and peer “natural helpers,” support and skill building groups for at-risk groups in the population, and enhanced accessible crisis services and referral sources.

Indicated strategies address specific high-risk individuals within the population—those evidencing early signs of suicide potential. Programs are designed and delivered in groups or individually to reduce risk factors and increase protective factors. At this level, programs include skill-building support groups in high schools and colleges, parent support training programs, case management for individual high-risk youth at school, and referral sources for crisis intervention and treatment.

UNIVERSAL PREVENTIONS

Using health promotion strategies to combat symptoms of mental illness, including suicidality, represents a primary aspect of many universal suicide prevention programs. Although the field has traditionally separated health promotion from prevention (IOM, 1994), preventionists in the United States and abroad have increasingly turned to mental health promotion as a means of universal prevention (Beautrais, 1998; Cowen, 1994; Durlak, 2000; Waring et al., 2000). Reviews (Cowen, 1994; NRC, 2002) and at least one meta-analysis (Durlak, 2000) demonstrate that school-based programs employing such a health promotion approach can effectively prevent and/or reduce suicide risk factors and correlates like adolescent pregnancy, externalizing disorders (such as delinquency and substance abuse), and depression. These programs also promote protective factors against suicide including: self-efficacy, interpersonal problem solving, self esteem, and social support (see Chapters 3 and 6). Furthermore, throughout the 1990s, the World Health Organization developed evidence-based policies and recommendations for how schools can effectively engage in health promotion using a four-level model (see, WHO, 2002). The WHO model promotes universal prevention, targeting environmental conditions and mental health education for all students, as well as selective and indicated prevention, providing psychosocial interventions and professional treatment for those with mental illness or at significant risk (see also Waring et al., 2000; WHO, 1999; 2000a). As mentioned in Chapter 3, the U.S. Surgeon General (PHS, 2001), the United Nations (1996), and the World Health Organization (1999) have endorsed promoting mental health/resiliency as part of universal suicide reduction strategies.

Population-based prevention programs with a school or community focus have an important advantage over those aimed at individuals. There is usually a high participation rate in such programs because all students are exposed, for instance, to a teacher’s classroom management practices



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