Paper Outline

Suicide_clusters_in_young_peop.pdf

Home >Nursing homework help >Paper Outline

Research Trends

Suicide Clusters in Young People Evidence for the Effectiveness of Postvention Strategies

Georgina R. Cox1, Jo Robinson1, Michelle Williamson2, Anne Lockley2, Yee Tak Derek Cheung2, and Jane Pirkis2

1Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, Australia, 2Centre for Health Policy, Programs & Economics, Melbourne School of Population Health,

University of Melbourne, Australia

Abstract. Background: Suicide clusters have commonly been documented in adolescents and young people. Aims: The current review conducts a literature search in order to identify and evaluate postvention strategies that have been employed in response to suicide clusters in young people. Methods: Online databases, gray literature, and Google were searched for relevant articles relating to postvention interventions following a suicide cluster in young people. Results: Few studies have formally documented response strategies to a suicide cluster in young people, and at present only one has been longitudinally evaluated. However, a number of strategies show promise, including: developing a community response plan; educational/psychological debriefings; providing both individual and group counseling to affected peers; screening high risk individuals; responsible media reporting of suicide clusters; and promotion of health recovery within the community to prevent further suicides. Conclusions: There is a gap in formal evidence-based guidelines detailing appropriate post- vention response strategies to suicide clusters in young people. The low-frequency nature of suicide clusters means that long-term systematic evaluation of response strategies is problematic. However, some broader suicide prevention strategies could help to inform future suicide cluster postvention responses.

Keywords: suicide clusters, young people, postvention response

A suicide cluster can be defined as “a group of suicides or suicide attempts, or both, that occur closer together in time and space than would normally be expected on the basis of statistical prediction/or community expectation” (Centers for Disease Control [CDC], 1988). Clusters can be split into two distinct groups: point clusters and mass clusters. Point clusters are close in both space and time, occur in small communities, and involve an increase in suicides above a baseline rate observed in the community and surrounding area. Mass clusters involve a temporary increase in suicides across a whole population (Mesoudi, 2009), and have been documented following suicides by high-profile celebrities or political figures which have received considerable media attention (Chen et al., 2010). This literature review outlines the evidence relating to the containment and future preven- tion of clusters and focuses solely on point clusters.

The mechanisms underlying suicide clusters are unclear, although it has been proposed that they may result from a process of “contagion,” whereby one person’s suicide in- fluences another person to either attempt or to complete suicide (O’Carroll & Potter, 1994). Suicide clusters have been most commonly observed in adolescents and young people under the age of 25 years (Hazell, 1993); this pop- ulation is the main focus of this review. However, it should

be noted that suicide clusters have also been observed in other high-risk groups, including indigenous communities (Hanssens & Hanssens, 2007; Wilkie, Macdonald, & Hil- dahl, 1998), prisoners (McKenzie & Keane, 2007), and people with mental illness (McKenzie et al., 2005), partic- ularly within inpatient settings (Haw, 1994).

Youth suicide rates have gradually increased, and this age group is now at the highest risk of suicide in one third of all countries (World Health Organization [WHO], 2010). At least 100,000 adolescents complete suicide every year (WHO, 2002); worldwide suicide ranks in the top five causes of mortality among 15- to 19-year-olds (WHO, 2000). In adolescents and young people, it has been esti- mated that between 1% and 5% of all suicides are part of a cluster (Gould, Wallenstein, & Kleinman, 1987). Further- more, contagion is thought to be a key factor in 60% of all suicides in this population (Davidson, Rosenberg, Mercy, Franklin, & Simmons, 1989). The death of a peer can be a traumatic experience for a young person, and it is estimated that for every suicide, three friends are strongly affected (Mauk & Gibson, 1994). Although the exact process by which suicide contagion operates is still unclear, suicidal behavior in peers may act as a risk factor to exacerbate underlying psychiatric disturbances in young people. For

T hi

s do

cu m

en t i

s co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

tio n

or o

ne o

f i ts

a lli

ed p

ub lis

he rs

. T

hi s

ar tic

le is

in te

nd ed

s ol

el y

fo r t

he p

er so

na l u

se o

f t he

in di

vi du

al u

se r a

nd is

n ot

to b

e di

ss em

in at

ed b

ro ad

ly .

