students at Boston Arts Academy reflect these economic burdens: Two thirds come from economically disadvantaged families, and one third entered ninth grade reading below grade level.

Students at the Academy, the Boston school system's only public high school for the arts, carry the weight of stress and community violence, said Charmain Jackman, the school's dean of Health & Wellness. Students embody these stressors with increased levels of depression and trauma. Thought disorders like schizophrenia and delusional disorder are also up here, all made worse, said Jackman, by the recent death of a beloved teacher.

That has placed pressure on the school's mental health services, and its Bridge program, which is similar to the BRYT model used at Rindge & Latin. Besides helping students reenter school after mental health-related absences, the program, started in 2014, focuses on what directors call pre-emptive help. If program coordinators notice a student becoming high risk - excessive absences or tardiness -they will intervene.

The dedicated classroom here is tiny, a roughly 12- by 15-foot room crammed with a few 5-foot-long desks and two computers. A tack board welcomes the program's nine participants and helps coordinators keep track of student comings and goings.

Despite its narrow confines, the room served as a home for Dashawn, a senior here, at a time he desperately needed shelter. As a sophomore, Dashawn lost his father. Devastated family members went their separate ways. Dashawn's mother slid into depression, exacerbated by her inability to afford the rent after her husband's death; she moved to Georgia to start a new life. Penniless and alone, Dashawn drifted from friend's house to friend's house. Inevitably, he was asked to leave after a few weeks. He slept in hallways at times.

"Outside it's like, 'Damn, where am I going to sleep tonight?'" said Dashawn, now 19. "Coming to school is the part where, 'OK, you're good for now.'"

Dashawn credits Bridge with giving him a space where he could be vulnerable and let his emotions out. Sarah Nichols, coordinator of the Bridge program, and Jackman helped just by being there and reassuring him he could get through a rough patch in his life, he said. The program also helped him communicate with his teachers and make up assignments. Program coordinators gave him gift cards for food and helped him fill out applications for housing. But they also gave him a space to sit down and gather his thoughts.

"I've had tensions with teachers because they think, 'Oh, you're not working, your quality is not good enough,'" said Dashawn, who now lives with an uncle in a stable setting.

"It's hard to meet these expectations when you're going through a lot outside of school," he said, crediting Bridge with helping him sprout into adulthood. "I'm starting to walk now, and I'm just thankful."

Boston Arts Academy does not have the resources that Rindge & Latin enjoys. Students shuffle through dim corridors. The school's makeshift library spills from one dedicated classroom into an adjacent hallway. Substance abuse is up among students, 90 percent of whom are people of color, mostly Latino and black. Jackman, who said her mornings are filled with "back-to-back" students, described the Academy as an urban school with a lot of stress and few resources.

"Every school personnel I've spoken to have talked about increased stress and anxiety of students in general," said Jackman. "It's relentless right now."

But staff at both schools said one of their biggest frustrations is that, although anxiety is widespread, they only have time for the students with the most acute problems.

"Early intervention is much more effective than waiting until a kid is in a crisis, and that's what happens in a lot of schools that don't have these adequate members of mental health staff," said Vaillancourt Strobach of the National Association of School Psychologists. "There is an entire population of students who really aren't getting the care that they need, or it's putting the responsibility on the community, where there is also a significant shortage."

Sitkin at Rindge & Latin emphasized that BRYT is a short-term stabilization model. She agrees with Vaillancourt Strobach - schools need to be better equipped to help students cope with social-emotional issues when they're younger, before the problems grow. Only focusing on students in crisis is unsustainable, she said.

Sitkin, referring to herself, said, "Ten Ashleys can help 100 more students, but it's not going to solve the problem. But how do we help the majority of students who also have struggles? There is always going to be those students."

But for struggling students like Ava at Rindge & Latin, the help they receive at school can alter the course of their lives.

"BRYT is a miracle worker in a way. I wasn't going to finish high school," said Ava. "It's about getting out of the car. It's about being here and being OK."
*Correction: This sentence has been updated to correct the name of the Brookline Center for Community Mental Health and the number of schools in which it was started. This story about mental health in schools was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for the Hechinger newsletter.

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How a Program Can Help Students Re-enter School After a Mental Health Crisis | KQED

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"Districts that are less resourced might be sharing one psychologist for the entire school district, or one psychologist who is responsible for 3,000 kids," said Kelly Vaillancourt Strobach, policy director for the National Association of School Psychologists (NASP). "When you have these shortage of these professionals, you're really only able to serve those kids who are in extreme crisis."

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All it takes is the shrill sound of a fire alarm.

When Ryan Deitsch heard the sound in his dorm at American University earlier this month, he froze. As the rest of the students fled, yelling at him to follow, the freshman's heart raced as he relived the afternoon of Feb. 14, 2018 - when a fire alarm put students and teachers directly in a shooter's path.

Earlier this week, the blare of a fire alarm at Marjory Stoneman Douglas High School in Parkland brought frightened teenagers to tears.

"Nobody who was there is OK. I know that," said Sam Zeif, an MSD graduate. "This is something that will be part of everyone's lives for a long time."

In the immediate aftermath of the Parkland shootings where 17 people died and 17 were injured, angry outspoken students said "never again." They became instant activists, organizing protests and marches, and the national faces of gun safety advocates on television, in magazines and on social media. But now that the intensity of their efforts to bring change has slowed and the media spotlight has dimmed, many face the real struggle. Depression, anxiety and severe post traumatic stress disorder have forced them to drop out of high school or college, or rely on medication and therapy to get them through each day.

"These kids are trying to adjust to a new normal and it's difficult," said Liz Deitsch, Ryan's mother. "They are forever changed and that's the aspect people don't realize."

Mental health experts say PTSD can crop up any time after a trauma in the form of flashbacks, insomnia, misguided anger and overwhelming sadness. Because processing trauma differs for everyone, "some are just beginning to work through the stages of bereavement," said Dr. Pamela Baker, a licensed clinical psychologist in Coral Springs who has dealt directly with MSD students.

The reaction of the Parkland students in the aftermath of the tragedy differed greatly from past school shootings; they sought purpose and activism as an outlet for grief. The students began the Never Again movement; organized the Washington, D.C. protest, March for Our Lives, that drew students nationwide; founded the advocacy group Students for Change. Over summer vacation in 2018, they spent 60 days touring 20 states to push voter registration and stricter gun legislation.

Three months ago, Emma Gonzalez tweeted about her mental health struggles, telling her 1.6 million followers she has depression, anxiety and PTSD. Gonzalez is a survivor of the shooting and well known for having transformed her heartbreak into activism for stricter gun laws. She co-founded March for Our Lives, and gave interviews in the national media.

In a documentary called US KIDS, she gives a glimpse into her recognition of how real the mental health struggle has been: "It might be good to emphasize how unhealthy we were so people don't think it's a good idea to do a bus journey of their own," she said.

