including improved analytic tools and sophisticated models for measuring change over time in prevention trials (Brown and Liao, 1999).

In contrast to clinical approaches that explore the history and health conditions leading to suicide in the individual, the public health approach to suicide prevention focuses on identifying broader patterns of suicide and suicidal behavior throughout a group or population. The public health approach to suicide prevention is also reflected in an organized five-step process that has been developed for ensuring the effectiveness of preventive efforts (PHS, 2001:11). This chapter will describe the current public health preventive framework and then review some of the interventions for preventing suicide at each level. The focus will be primarily on school-based programs. As with all other behavioral interventions, the best effects are most likely to be achieved with multidimensional interventions (IOM, 2001), given the overlapping nature of risk and protective factors across domains of influence. The chapter then explores examples of programs targeting specific populations and concludes with an analysis of an integrated approach for reducing the incidence of suicide in the broad population.

FRAMEWORK FOR PREVENTION

The prevailing prevention model in the interdisciplinary field of prevention science is the Universal, Selective, and Indicated (USI) prevention model. This USI model focuses attention on defined populations—from everyone in the population, to specific at-risk groups, to specific high-risk individuals—i.e., three population groups for whom the designed interventions are deemed optimal for achieving the unique goals of each prevention type.

Universal strategies or initiatives address an entire population (the nation, state, local county or community, school or neighborhood). These prevention programs are designed to influence everyone, reducing suicide risk though removing barriers to care, enhancing knowledge of what to do and say to help suicidal individuals, increasing access to help, and strengthening protective processes like social support and coping skills. Universal interventions include programs such as public education campaigns, school-based “suicide awareness” programs, means restriction, education programs for the media on reporting practices related to suicide, and school-based crisis response plans and teams.

Selective strategies address subsets of the total population, focusing on at-risk groups that have a greater probability of becoming suicidal. Selective prevention strategies aim to prevent the onset of suicidal behaviors among specific subpopulations. This level of prevention includes screening programs, gatekeeper training for “frontline” adult caregivers



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