example, the presence of suicidal ideation in young people has been estimated to lie between 20% and 30% (Evans, Hawton, Rodham, & Deeks, 2005; Nock et al., 2008), which may act as an additional risk factor for contagion to occur. Furthermore, adolescent peers of suicide attempters and completers report significantly more suicidal behavior compared to those who have not been exposed to the sui- cidal act of a peer (Ho, Leung, Hung, Lee, & Tang, 2000). Young people also appear to be particularly susceptible to contagion effects brought about by certain types of media reporting of suicide (Gould, Jamieson, & Romer, 2003).

It is difficult to predict exactly when and where a suicide cluster will occur, and as a result, there is a need to develop a set of postvention strategies that can be implemented fol- lowing the identification of such a suicide cluster. One of the most widely quoted documents concerning the manage- ment of suicide clusters is the CDC community plan for the prevention and containment of suicide clusters (CDC, 1988). The report was originally developed to assist com- munity leaders from a variety of backgrounds, including public health, mental health, and education, implement pre- vention, and containment strategies to manage a suicide cluster. The community plan focuses strongly on commu- nities developing a response plan that can be implemented before the onset of a suicide cluster, and on postvention responses once a cluster has occurred.

The current literature review conducts a search of the academic and gray literature on suicide clusters that have been documented in young people. Key postvention strat- egies implemented in response to a suicide cluster in this population were identified, and evidence for their effective- ness is discussed.

Method

Medline, Psychinfo, and Embase were searched using search strings including the following keywords; “suicid*” AND (“cluster” OR “epidemic” or “copycat” OR “conta- gion” OR “multiple” OR “postvention”). Hand searching of references and specialist journals was also conducted. The above search terms were also used in the search engine “Google” in order to identify gray literature.

Results

A total of 155 articles were retrieved in the database search, the majority of which related either to the identification of clusters in high-risk groups or to the mechanisms underly- ing why suicide clusters occur.

The literature search identified two publications that have formally documented postvention strategies em- ployed following a suicide cluster in young people within a community setting (Askland, Sonnenfeld, & Crosby, 2003; Hacker, Collins, Gross-Young, Almeida, & Burke, 2008). An additional three publications detailed more lim- ited and specific strategies that have been employed in a school setting either following a suicide cluster, or where individuals were identified as being at risk of imitative sui- cidal behavior (Brent et al., 1993; Hazell, 1991; Poijula, Wahlberg, & Dyregrov, 2001).

There was consistency in the type of postvention strate- gies adopted by the wider community and in schools, in order to “contain a cluster” once it had begun to evolve. These strategies tended to involve six main approaches: development of a community response plan; education- al/psychological debriefings; providing both individual and group counseling to affected peers; screening of high- risk individuals; responsible media reporting of the suicide cluster; and promotion of health recovery within the com- munity to prevent future suicides (see Table 1).

Development of a Community Response Plan

A response plan has tended to involve members of commu- nity-based trauma teams or networks, and, ultimately, a “re- sponse team” has been formed. The role of this team has been to investigate the events that have affected the com- munity, be on the frontline to respond to young people who show signs of distress as a result of a suicide, and imple- ment postvention strategies such as improving media rela- tionships or setting up focus groups for survival victims. Teams have commonly consisted of teachers, mental health professionals, parents, representatives from a local crisis center, law enforcement, and liaison members from the lo- cal media and community (Hacker et al., 2008). Training

Table 1. Common postvention strategies employed following a suicide cluster in young people

Study Development of a community response plan

Educational/psy- chological debriefings

Counseling for high-risk individuals

Screening of high-risk individuals

Promotion of health recovery and prevention

Responsible media reporting

Brent et al. (1989) ×

Hazell (1991) ×

Poijula et al. (2001) ×

Askland et al. (2003) × × × ×

Hacker et al. (2008) × × × × ×

G. R. Cox et al.: Suicide Clusters in Young People 209

T hi

s do

cu m

en t i

s co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

tio n

or o

ne o

f i ts

a lli

ed p

ub lis

he rs

. T

hi s

ar tic

le is

in te

nd ed

s ol

el y

fo r t

he p

er so

na l u

se o

f t he

in di

vi du

al u

se r a

nd is

n ot

to b

e di

ss em

in at

ed b

ro ad

ly .

for team members (such as posttraumatic stress manage- ment) is often required in order for individuals to deal with the crisis in an appropriate manner (Hacker et al., 2008). A collaborative approach, using existing partnerships within the community, has been highlighted as essential in imple- menting an effective trauma team and network (Hacker et al., 2008).