Like Gonzalez, Cameron Kasky, founder of March for Our Lives, is working through his PTSD. He has taken the semester off from Columbia University. His father, Jeff Kasky, said Cameron has good days and bad days, and now limits his public speaking and media interviews. "It takes a lot out of him," Jeff said.

"With the March for Our Lives students, they are realizing when the lights go off and there are no reporters to talk to and no audience, that's when reality hits," Jeff said. "Using their platform was part of their mental health process, and they continue to process."

Some parents and therapists now question whether their pace and the difficult fight against a powerful gun lobby exacerbated the emotional toll.

[ RELATED: Unprepared and Overwhelmed ]

"After what they went through, we put changing the world on their shoulders," said Nicole Cook, a mother of two daughters who were at the school during the shooting. "We don't know if it was emotionally helpful or not. What they are experiencing now is a reaction."

Immediately after the tragedy, counselors descended on the Parkland high school, offering therapy. Some students took advantage, others resisted. Some complained it was inadequate - a mere surface attempt to address an enormous problem. Just after the first anniversary, when two survivors took their own lives, South Florida nonprofits opened Eagles' Haven, a special wellness center created just for the Marjory Stoneman Douglas community.

But now, two years after the tragedy, the juniors and seniors from the high school are freshmen and sophomores at colleges across the country - no longer surrounded by friends in Parkland who relate, teachers who understand their lack of motivation, and therapists who have treated groups of students and parents at the school.

Sam Zeif, 19, lost one of his best friends - Joaquin Oliver - in the shooting in Parkland. Heartbroken, he joined other survivors months later at the White House to speak openly about gun control measures and later appeared on NPR. Now, Zeif is a sophomore at the University of Central Florida, making his way through college without Oliver, who was killed by the shooter in a hallway outside his creative writing class.

Zeif says recently he sat in his car in a parking lot and cried after hearing a Mac Miller song that reminded him of Joaquin.

"There are just those moments where everything catches up to you," he said. Zeif said he went back to therapy a month ago, after more than a year of trying to cope on his own. "I'm glad I did," he said, encouraging others to do so.

Therapists and Parkland parents who spoke with the Sun Sentinel said they know at least a dozen alums who have gone away to college and returned home - unable to motivate themselves to go to class or control panic attacks.

"They are going to counseling centers on their campuses that are not equipped to handle their issues, and they are feeling discouraged," said Baker, the Coral Springs psychologist. "They tell me the counselor doesn't get why they care where their seat is or why they can't go to class certain times of day ... they feel people outside of their community don't understand."

Rather than traditional mental health counseling, Parkland students tend to require trauma therapy, which helps them recognize triggers and manage their responses.

Michael Houghtaling, program manager for Smith Community Mental Health, said right after the school shooting, Broward trauma therapists were overwhelmed. And while many students have received treatment, some Parkland teens even two years later still don't recognize they need help, he said.

Broward County public schools:
Family Counseling Office 754-321-1590;

MSD Wellness Center 754-322-2266;

BCPS Mental Health Portal: bcps-mentalhealth.com;

Broward County Public Schools Recovery Program: browardschools.com/recovery.
Other resources:
2-1-1 Broward;

National Suicide Prevention Hotline: 1-800-273-8255;

Substance Abuse & Mental Health National Helpline: 1-800-662-HELP;

Eagle's Haven: 954-618-0350;

"Trauma has a way of rearing its head at times when you don't expect it," he said. "I can understand why they are struggling two years down the road if the trauma wasn't initially addressed."

Rebecca Boldrick, mother of David and Lauren Hogg, said both her children are receiving trauma therapy. David, who helped lead several high-profile protests, marches, and boycotts, attends Harvard University. The rest of the family has moved to Maryland.

"I think David and his friends were so busy they didn't deal with their trauma," she said. "As a mother of someone just dealing with this at Harvard freshman year, I can tell you it's hard."

Boldrick said she has a trauma therapist and psychiatrist for both her children. She worries some teens remain in denial or are self-medicating. "They are doing whatever it takes to numb the feeling, which is sad. They need to reach out and get help."

In Parkland, where Valentine's Day marks two years since the mass shooting, students like junior Holden Kasky, Cameron's younger brother, still walk by the freshman building where their friends were killed. The building is fenced off with a mural around it. Students say the reminder is hard, as are loud sounds and fire drills like the one this week.

"Some of the kids were crying. I could tell from the look on their faces they were really scared," Holden Kasky said.

The mental health community is aware that these students will need therapy for at least several more years, said Nicole Mavrides, a UM Health assistant professor and adolescent psychiatrist who has worked with Parkland teens.

"There is a lot of push to continue to offer services to these kids," she said.

[ RELATED: Eagles' Haven center offers free help to Stoneman Douglas community a year after Parkland shooting ]

Eagle's Haven, which opened in Coral Springs in March 2019, has become a therapeutic place to try out kickboxing, yoga or drumming circles, or participate in support groups. When families need trauma therapy, professionals at Eagle's Haven connect them with resources. A state grant allows people in the Parkland/Coral Springs community to get mental health counseling at no cost. Sarah Franco, executive director of JAFCO, which runs Eagle's Haven, said 2,000 people have walked through the door, and the center has made 776 mental health referrals.

In addition, Marjory Stoneman Douglas also has turned two portables into a wellness center. This week, counselors in the center conducted wellness checks with each of the teens in the freshman building at the time of the shooting, students told the Sun Sentinel.

"It's never going to be easy, but I think as time goes on we are learning coping mechanisms," said Dara Rosen, a senior at Marjory Stoneman Douglas and editor-in-chief of the school newspaper. "It has taken certain people longer to show their emotions. I didn't seek therapy until after a year. Mental health may have a stigma in America but not at my school. Everyone talks about it. You know who is going to therapy."

Diane Wolk-Rodgers, an AP World History teacher at Marjory Stoneman Douglas, said she has given struggling students an alternative to therapy, training them in mindfulness and the mind-body connection. She practices the skills, too.

"Many of us feel this year is harder than the first anniversary," she said. "The first stage is denial, but I recognize it's so important for kids to see healing together takes a village."

Watching their children grapple with horrific flashbacks, crying spells, and days where they don't want to go to school has taken a toll on Parkland parents.

"We are not in a great place," said Doug Zeif, father of four boys, two of whom were at the high school during the shooting. "We have all been in and out of therapy to try to figure out how to deal with this." Zeif said he even attended a suicide-watch class to learn the warning signs.

[ RELATED: Parkland teen suicides shine spotlight on need for prevention ]

Each day, Zeif said he internalizes guilt. "I blame my generation for this occurring. We watched Columbine and Virginia Tech, and we sat in our living rooms thinking 'those poor people.' Now we are 'those poor people,' and this is going to be with us forever."