Evidence for the effectiveness of response plans was predominantly descriptive in nature and lacking in long- term follow-up. Askland et al. (2003) developed a “real- time” community response plan following a suicide cluster involving adolescents in a rural community of Maine, USA. Key strategies included educational debriefings giv- ing young people information about suicide; suicide pre- vention and coping strategies; individual screening of young people identified as being at-risk for suicide (by their parents, other students, or school staff); and crisis evalua- tion, whereby young people who were felt to be at imme- diate high risk of self-harm or suicide were referred to the appropriate mental health service (which included outpa- tient services, crisis stabilization services, or psychiatric hospitalization). The collaboration that occurred between law enforcement, school staff, and health services (both public and private) allowed the community to gather infor- mation about potential high-risk individuals, carry out screening in schools in order to facilitate referral to mental health services, and offer suicide awareness and prevention training to key stakeholders. Overall, 39 individuals were identified as needing intervention for potential suicidal be- havior and were referred in a streamlined manner to the relevant services.

Hacker et al. (2008) reported on the implementation of a community response to a suicide cluster primarily via drug overdose in young people in 2002; this was the only study to include a long-term follow-up on the effectiveness of their response plan. After implementing their response plan, they recorded only one death by suicide which was unrelated to the previous cases of suicide contagion. In ad- dition, since 2004, hospital discharges for nonfatal self- harm and nonfatal opiate related discharges have steadily decreased.

The CDC guidelines recommend developing a response plan before a cluster occurs, but timely implementation of a response plan following a suicide cluster in a school set- ting has been associated with fewer students showing symptoms of PTSD (Poijula et al., 2001). This underscores the importance in making a response plan a possible strat- egy to consider when managing an evolving suicide cluster.

Educational/Psychological Debriefings

The death of a young person can have a deep and far-reach- ing effect on individuals close to the deceased, other young people in their school, and the community in general. After a suicide cluster has been identified, schools have raised the awareness of the issue in a sensitive and timely manner.

Information regarding suicide and suicide risk has been de- livered either to a whole school, in order to raise awareness universally, or to high-risk individuals there. Askland et al. (2003) disseminated information about suicide, suicide prevention, and coping strategies to school students over 3 days, in 1.5 h small group educational debriefing sessions, led by trained clinicians. No evaluation, however, was car- ried out regarding the effectiveness of the sessions.

Individual and Group Counseling for Affected Peers

Friends of a young person who dies by suicide experience a range of emotions, including guilt for “missing the signs” of their friend’s distress, or anger with themselves or others for not having prevented it. It has been suggested that adolescent suicide is closely related to posttraumatic stress (PTSD), major depression, and suicidal ideation in peers following exposure to a suicide (Brent et al., 1993; Poijula et al., 2001). Crisis counseling sessions have been highlighted as important in addressing the needs of these high-risk individuals, and they have been employed in a postvention strategy following suicide clusters. Group counseling sessions for young people affected by the sui- cide of a peer have centered around four themes: addressing guilt and responsibility following the death of a friend; dif- ficulties in interpreting the signs of suicidal behavior; rec- ognizing reactions to grief; and directing adolescents to- ward appropriate services for help should they feel suicidal themselves (Hazell, 1991). Counseling sessions have also been delivered in schools to both students and parents, in collaboration with local mental health services, and com- munity-based trauma teams (Hacker et al., 2008). Howev- er, the effectiveness of these sessions was not evaluated.

Screening High-Risk Individuals

The CDC recommended, and Hazell (1993) highlighted, the fact that risk assessment and screening of high-risk in- dividuals is an important postvention response strategy to a suicide cluster. A number of young people can be classi- fied as high risk following the suicide of someone in their community including friends or acquaintances of the suicide victim, individuals with an existing psychiatric dis- order, and/or young people who have recently attempted suicide themselves. Screening has taken place following a suicide cluster for a number of risk factors, most notably suicidal behavior including recent attempt or ideation (Brent et al., 1989) and symptoms of PTSD (Poijula et al., 2001).

Schools play an important role in the response to suicide clusters in young people and have the potential to play a pivotal role in implementing screening programs for high- risk individuals. Following a suicide cluster among teenag-

210 G. R. Cox et al.: Suicide Clusters in Young People

T hi

s do

cu m

en t i

s co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

tio n

or o

ne o

f i ts

a lli

ed p

ub lis

he rs

. T

hi s

ar tic

le is

in te

nd ed

s ol

el y

fo r t

he p

er so

na l u

se o

f t he

in di

vi du

al u

se r a

nd is

n ot

to b

e di

ss em

in at

ed b

ro ad

ly .

ers, 33% of the school population screened were identified as “at risk.” Furthermore, 28% of this screened population reported current or recent suicidal ideation – and of these individuals, 17% reported a suicide attempt occurring with- in the previous 4 weeks. Furthermore, following screening for PTSD symptoms in three secondary schools where teenage suicides had occurred revealed that friends of the suicide victims were more likely to be in the high-risk group showing PTSD symptoms compared with those who were not friends with the victims (Poijula et al., 2001).

Individuals at high risk of suicidal behavior have also been identified through a number of other sources. Parents play a role in recognizing signs of distress in their offspring, especially after the death of someone close, and trauma response teams have acted to increase awareness of suicide “warning signs” in the community. Professionals that come into contact with young people such as school staff – in- cluding teachers, school guidance counselors, or school nurses – and health professionals are also key individuals in identifying young people at risk of suicidal behavior. Although GPs have been identified as playing a key role in helping families, friends, and those close to the deceased after a teenage suicide, and as having the potential to iden- tify high-risk individuals (Johansson, Lindqvist, & Eriks- son, 2006), no formal evaluation regarding the effective- ness of GPs in identifying young people at risk of suicide following a suicide cluster has been reported.

Responsible Media Reporting of Suicide Clusters

Literature retrieved from the database search highlighted that suicide clusters often receive a large volume of media attention. Young people are thought to be particularly sus- ceptible to suicide contagion effects as a product of certain types of media reporting (Gould, Jamieson et al., 2003), so that inappropriate media attention may contribute to the cluster continuing.

Previous postvention strategies included the media as part of the development of a community response. This al- lowed information to be disseminated and reported on in a sensitive and responsible manner. For example, members of community trauma teams met with the local newspaper editor to clarify CDC recommendations on reporting sui- cide clusters (Hacker et al., 2008). As a result, the deaths of the young people who were part of the suicide cluster were reported in a nonsensational manner.

It has also been suggested that media reporting of suicide clusters should be kept to a minimum, due to the risk of imitative suicide in the community. A body of evidence suggests that irresponsible reporting of suicide in the media can potentially lead to “copycat” suicides and could thus act as a tipping point upon which a cluster could begin or be exacerbated. (Pirkis & Blood, 2001).

Promotion of Health Recovery Within the Community to Prevent Further Suicides

Although crisis management of a suicide cluster appears to be imperative, communities in which suicide clusters have occurred highlight a number of long-term steps that must also be taken in order to promote the recovery of the com- munity. Poijula et al. (2001) found that, 6 months after a suicide cluster had occurred in a school, 30% of the class- mates of the suicide victim still continued to show signs of PTSD, and 9.8% showed a high level of grief reaction. This highlights the need to implement long-term programs to prevent suicide in the population within which the suicide cluster occurred.

Whole school screening and ongoing surveillance of sui- cidal behavior has contributed to the development of a community response plan and has aided the recovery of a community by identifying risk factors and risk behaviors that may have contributed to the suicide cluster. For exam- ple, Hacker et al. (2008) identified poor social functioning and school adjustment as risk factors for suicide attempts in the community. They also reported that surveillance of suicidal behavior in the community had been collected via surveys, death certificates, hospital discharge data, and 911 calls.