Liz Deitsch, who still has a daughter at MSD, says living a new normal is difficult. She continues to search for a therapist who her daughter will open up to as well as coaxing her to see a counselor at school. "Everything you thought or wanted for your kids, you let go of in a way. Tests you would get upset over you don't. You still want them to have a future, but it's shifted completely. Mental health and happiness become critical."

Patricia Oliver celebrated her son Joaquin's 19th birthday in August without him. She said she looks around at her son's friends and their parents and she sees signs of PTSD everywhere.

"It doesn't have a time or schedule. We all react in different ways," she said. "The love and counseling have to be always there."

She urges adults to attend events with kids trying to cope and advocate for change.

"We have to be there supporting them - all of us."
Cindy Krischer Goodman can be reached at cgoodman@sunsentinel.com, 954-356-4661, Twitter and Instagram @cindykgoodman

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With national spotlight dimmed, Parkland students tackle the real struggle: mental health

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All it takes is the shrill sound of a fire alarm. When Ryan Deitsch heard the sound in his dorm at American University earlier this month, he froze. As the rest of the students fled, yelling at him to follow, the freshman's heart raced as he relived the afternoon of Feb.

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Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm?

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Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm?

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A poetry-sharing exercise helped this teacher support a student struggling with suicidal thoughts

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April McNary, a teacher at Sunnyslope High School in Phoenix, Arizona, has always believed in the transformative power of reading and writing. The honest conversations that are sparked by this creative work, she says, are some of the most valuable to her. "Allowing students to wrestle with their th...

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May 13th 2017 was a wet Saturday afternoon when my husband, my two young daughters and I filed into our car on a stealth mission in our small town of Newberg, Oregon:

Anonymously stake 20 yard signs.

The signs said:

Don't give up

You are worthy of love

Your mistakes don't define you

A few weeks before, we were hanging out with friends when one of them mentioned the suicide rates in our community and I about fell out of my chair. I felt completely hopeless and ill equipped to be part of a solution. After all, I wasn't a therapist. I didn't know of anyone suffering with thoughts of self-harm. What on earth could I do?

But it was clear in my heart, I had to do something.

The idea of encouraging yard signs had been bouncing around in my head for years but it was always 'just a silly idea'. That is until May 2017 - then it became the something.

When we knocked on strangers' doors asking to place signs in their yard for 2 weeks, they didn't hesitate. Once they saw the signs had no branding, no website, no organization, no strings attached, just a young family trying to spread love and hope, they were all in.

Within a few hours of returning home, the community was buzzing about the signs, and when we realized people wanted to purchase signs for their yards, we spoke up and offered to help! My friend Jessica Brittell, a talented graphic designer, designed and printed our first batch for us. And the second batch. And pretty soon I was emailing her in a panic after being flooded with orders. Within a few days, our community ordered over 150 yard signs.

I vividly remember that week sitting on the couch feeling totally elated and completely overwhelmed.

I looked at my husband and said, "This is big. Are we all in? Do we want to do this? Because now it's a thing. Do we want a thing?' Without hesitation, he confirmed: we're all in. That night he built me a website. The next day I opened a separate bank account for the movement.

Over the next few weeks we added more messages: You matter. You are not alone. One day at a time. It's not too late. We also added smaller cheaper products: wristbands, stickers, encouragement cards - selling everything at-cost...

The movement really picked up traction when family friends road tripped that summer from Portland, OR to Rochester, NY leaving a trail of our product in every public bathroom, restaurant, and rest station across this great country. Their stories of beautiful connection with strangers through our product stirred my heart.

​

Indeed, this was big.

Within a year we had news outlets in Dallas, Boston, Cincinnati, and Portland cover our movement. I guess generous love with no strings attached was newsworthy. I guess yard signs were genius.

People are using our product in love packages to the homeless, corporate gifts boxes, handouts at family reunions and swim tournaments, and tokens of hope at funeral services. Stickers have been plastered in Manila, Philippines. Yard signs have been posted in Mbabe, Rwanda, and wristbands handed out in Costa Rica and Zambia. Sign rallies are being organized by generous kind souls all around the country. Schools, churches, businesses, neighborhoods, and nonprofits are using our tokens of hope and love to be a voice of support in their communities.

And it's all organic.

In the Fall of 2018, when we realized the movement wasn't slowing down, we decided to legally become a 501(c)(3) non-profit organization. Our board consists of Jessica Brittell (our original dream enabler) and Evangeline Pattison (the friend I called in a panic in May 2017 "Are we a business? Are we a non-profit? Are we just a movement? WHAT IS THIS!?")

Our product has shipped to all 50 states and made it's way to over 26 countries in several different languages.

But the most encouraging and fulfilling part of running this movement are the stories. With permission, below are just a few from the first 3 months. I simply could not keep up with all the stories but this will give you an idea of the impact love and kindness can have.

Friends, let's not underestimate the power of simple kind words at the right place at the right time for the right person. Let's not wait for someone more qualified or less broken to spread hope and and love.

​

​Life is messy but we're in this together.

​

Amy Wolff

​

​

"Our son was a victim of suicide about three weeks ago. We read about your efforts with the signs when his fiancé "liked" your post. We are trusting God to bring about good from the pain and we see this as one of those good things. It means a lot to us that you are caring about people that you don't even know and following it up by actually doing something... We don't know if a sign message would have helped our son but we pray that it will help others. As you said, we believe that love always wins, especially God's love, and what was meant for evil, God will use for good. Our grief is so raw right now, it is hard for us to think about helping others yet, so thank you for stepping forward."

​

"So when I say your signs saved my life, I mean I feel like your signs pulled me out from the feeling of complete hopelessness. They gave me back perspective. I didn't have a plan to kill myself but I really felt like dying. Things are still really hard and yesterday was one of the harder days but sometimes we just need a random sign to break up the negative voice in our heads. I don't think it's coincidence those signs showed up on my route to work and I'm sure they spoke to many others too... Life can be hard but it is so worth it. Sometimes all it takes is the reminder we aren't alone and even a stranger can impact your life when you need it most."

​

"I am a gay man. Never did I think that anyone in my family, or community would accept me for me or help me find the resources I desperately needed. I often thought of taking myself, and unfortunately followed through with attempts... If I had seen those signs when I was on the bus to school..."

​

"I am an eating disorder dietitian and cannot tell you how important these messages are to myself and the population I work with. I've already purchased signs from your website but I want to help spread the message in any and every way that I can." (We sent her 1000 custom cards that read 'Your weight does not define you'.)

​

"38 days ago I had a heart attack. When I came back to work a week after leaving the hospital I started to see your yard signs... At lunch I decided to go on a walk. I kept seeing more and more signs! It was crazy! It was like they were put there just for me. I actually called my office and asked if anyone knew what they were about because why would all these signs telling me not to give up and to not beat myself up over my mistakes be in every yard around my workplace... I was in a pretty dark and scary place but your signs gave me some much needed encouragement."