Prevention training for community stakeholders and gatekeepers has been given in order to increase awareness of the warning signs of suicide and to aid early intervention (Hacker et al., 2008). For example, teachers, parents, and mental health professionals were trained in posttraumatic stress management, which acted not only to provide key community members skills essential to deal with the cur- rent suicide cluster, but also equipped them with the knowl- edge and strategies to be implemented in the future.

The anniversaries of suicide deaths can also unearth a range of difficult emotions for the family and peers. In the long term, suicide prevention articles could be published in the local media around the anniversary of a youth death to promote timely help-seeking and awareness (Hacker et al., 2008).

Discussion

Despite young people being a high-risk population in which suicide clusters occur, the current review highlighted the limited number of studies published on postvention strategies in response to suicide clusters in this group. At present, two community case studies have been published illustrating that the CDC guidelines are helpful in allowing a community to contain, manage, and curtail a suicide clus- ter specifically among young people (Askland et al., 2003; Hacker et al., 2008). However, only one evaluated the long- term gain from postvention strategies (over the period 2002 to 2006; Hacker et al., 2008), while the other reported on

G. R. Cox et al.: Suicide Clusters in Young People 211

T hi

s do

cu m

en t i

s co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

tio n

or o

ne o

f i ts

a lli

ed p

ub lis

he rs

. T

hi s

ar tic

le is

in te

nd ed

s ol

el y

fo r t

he p

er so

na l u

se o

f t he

in di

vi du

al u

se r a

nd is

n ot

to b

e di

ss em

in at

ed b

ro ad

ly .

immediate “crisis management” of a cluster, without long- term evaluation of its effectiveness (Askland et al., 2003). These publications, while rich in information concerning the nature of interventions implemented following a sui- cide cluster, did not evaluate the overall effectiveness of such steps in preventing future clusters. Furthermore, many papers identified in the search were epidemiological stud- ies assessing risk factors and previously observed clusters, lacking in information regarding the response to such situ- ations. This finding mirrors the general suicidology litera- ture, which has a disproportionately strong focus on epide- miology rather than intervention (Robinson et al., 2008).

A number of limitations need to be considered about the nature of the review. First, many communities that have experienced a suicide cluster may have developed, or al- ready implemented, postvention strategies that are not in the academic or public domain, where documents are cir- culated only at a local level. As the suicide cluster abates, resources are directed into community recovery, rather than to a formal and scientific evaluation of their experience. Indeed, the lack of opportunity to evaluate postvention strategies using randomized controlled trials (RCTs) means that formal evaluation of such approaches is problematic. Second, because of the guidelines surrounding media re- porting of suicide (Commonwealth of Australia, 2010), and the potential negative effects that inappropriate media cov- erage can cause following a suicide cluster, many clusters may not have been identified by our search, as they were not reported in the media in the first place. In addition, because suicide is a rare event – and suicide clusters even more so – the availability of information regarding such experiences is likely to be limited in nature. The CDC rec- ommendations on how to contain and manage a suicide cluster were initially developed in 1989 and have, to the authors’ best knowledge, not been updated. Given the ways in which young people now communicate, such as through email, social networking sites, and mobile phones, it may be advantageous to update these guidelines with these com- munication methods in mind. Mobilizing resources and dis- seminating information following a suicide cluster may be helped by exploiting these methods of communication. Re- cent reviews on the prevention and treatment of mental ill- ness in young people using internet delivered programs suggest that they are an effective means of intervention (Calear & Christensen, 2010; Richardson, Stallard, & Vel- leman, 2010). With the advent of newer media, which al- lows for more rapid and more widespread communication between young people, it will become even more important to investigate and understand how clusters operate within these communication methods.