"I'm obese and have struggled with my weight all my life. I've recently been diagnosed with diabetes and need to make changes. I found myself in a lonely situation where I have a family but they're not all that supportive or willing to help me. I've been forcing myself to start taking walks even though it hurts to be active.There have been times where I've found myself crying as I'm walking around the neighborhood. Then all at once your signs popped up and literally told me, 'Don't give up' and 'You matter.' It feels like I have my very own support group cheering me each step of the way. Whether it be depression, diabetes, or a billion other things, we are all human and struggling in some way."

"This morning as I was leaving for work, a woman was stopped outside our house in her car with tears in her eyes. She thanked me, with her hand over her heart, for posting the sign. She told me that I mattered too and that I helped her."

​

"So someone just knocked on my door almost in tears. He told me about his daughter and her struggles with drugs and asked if he could buy my sign. Of course I said no he could have it. I prayed for both of them and he left. I will be ordering more signs..."

​

"I just had a woman knock on my door. She began to cry and thank me for the signs in my yard. She lives up the road and said her son had attempted suicide and these signs were in the yard the day they came home from the hospital. She drives by every day and for her, her son, and her daughter - the reminder is profound."

​

​

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May 13th 2017 was a wet Saturday afternoon when my husband, my two young daughters and I filed into our car on a stealth mission in our small town of Newberg, Oregon: Anonymously stake 20 yard signs.

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​​​​​​​​​​​​​​​​​​​​​​​​​​​​​ A bully at school. That rough break up. Thinking about suicide. Life can give you challenges. We have some tips and tools to help you deal. It looks like your browser does not have JavaScript enabled. Please turn on JavaScript and try again. It looks like your browser does not have JavaScript enabled.

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Mental Health Foundation of West Michigan - be nice.

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501c3 educating individuals in schools, workplaces, faith institutions, and communities in mental health using the be nice. program.

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After the recent report by The Children's Society that a quarter of 14-year-old girls have self-harmed, many campaigners have called for the root causes of the adolescent mental health crisis to be tackled - rather than just firefighting the symptoms.

Resilience lessons, peer mentoring, awareness campaigns and provision of early intervention may be valuable initiatives. But they do little to challenge the main causes of mental health issues - which are likely to be integral characteristics of a neoliberal economy, including austerity, global uncertainty and a highly pressured education system.

The British Psychological Society's recently published Power Threat Meaning Framework also supports this viewpoint. It sees mental distress less as an individual medical issue, and more as an intelligible response to the social, material and cultural pressures acting on people.

Much of my experience is as a storyteller and community artist, and I coordinate the Things As They Are network for young artists with experience of mental ill health. I have found that young people with mental health conditions often have a keen perception of how the media, economy and society contribute to their problems. These large-scale issues are often beyond the scope of schools to address, but with a change of focus, the educational environment could move beyond firefighting problems to play a more fundamental role.

More time for play

A vital first step would be measures to reverse the shrinkage of what might be called the "youth public sphere". By this I mean the space and time that is allowed for dialogue, self-expression, playfulness, exploration, development of personal initiative, and just plain chatting, between young people and caring adults.

These opportunities enable young people to understand the world around them and thrive despite adversity. But they have been dangerously eroded by closely specified curricula, performance-focused education systems and the decimation of the youth service.

The Pupil Referral Units to which ever increasing numbers of young people are being sent - because they cannot cope within mainstream schools - make an interesting contrast. These units are frequently criticised, but they do allow space for dialogue and responsiveness to young people's needs and interests.

I have witnessed conversations between young people too anxious to attend school sharing tips on how to get referred to a unit - because "they treat you like a human being there", unlike in mainstream school.

Space to grow

At the risk of sounding bitter, I could also cite my own frustrating attempt to establish a lunchtime storytelling club with a group of keen, and vulnerable, young people in a local secondary school. The teachers were supportive - we wanted to establish a space where different "tribes" of young people could make friends and collaborate creatively outside the constraints of the curriculum, which allowed little space for creative writing or group work.

Yet with lunch breaks cut to 35 minutes to maximise lesson time and manage behaviour, and further shortened by frequent detentions, it proved impossible to build up a stable group, and teachers lacked the time to support the ideas for performances and projects from pupils.

It is widely agreed that education systems centred on exams place stress on young people, yet there is less understanding of their more insidious effect. That is, their tendency to reshape every exchange between teachers and pupils into something directed at an assessment goal.

They also squeeze out of the school day anything that does not contribute to this. Arts and sports activities dwindle away from the curriculum, and teachers find themselves less often in the informal, supportive roles of mentor, facilitator, and guide.

Meanwhile, outside schools, austerity has led to open access youth clubs being gradually replaced by targeted provision to improve "outcomes" for school refusers, teenage parents, or young people in care - and even these are being cut in most areas. Mental health and well-being are also effectively being converted into goals which young people must individually achieve through learning strategies.

Beyond league tables

To thrive emotionally, young people need their own time and space, that is not explicitly directed at particular outcomes. This should be an arena in which diverse groups of young people can form their identities and agendas - perhaps with the non-coercive oversight of sympathetic adults. The arts provide some of the key forums for this - I gratefully remember the music teacher that helped me and my friends set up our band in the lunch break.

To try and tackle the challenge young people are facing, the government could start by mandating time and space in schools for exploratory, informal, and pupil directed activity. This could be done by reinstating leisurely lunch breaks and allowing for extracurricular activities within them. Arts and sports lessons also must be restored where they have been reduced within the curriculum.

The education sector should pay attention to solutions to the mental health crisis which arise from young people themselves - I'm thinking of the group of GCSE students whose protest on London's tube trains proclaimed the human cost of pupil exclusions in a system focused on exam results rather than compassion and support.

As mental health campaigner Natasha Devon points out, self-harm is frequently a way of being heard. Perhaps then, if we help young people find other, more creative outlets, we might find it easier to hear what they're trying to tell us.

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Mental health crisis in teens is being magnified by demise of creative subjects in school

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After the recent report by The Children's Society that a quarter of 14-year-old girls have self-harmed, many campaigners have called for the root causes of the adolescent mental health crisis to be tackled - rather than just firefighting the symptoms. Resilience lessons, peer mentoring, awareness campaigns and provision of early intervention may be valuable initiatives.

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Related Condition Centers

Talking about it can be hard, but it's so important.

As someone who struggled with suicidal ideation as a teen, I remember how it felt like a dirty little secret-and how little support I had. I can't imagine how different my experience would have been if I'd had a safe and nonjudgmental environment where I could discuss it out in the open, especially with adults. With teen suicide rates rising, it's more important than ever that parents know the facts, are familiar with the warning signs, and are equipped with the tools not only to intervene when necessary but to have ongoing conversations with their kids about mental health.

According to an October 2019 Centers for Disease Control and Prevention (CDC) report, the suicide rate in kids, teens, and young adults increased by 56 percent from 2007 to 2017. People between the ages of 10 and 24 are dying by suicide at a rate of 10.6 deaths per 100,000 individuals, up from 6.8 deaths per 100,000 people in 2007. Things become even more upsetting when you focus on certain age ranges, like kids between the ages of 15 to 19, who experienced a 76 percent increase in suicide between 2007 and 2017. In 2017 suicide was the second leading cause of death for people in this age range.

In an ideal world, no parent would ever have to think about watching their kid for warning signs of suicide. But the reality is, we need to be talking openly about suicide and suicidal ideation to reduce stigma and to keep children, adolescents, and young adults safe.

This can be particularly important when it comes to teenagers since a lot of parents mistake warning signs of suicide for the regular ups and downs of adolescence. To help make this easier, SELF talked to three experts on teen suicide about what they want parents to know.

1. Asking about suicide doesn't increase the risk of suicide.

Before we get into anything else, all three of the experts SELF talked to emphasized the importance of dispelling this harmful myth. "Parents are fearful that if they ask about suicide, they're going to cause their kid to be suicidal, and that's simply not the case," Jill Emanuele, Ph.D., senior director of the Mood Disorders Center at the Child Mind Institute, tells SELF.

Depending on your situation, it might feel like a scary or even overdramatic topic to raise, but it's better to be safe than sorry. "You have no risk in asking your child if they're thinking about hurting themselves," James Mazza, Ph.D., professor in the School Psychology Program at the University of Washington, tells SELF. "Your kid may say, 'Oh, I'd never do that. Don't be dramatic.' But you can say, 'I know, but sometimes people feel that way, and I don't want to be the parent who didn't ask.'"

We'll get into how and when to have these conversations later in the article, but if you take anything away from this story, let it be this.

2. Experts don't know exactly why the rate of teen suicide is rising.

There's no question that existing as a teen today is a very different experience than it was in previous generations. There's the whole social media thing, which studies have shown can negatively impact mental health (though others have shown no connection or even a positive one). Academic pressure may be at an all-time high too, thanks to decreasing acceptance rates and increasing tuition prices that drive a more competitive academic environment than ever. Emanuele also points out that there are theories that teens are a lot more isolated than they used to be, whether due to technology or a shift in culture.

It's also worth mentioning that there's a possibility the rate isn't going up as much as it seems. It may be that as it grows more culturally acceptable to talk about mental health-although stigma hasn't disappeared by any means-more people are reporting suicide deaths than before. (Stigma surrounding suicide typically leads to underreporting, according to the American Foundation for Suicide Prevention.) If that's the case, experts could have access to data that more accurately reflects how high the suicide rate has always been, says Emanuele.

All that said, there is currently no research that ties anything directly to the rising teen suicide rate. But it's helpful to keep these things in mind as you make an effort to understand what your teen might be going through.

3. Some teens don't show outward signs when they're suicidal, so you should also be aware of the risk factors.

While knowing the signs is extremely important, they're not a definitive litmus test for how your child is doing. "The challenge is that there are a lot of people who are struggling and suffering in silence," says Emanuele.

Some risk factors to keep in mind, according to the CDC:

A family history of suicide

A family history of child maltreatment

At least one previous suicide attempt

A history of mental illness, especially clinical depression

A history of substance abuse

Local suicide epidemics

A significant physical illness

Barriers to mental health support and treatment

Easy access to methods of suicide

We also know that LGBTQ youth are at higher risk of suicide than their straight and cis counterparts. Bullying is also a risk factor worth paying attention to from both sides. According to Emanuele, being a victim of bullying is a risk factor, but there's also some evidence that kids who are bullies may be at increased risk for suicidal behavior. Researchers have also theorized about a relationship between perfectionism and suicide risk.

4. There are many observable warning signs of suicide.

An easy way to remember the warning signs of suicide is with the acronym FACTS, which stands for Feelings, Actions, Changes, Threats, and Situations, Susan Tellone, R.N., clinical director of the Society for the Prevention of Teen Suicide (SPTS), tells SELF. It breaks down like this:

Feelings such as expressing emotions like hopelessness about the future and depression

Actions such as acting out and displaying impulsive or aggressive tendencies; giving away possessions

Changes such as withdrawing from friends, sleeping and eating more or less, or acting in worrisome ways that aren't typical for them

Threats such as talking about, writing about, or making plans for suicide

Situations such as going through loss, change, trouble at home, breakups, stressful situations at school, or other significant events that may trigger suicidal feelings

Of course, it's worth mentioning that there is a lot of overlap between signs of suicide risk and symptoms of mental illnesses like major depressive disorder. According to Emanuele, not everyone who is at risk for suicide is dealing with a depressive disorder, and not everyone with a depressive disorder is at risk for suicide. There's still a lot that experts don't know about suicide and suicide risk, but regardless, the signs above are indicative of a larger problem you should be paying attention to. Even if a depressed teen isn't suicidal, they still need your help.

5. There are important differences between "normal" teen moodiness and red flags.

You might be wondering, Wait, some of those signs sound like normal teenage behavior. What teen doesn't deal with stressful situations or occasionally get depressed or angry? It's true that teens will sometimes deal with sadness, stress, anger, and basically every other unpleasant kind of mood. But sometimes those emotions can signal larger issues.

Specifically, it's really important to pay attention to the duration of these signs, according to Emanuele. If you're noticing worrisome symptoms or behaviors that are persistent and don't go away after two weeks, that can be a red flag.

In fact, Tellone advises staying away from splitting hairs about whether something is "typical" teen behavior or something more serious. Attributing things to teen moodiness might lead to you miss some pretty important signs that your child isn't doing well-or it might lead to assuming it's not important enough to ask about. Even if it is typical teen behavior now, you want to open up the support channels and show your child that they can come to you if it ever becomes more than that.

6. One of the most important steps you can take is talking to your child regularly.

"You'd be surprised by how many people just don't talk to their kids," says Emanuele.

The good thing is that it's never too late to start. "The first couple of times [are] going to be awkward," says Mazza. "You can even say, 'Hey, we haven't been chatting much, and part of that is my fault for not putting in the effort. So I want to ask how you're doing.' The message is, 'I care about you and I don't know what's going on in your life. Can you please share with me?'"

Adolescents also tend to respond better to routine than you might think, says Tellone, so if you're having a hard time connecting with them, it could be worth scheduling regular time to catch up. (Maybe over something fun, like a pizza or game night.) Not only will that help you check in regularly, but knowing that time for connection is on the calendar can also make it easier for your kid to bring up hard topics.

7. If you're worried about your child's mental health, you can take action.

Remember when I said that the most important thing you can do when you're worried your child is at risk for suicide is to talk to them about it? Here's how.

First, prepare yourself emotionally and mentally to have this conversation.

According to Tellone, parents should do some honest self-reflection before bringing up suicide and mental health. Personal, religious, or moral biases against suicide or a strong fear of the topic can get in the way of coming at it from a place of compassion instead of judgment or alarm. Awareness of how these beliefs and attitudes might come through is a good place to start.