As discussed, there are a handful of published articles on postvention strategies that appear to show promise in managing and containing suicide clusters in young people. We need to develop a better evidence base to confirm the effectiveness of these strategies, but as alluded to above, this can be challenging given the nature of suicide clusters and suicide prevention in general. However, evidence of

effective interventions from the broader suicide-prevention literature could be adopted and applied to the notion of suicide clusters. For example, screening high-risk individ- uals has been shown to be effective in identifying young people at risk of suicidal behavior (Gould, Greenberg, Vel- ting, & Shaffer, 2003; Shaffer et al., 2004) and may in- crease the likelihood of such individuals subsequently ac- cessing services (Gould et al., 2003, 2009). Providing gate- keeper training to school staff also has the potential to prevent a suicide cluster, by aiding professionals in identi- fying individuals at risk of suicidal behavior. Gatekeeper training programs such as the Sources of Strength Program (Wyman et al., 2008) and Question, Persuade, and Refer (Reis & Cornell, 2008), delivered to school staff, have been shown to increase knowledge of suicide risk factors and self-efficacy in performing help-seeking behaviors. Fur- thermore, universal prevention programs delivered to school students, such as the Signs of Strength (SOS) pro- gram (Aseltine & DeMartino, 2004) and Surviving the Teens (King, Strunk, & Sorter, 2011), have been shown to increase knowledge of suicide warning signs in oneself and others. However, concerns have been expressed previously regarding potentially negative effects such programs may have (Shaffer & Gould, 2000). In the absence of evidence indicating otherwise, solid recommendations for their use cannot therefore be made. Given that these types of pro- grams are preventive in nature, providing intervention op- tions to schools affected by a suicide cluster can assist them in developing a long-term suicide prevention program.

In addition, providing young people with information following a suicide may be a useful postvention strategy that could be applied following a suicide cluster. In Aus- tralia, the “Toughin’ It Out” pamphlet was first designed to help young people talk about their own suicide risk after the suicide of a loved one. Bridge, Hanssens, and Santha- nam report that, since 1999, this pamphlet has been used extensively as a brief intervention and educational resource in the Northern Territory and Queensland (Bridge, Hans- sens, & Santhanam, 2007) where a number of suicide clus- ters have occurred. However, no formal evaluation of its effectiveness in relation to dealing with suicide clusters could be located.

In summary, there is limited evidence regarding the effectiveness of postvention strategies in response to sui- cide clusters. The most commonly implemented strate- gies are developing a community response plan; educa- tional/psychological debriefings; providing both individ- ual and group counseling to affected peers; screening high-risk individuals; responsible media reporting of sui- cide clusters; and promotion of health recovery within the community to prevent further suicides. However, adopting a broader perspective on the interventions that have been shown to be effective in preventing suicide in youth and identifying young people at risk of suicidal be- havior may be beneficial in helping communities to de- velop effective evidence-based response strategies to a potential suicide cluster.

212 G. R. Cox et al.: Suicide Clusters in Young People

T hi

s do

cu m

en t i

s co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

tio n

or o

ne o

f i ts

a lli

ed p

ub lis

he rs

. T

hi s

ar tic

le is

in te

nd ed

s ol

el y

fo r t

he p

er so

na l u

se o

f t he

in di

vi du

al u

se r a

nd is

n ot

to b

e di

ss em

in at

ed b

ro ad

ly .

References

Aseltine, R. H., Jr., & DeMartino, R. (2004). An outcome evalu- ation of the SOS Suicide Prevention Program. American Jour- nal of Public Health, 94, 446–451.

Askland, K. D., Sonnenfeld, N., & Crosby, A. (2003). A public health response to a cluster of suicidal behaviors: Clinical psy- chiatry, prevention, and community health. Journal of Psychi- atric Practice, 9, 219–227. doi 00131746-200305000-00005

Brent, D. A., Kerr, M. M., Goldstein, C., Bozigar, J., Wartella, M., & Allan, M. J. (1989). An outbreak of suicide and suicidal be- havior in a high school. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 918–924. doi 10.1097/00004583-198911000-00017

Brent, D. A., Perper, J. A., Moritz, G., Allman, C., Schweers, J., Roth, C., . . . Liotus, L. (1993). Psychiatric sequelae to the loss of an adolescent peer to suicide. Journal of the American Acad- emy of Child and Adolescent Psychiatry, 32, 509–517.