Second, ask yourself, Am I prepared to hear the answer to this question? Finding out that your child has been thinking about hurting themself can be terrifying and might lead you to say things that aren't exactly helpful. The other items on this list will help you develop a plan for responding.

Ask directly about self-harm and their emotions.

I know we went over this earlier, but it bears repeating: Don't beat around the bush. "If you're starting to get concerned, it's important that you come right out with the question," Tellone says. "For example, 'Are you feeling so sad that you're thinking about hurting yourself?' or, 'Are you feeling so sad that life is getting hard to live?'" The exact way you ask can differ depending on your relationship, but doing this in an empathetic, loving way is most important.

Keep checking in if your child isn't forthcoming the first time.

Even if you do everything you should to engage your kid, there's a not-insignificant chance that they'll still brush you off. "Keep asking," says Emanuele. "Don't just say, 'Well, they said they were fine!' and move on. You stick with it."

Listen more than you talk.

As parents, it's natural to want to jump into Advice Mode or Encouragement Mode when your child is sharing something hard. Resist those urges. "When your child starts to talk, listen," says Emanuele. "This is not a time for you to lecture. This is not a time for you to give information. Don't interrupt. Don't try to problem-solve. Validate them. Show them that you understand where they're coming from, even if you're freaking out inside."

Along those lines, here are more "don'ts" to keep in mind, especially if the conversation turns explicitly to suicide and suicidal ideation:

Don't provide cliches or passive optimism. Saying vague things like, "Don't worry, it gets better" or, "You'll be over it eventually" negates and belittles their experience.

Don't say you know what they're going through, because honestly, you don't. Instead, express empathy with something like, "It sounds like you're in so much pain right now. I can't imagine how hard that is."

Don't debate whether suicide is right, wrong, or selfish. Don't even make comments remotely to that effect. Remember those biases we want to check at the door?

Don't talk about the value of life or list the reasons you think they shouldn't feel this way. You might want to remind them of reasons they have for living, which is a compassionate instinct, but in the moment it will likely sound like, "How can you feel this way when you have all this good stuff going for you?" That's not how suicidal ideation works.

Ask other people in your child's life for information.

If you have a gut feeling that something is wrong but your child won't talk to you, Emanuele suggests checking in with the other adults in their life (like teachers and coaches) to see if they've noticed anything. You can also use this opportunity to mention your concerns and ask them to keep an eye out moving forward.

"Suicidal ideation happens when a child feels like they have a problem and they do not feel that they have the skills or the support to solve the problem," says Tellone. After listening thoroughly, your job as a parent is to convey that options for feeling better are out there and you'll support your kid along the way.

A big part of that is going over the possibility of seeking professional help. For someone dealing with suicidal ideation, therapy and/or medication can be crucial, but you don't want your teen to feel like you're forcing them into it. Go over the options together and let them have a say in the matter. For example, maybe they'd rather utilize a teletherapy service like BetterHelp or Talkspace instead of going into the office.

If you haven't taken the steps to do this and you're concerned about your child's mental health, now is certainly the time. But because easy access to lethal means of suicide is a risk factor in and of itself, it's a good idea to make sure your home is safeguarded no matter what, not just when you're worried.

Tellone recommends removing any firearms from your home completely. "I've heard too many stories from parents about how their gun was locked up and their children got to it anyway," she says. "Kids will find a way."

The same goes for any medication that someone might be able to use to overdose. Pay attention to the seemingly harmless medications you buy in bulk, too, such as over-the-counter pain relievers.

Only you know what might be dangerous in your home, but take the time to think about it and do what you can to keep your child safe.

Contact a crisis resource if need be.

If you're worried that your child is at risk of hurting themself, resources like the National Suicide Prevention Lifeline (1-800-273-8255) and the Crisis Text Line (text HOME to 741-741) can help diffuse the situation and offer advice. You can call or text yourself, encourage them to call or text, or do it together.

8. Keep in mind that this isn't about you.

It's common for parents of children who deal with suicidal ideation to question what they could've done better or differently or to wonder what else is going on with their child that they don't know about. You might find yourself asking, What did I do? Is this my fault?

According to Emanuele, this line of thinking is too simplified. "There are a lot of factors that go into why people start to think about ending their life, and it may not just be one thing," she says.

Even if your kid does tell you that you've screwed up somehow or that you've influenced how they currently feel, it's crucial to remember that you're allowed to make mistakes. "Parents aren't perfect," says Emanuele. "But self-blame is actually distracting from the problem at hand. Your kid needs help, and that's your focus."

That said, it's still important that you have your own outlets to explore those feelings. It's not a conversation you should be having with your teen, at least not at this stage when your focus should be on getting them the help they need. "If you need help dealing with the distress you're feeling, get therapy yourself or turn to family or friends for support," says Emanuele. (As long as you trust that said family and friends won't go rogue and talk to your child in a stigmatizing or unhelpful way.) "Have others support you in supporting your child."

9. Lastly, here are some resources for your child and yourself.

It's good to equip your kid with tools that can help, especially if you're worried that they won't tell you when they need help. But don't be afraid to utilize resources too. While your child might be the one who is suffering, it's important to look after your own mental health-both for your own sake and so you can be an effective support system for them.

Some of these tools are to help you find resources like therapists, support groups, or peer support, while others might help you manage what you may be feeling:

Psychology Today therapist finder allows you to sort by distance, specialty, and insurance, among other filters. (You can also read SELF's guide to finding an affordable therapist here.)

7Cups is an online emotional health service with self-help guides, self-care ideas, and one-on-one chatting with trained listeners.

The Trevor Project is home to various mental health resources for LGBTQ young people.

NAMI HelpLine can connect you and/or your teen with a volunteer who can answer questions about mental health issues.

PsyberGuide helps people find the best software and apps for managing mental health.

MentalHealth.gov offers information on how to get help, support someone you love, or start a dialogue about mental health in your community (also available in Spanish).

If you're thinking about suicide or just need someone to talk to right now, you can get support by calling the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or by texting HOME to 741-741, the Crisis Text Line. And here is a list of international suicide helplines if you're outside the United States. Related:

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Parents, You Need to Talk to Your Kids About Suicide. Here's How.

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Related Condition Centers Talking about it can be hard, but it's so important. As someone who struggled with suicidal ideation as a teen, I remember how it felt like a dirty little secret-and how little support I had.

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When things are hard in the classroom, it's tempting to blame the kids, their parents, or the communities they come from, but those are not things an individual teacher can control. Building personal resilience is about responding to adversity, to setbacks, to getting knocked down. The resilience comes from learning something in those moments.

"Resilience is about thriving and not just surviving," Aguilar said. "Because I think there are places where people use the term and they're just talking about survival. But resilience is when you experience a challenge or a setback and you come out stronger than you were before, having learned something new."

After decades of teaching and coaching, Aguilar has written a book that joins her years of experience in classrooms around the country with the research about resilience. Called Onward: Cultivating Emotional Resilience in Educators, the book offers practical ways educators can build their resilience mapped to months of the year, and the ebbs and flows of energy that dictate school life.

But this isn't the average self-help book. Aguilar, like many educators, sees real issues in the systems and structures of education. But she also knows teachers are too overwhelmed and tired to pick their eyes up and see the bigger issues. Aguilar believes that building personal resilience leads to action. In Onward she writes:

"Here is my theory of action: If we boost our individual resilience, then we will have more energy to address organizational and systemic conditions -- to elect officials who will fund public education, organize against policies that dehumanize educators, and push back on punitive assessment policies and scripted curriculum that turn teachers into robots and students into depositories to be filled. With more energy and more resilience, we can build and strengthen the kinds of communities in which we can thrive, where we can engage in professional development that allows us to reflect on our own biases, and where we can observe and learn from each other."

As a coach, Aguilar is action oriented. She wanted to give educators things they can do, habits they can form to boost their resilience. The current research isn't framed that way; it describes dispositions, which are more like attitudes or ways of being. Resilient people tend towards optimism, for example, and they're curious and courageous.

Aguilar has taken that research and developed a sequence of reflections and activities that teachers can do throughout the year to build habits that cultivate a resilient disposition. She thinks they will be most powerful if educators do them together.
1. Know Yourself
"You'd need to do this in the summer when you have a bit of a break," Aguilar said. She recommends June, when school has ended and teachers have had a little time to recover. In June many educators are reflecting on the end of the year anyway, so why not go a bit deeper to think through the values, socio-political identity, strengths and personality traits that define each of us?

In Onward, Aguilar writes: "Self-knowledge helps us to be more confident about our actions and clear on our decisions. It's what enables us to show up in a way we want to show up."

This is foundational work. Everything else depends on self-knowledge because so much of how one reacts to a situation is rooted in experience, context, identity and perception.
2. Emotions
There's been an increased focus on social and emotional learning for kids in classrooms, but much less attention is paid to helping teachers manage the array of emotions that come up over the course of a school day. Just because teachers are adults doesn't mean they've had practice recognizing, naming and reckoning with their emotions.

"Embedded within emotional resilience is emotional intelligence," Aguilar said. "And I find so many adults have never had an opportunity to really learn about emotions."

In the workbook that accompanies Onward, Aguilar offers activities that walk educators through a process of thinking through what an emotion is, how to understand their own, and offers language to talk about emotion. This is reflective work, perfect for July when teachers have a little distance from the classroom.
3. Tell Empowering Stories
"It really might be the most important habit, but you can't practice it well without understanding your emotions, so they all connect," Aguilar said.

The stories educators tell dictate the experience they'll have, she said. The story could be about kids and parents that don't value education. Or, it could be that teaching in a particular context is hard because the political and economic systems aren't set up to support this community. "You can tell really different stories about the same thing," Aguilar said.

She has found that educators often get excited about this habit: "When they realize they have the power to reframe a situation, it's actually very empowering. It can be a big relief to people."

It can also open up avenues of creativity. Sometimes teachers can feel so overwhelmed that it's difficult to see a situation in any other way than the one they're already locked into. Aguilar has seen this time and again when coaching. She often asks teachers and leaders probing questions to shift the way they see the constraints and structures within which they are working.

"I think it's really critical because so many educators almost can't imagine how things could be better," she said.
4. Build Community
Aguilar imagines this habit tied to September when school is back in session and people have energy and hope for the year ahead. "One of the visions I had when I wrote this book was that teachers would read this book together," she said. "They'd talk about it together, and they'd do the workbook activities together."

And in doing so, they'd deepen relationships with one another. Those relationships can be a crucial source of resilience when setbacks occur.
5. Be Here Now
This section draws from mindfulness practices and their power to ground educators in the present moment. Mindfulness in schools has exploded over the past few years, especially on the West Coast where Aguilar lives. So she was surprised when readers from elsewhere in the country had never heard of it.

"The ability to be present in the moment allows you to be clear on what story you're telling," Aguilar said. "It's really hard to tell powerful stories if you're not able to recognize when you're telling a story."

She equates this set of strategies with October because towards the end of this month things can start to get hard for educators. It's a time for deep breaths, creating some metacognitive space before reacting to students, and taking care of oneself.
6. Take Care of Yourself
November is often a hard month for teachers. The excitement from the beginning of the year has worn off, the days are getting shorter and darker, and exhaustion becomes a factor. Most educators have probably heard they should take care of themselves and yet many still don't. Aguilar uses this section to help educators interrogate why this might be.

"Teaching is so dominated by women and there's so much messaging to women about self care, but they also get messages about giving to everyone else," Aguilar said. Sometimes deep values come up about who deserves rest and what it means to prove one's worth.

"It's intended to help people untangle what's going on," Aguilar said.

7. Focus on the Bright Spots

"This is an opportunity to focus on strengths and assets and skills and shine a light on what's working," Aguilar said. Again, in the heart of winter it can be easy to let a natural negativity bias take over. It requires active work to push back against those thoughts and create structures to notice the progress students have made and the many beautiful things happening in schools and classrooms.

"Resilience has a lot to do with how often we experience what is thought about as positive emotions. That is in part how we get to the thriving part of the definition, and not just the surviving," Aguilar said.

It's easy to dwell on the negative, the lesson plan gone awry, the one kid who won't engage. But Aguilar says that unless educators actively work to refill the reserves of satisfaction, meaning and connection it's hard to keep going.
8. Cultivate Compassion
In January it might seem like teachers would return from a vacation and feel rested, ready to jump back into the classroom with energy. That's partly true, but Aguilar has also found that the time off can decrease people's tolerance for stuff they have to deal with in the classroom. They've felt like a normal human for a few weeks and they don't want to go back. That's why she suggests cultivating compassion for oneself, colleagues and students during this time.

"Recognize that if you're cultivating compassion you can have greater understanding with a student who lost their temper and did whatever they did, and you can respond differently in that moment."
9. Be A Learner
Learning is something resilient people do. They take away a lesson from hardships they experience.

"One of the most useful prompts for someone when they're in a challenging situation is to ask, is there any possibility I could learn something from this experience?" They don't even have to know what they're learning yet, but just asking if there's something that will reveal itself later can make it feel possible to get through.

Aguilar used the example of her mother's battle with cancer and ultimate death. In the moment, she felt horrible and couldn't see her way out of the pain and grief she was experiencing.

"When I think back to that time, now I can see there were things that I learned," Aguilar said. "But it's definitely not a situation in which I would say that was a great gift because I learned this or that. Without question I would rather have my mother back."

In those difficult moments, it helps to acknowledge and value the emotions someone is feeling. Without that acknowledgement people don't feel heard and they can get stuck in the negative emotions.
10. Play and Create
There's a lot of research showing that play is fundamental to learning and to human nature. Yet it's often stripped from schools. Play also helps people to be creative, deal with stress and solve problems, all qualities connected to a common disposition of resilient people -- courage.