Bridge, S., Hanssens, L., & Santhanam, R. (2007). Dealing with suicidal thoughts in schools: Information and education direct- ed at secondary schools. Australasian Psychiatry, 15(Suppl.), 58–62.

Calear, A. L., & Christensen, H. (2010). Review of internet-based prevention and treatment programs for anxiety and depression in children and adolescents. Medical Journal of Australia, 192(Suppl. 11), S12–S14.

Centers for Disease Control [CDC]. (1988). CDC recommenda- tions for a community plan for the prevention and containment of suicide clusters. Morbidity and Mortality Weekly Report, 37(S-6), 1–12.

Chen, Y. Y., Tsai, P. C., Chen, P. H., Fan, C. C., Hung, G., & Cheng, A. T. A. (2010). Effect of media reporting of the suicide of a singer in Taiwan: The case of Ivy Li. Social Psychiatry and Psychiatric Epidemiology, 45, 363–369. doi 10.1007/ s00127-009-0075-8

Commonwealth of Australia. (2010). Reporting suicide and men- tal illness. Retrieved from http://www.mindframe-media.in- fo/client_images/944325.pdf

Davidson, L. E., Rosenberg, M. L., Mercy, J. A., Franklin, J., & Simmons, J. T. (1989). An epidemiologic study of risk factors in two teenage suicide clusters. Journal of the American Med- ical Association, 262, 2687–2692.

Evans, E., Hawton, K., Rodham, K., & Deeks, J. (2005). The prevalence of suicidal phenomena in adolescents: A systematic review of population-based studies. Suicide and Life-Threat- ening Behavior, 35, 239–250.

Gould, M. S., Greenberg, T., Velting, D. M., & Shaffer, D. (2003). Youth suicide risk and preventive interventions: A review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 386–405.

Gould, M. S., Jamieson, P., & Romer, D. (2003). Media contagion and suicide among the young. American Behavioral Scientist, 46, 1269–1284. doi 10.1177/0002764202250670

Gould, M. S., Marrocco, F. A., Hoagwood, K., Kleinman, M., Amakawa, L., & Altschuler, E. (2009). Service use by at-risk youths after school-based suicide screening. Journal of the American Academy of Child and Adolescent Psychiatry, 48(12), 193–201.

Gould, M. S., Wallenstein, S., & Kleinman, N. (1987). A study of time-space clustering of suicide: Final report. Atlanta, GA: Centers for Disease Control.

Hacker, K., Collins, J., Gross-Young, L., Almeida, S., & Burke, N. (2008). Coping with youth suicide and overdose: One com- munity’s efforts to investigate, intervene, and prevent suicide contagion. Crisis, 29, 86–95.

Hanssens, L., & Hanssens, P. (2007). Research into the Clusters Effect of Suicide within Indigenous communities, Northern Territory, Australia. Aboriginal and Islander Health Worker Journal, 31(3), 3–11.

Haw, C. M. (1994). A cluster of suicides at a London psychiatric unit. Suicide and Life-Threatening Behavior, 24, 256–266.

Hazell, P. (1991). Postvention after teenage suicide: An Australian experience. Journal of Adolescence, 14, 335–342.

Hazell, P. (1993). Adolescent suicide clusters: Evidence, mecha- nisms and prevention. Australian and New Zealand Journal of Psychiatry, 27, 653–665.

Ho, T. P., Leung, P. W., Hung, S. F., Lee, C. C., & Tang, C. P. (2000). The mental health of the peers of suicide completers and attempters. Journal of Child Psychology and Psychiatry, 41, 301–308.

Johansson, L., Lindqvist, P., & Eriksson, A. (2006). Teenage sui- cide cluster formation and contagion: Implications for primary care. BMC Family Practice, 7, 32.

King, K. A., Strunk, C. M., & Sorter, M. T. (2011). Preliminary effectiveness of surviving the Teens® Suicide Prevention and Depression Awareness Program on Adolescents’ Suicidality and Self-Efficacy in Performing Help-Seeking Behaviors. Journal of School Health, 81, 581–590. doi 10.1111/j.1746- 1561.2011.00630.x

Mauk, G. W., & Gibson, D. G. (1994). Suicide postvention with adolescents: School consultation practices and issues. Educa- tion and Treatment of Children, 17, 468.