11. Ride the Wave of Change

"Springtime is when things start changing in schools," Aguilar said. "Spring time can be really unsettling and difficult." New initiatives are launched, hiring happens, teaching assignments change, it can be hard for teachers and deplete their energy.

Aguilar recommends that teachers engage with change, but think carefully about whether the change is within their sphere of influence. Making that distinction can help an educator decide where to spend their energy.

"We all have a finite amount of energy and we can make decisions about how and where we use it. Change gives us an opportunity to reflect on that."
12 Celebrate and Appreciate
"We need to end the year on a note of celebration," Aguilar said. Taking time to recognize growth and show gratitude offers a different perspective on what can be a tiring time of year. Many schools have end of year rituals to celebrate the achievements of the year, but personal rituals, as well as class rituals can also be powerful.

Aguilar has no illusions that teachers will pick up this book, do a few exercises, and magically become more resilient. She knows these qualities require cultivation and time, but from personal experience she also knows they work. She now has a daily gratitude practice, and she finds herself repeating over and over again the activities that help her deconstruct her thoughts and beliefs to gain a deeper understanding of her values.

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12 Ways Teachers Can Build Resilience So They Can Make Systemic Change | KQED

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When things are hard in the classroom, it's tempting to blame the kids, their parents, or the communities they come from, but those are not things an individual teacher can control. Building personal resilience is about responding to adversity, to setbacks, to getting knocked down. The resilience comes from learning something in those moments.

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Reaching Students with Emotional Disturbances 

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Reaching Students with Emotional Disturbances 

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Building Resiliency

The encouraging news is that young people have the innate capacity to bounce back from adversity. You can create an environment that feels safe and connected by helping students understand how negative emotions hijack our learning. I am currently teaching young adolescents, many with significant emotional and behavioral challenges. To facilitate a predictable and consistent environment, we create class guidelines, procedures, and engagement systems so each student knows the class expectations and routines. Here are four strategies that have really worked with my students.

1. Brain-Based Learning Centers

In my classroom, students can go to one corner to recharge and calm down from negative emotion. This corner is called the "amygdala first aid station" as the amygdala is the fight/flight/freeze center in the brain. Students needing a quiet area with tables to study or to complete work can go to the "hippocampus area," named after the part of the brain that memorizes and connects new information to what we already know. Finally, the "prefrontal cortex area"-named after the problem-solving center of the brain-includes tables and collaborative spaces for students who are ready to discuss projects or ideas, watch documentaries, and collaborate. When we teach students about their brain functions and connect them to specific activities, they become more self-aware and fluent in their own cognitive processes. Check out my post " Brain Labs: A Place to Enliven Learning " for a helpful resource as you think about how to design predictable and safe spaces to learn, socialize, and recharge.

2. Personalized Check-In Notes

If students are in a negative brain state, we must regulate behaviors before any learning will occur. The best way I have found is to first attend to their emotional temperature, to let them know I am present and available no matter the negative behaviors. To connect with and create consistency for a diverse array of students with different needs, I use waiter and prescription pads as a way of personalizing communication throughout the day. These are particularly effective for reaching those students who don't respond to spoken communication. Share notes, small goals, affirmations, and requests to maintain individualized consistent connections. Once the task or goal has been ordered and received, you can create fun ways to make a payment or incentivize.

3. Structured Emotional Support

The "2x10 Strategy" developed by psychologist Raymond Wlodkowski is an excellent brain-aligned strategy to implement with our most challenging students. For two minutes each day, 10 days in a row, teachers have a personal conversation-either written or in-person-with a student about anything the student is interested in, as long as the conversation is G-rated. Wlodkowski found an 85 percent improvement in that one student's behavior. In addition, he found that the behavior of all the other students in the class improved.

4. Locked Journal for Safe Self-Expression

When we write out our thoughts and feelings, we clear space in the frontal lobes for positive emotion and higher cognitive processes. A locked journal can give students a safe place to release anxiety while maintaining control over their own privacy. If a student chooses to write or draw their feelings and thoughts through this format, we discuss how this journal can become a trusted friend, and how they might be able to use it to prototype creative forms of expression to be shared under the appropriate circumstances.

Delivery Matters

In working with students, your method of delivery will make a big difference. Students who are emotionally shut down and unresponsive to words may respond better with written notes. You can create note cards for directions, choices, or explanations, and give students the opportunity to write their responses rather than speak. All behavior is communication. Although I might not get a verbal response from a student, I always keep trying with the option of sharing notes and letters.

What I am learning every day-even as a seasoned educator-is that I must regulate behaviors before any learning will occur, and the strategies above have helped immeasurably. Students who struggle with emotional disturbances are some of our most vulnerable, but when we can create predictable and consistent supports for them, their inner resilience can shine.

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Reaching Students With Emotional Disturbances

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A seasoned educator shares four ideas for supporting students who have suffered emotional trauma.

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Toolkit for “Being There for Nonbinary Youth”

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This toolkit synthesizes the key tips and takeaways from “Being There for Nonbinary Youth” and offers online resources for supporting transgender students.

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Suicide: The Conversation We Should Have With Our Kids

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One of the best things we can do is give our young people the power to talk about mental health issues and topics as challenging as suicide without shutting the door. Even if your child is doing well, this is a powerful opportunity to help your child see it is okay to be emotionally open and could help them talk openly with friends.

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The Movement for Children’s Mental Health

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On Our Sleeves is the national movement to break stigmas around children’s mental health. Our mission is to provide free mental health educational resources to every community in America to educate families and empower advocates.

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Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm?

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Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm?

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Joiner

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teen suicide prevention , Chicago based

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Elyssa's Mission - Creating A Safer Today For Our Youth®

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"Like last time, this program helped the lives of students immediately. We also had a student later in the week come forward with self-harm concerns about a friend. They directly quoted ACT as their motivation. So I am also seeing students retain the knowledge from the lesson and reflect on its meaning.

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Youth-Led Film Contest re: Mental Health Awareness and SI

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If you are experiencing an emotional crisis, are thinking about suicide or are concerned about a friend call the National Suicide Prevention Lifeline immediately: 1-800-273-8255 This is a free 24-hour hotline.

Directing Change is part of statewide efforts to prevent suicide, reduce stigma and discrimination related to mental illness, and to promote the mental health and wellness of students. These initiatives are funded by counties through the Mental Health Services Act (Prop 63) and administered by the California Mental Health Services Authority (CalMHSA), an organization of county governments working to improve mental health outcomes for individuals, families and communities.

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﻿ If you are experiencing an emotional crisis, are thinking about suicide or are concerned about a friend call the National Suicide Prevention Lifeline immediately: 1-800-273-8255 This is a free 24-hour hotline. Directing Change is part of statewide efforts to prevent suicide, reduce stigma and discrimination related to mental illness, and to promote the mental health and wellness of students.