McKenzie, N., & Keane, M. (2007). Contribution of imitative suicide to the suicide rate in prisons. Suicide and Life Threat- ening Behavior, 37, 538–542.

McKenzie, N., Landau, S., Kapur, N., Meehan, J., Robinson, J., Bickley, H., . . . Appleby, L. (2005). Clustering of suicides among people with mental illness. The British Journal of Psy- chiatry, 187, 476–480. doi 10.1192/bjp. 187.5.476

Mesoudi, A. (2009). The cultural dynamics of copycat suicide. PLoS One, 4, e7252. doi 10.1371/journal.pone.0007252

Nock, M. K., Borges, G., Bromet, E. J., Alonso, J., Angermeyer, M., Beautrais, A., . . . Williams, D. (2008). Cross-national prevalence and risk factors for suicidal ideation, plans and at- tempts. The British Journal of Psychiatry, 192, 98–105. doi 192/2/9810.1192/bjp.bp.107.040113

O’Carroll, P. W., & Potter, L. B. (1994). Suicide contagion and the reporting of suicide: Recommendations from a national workshop. United States Department of Health and Human Services. MMWR Recommendations and Reports, 43(RR-6), 9–17.

Pirkis, J., & Blood, R. W. (2001). Suicide and the media. Part I: Reportage in nonfictional media. Crisis, 22, 146–154.

Poijula, S., Wahlberg, K. E., & Dyregrov, A. (2001). Adolescent suicide and suicide contagion in three secondary schools. In- ternational Journal of Emergency Mental Health, 3, 163–168.

Reis, C., & Cornell, D. (2008). An evaluation of suicide gatekeep- er training for school counselors and teachers. Professional School Counseling, 11, 386–394.

Richardson, T., Stallard, P., & Velleman, S. (2010). Computerized cognitive behavioral therapy for the prevention and treatment of depression and anxiety in children and adolescents: A sys-

G. R. Cox et al.: Suicide Clusters in Young People 213

T hi

s do

cu m

en t i

s co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

tio n

or o

ne o

f i ts

a lli

ed p

ub lis

he rs

. T

hi s

ar tic

le is

in te

nd ed

s ol

el y

fo r t

he p

er so

na l u

se o

f t he

in di

vi du

al u

se r a

nd is

n ot

to b

e di

ss em

in at

ed b

ro ad

ly .

tematic review. Clinical Child and Family Psychology Review, 13, 275–290. doi 10.1007/s10567-010-0069-9

Robinson, J., Pirkis, J., Krysinska, K., Niner, S., Jorm, A. F., Dud- ley, M., . . . Harrigan, S. (2008). Research priorities in suicide prevention in Australia. A comparison of current research ef- forts and stakeholder-identified priorities. Crisis, 29, 180–190.

Shaffer, D., & Gould, M. (2000). Suicide prevention in schools. In K. Hawton & K. van Heeringen (Eds.), The international handbook of suicide and attempted suicide (pp. 645–660). Chi- chester: Wiley.

Shaffer, D., Scott, M., Wilcox, H., Maslow, C., Hicks, R., Lucas, C. P., . . . Greenwald, S. (2004). The Columbia Suicide Screen: Validity and reliability of a screen for youth suicide and de- pression. Journal of the American Academy of Child and Ad- olescent Psychiatry, 43, 71–79.

Wilkie, C., Macdonald, S., & Hildahl, K. (1998). Community case study: Suicide cluster in a small Manitoba community. The Canadian Journal of Psychiatry, 43, 823–828.

World Health Organization. (2000). Preventing suicide. A re- source for teachers and other school staff. Geneva: Author.

World Health Organization. (2002). Distribution of suicide rates (per 100,000) by gender and age, 2000. Retrieved from http://www.who.int/mental_health/prevention/suicide/suicid e_rates_chart/en/index.html

World Health Organization. (2010). Suicide prevention (SUPRE). Geneva: Author.

Wyman, P. A., Brown, C. H., Inman, J., Cross, W., Schmeelk- Cone, K., Guo, J., & Pena, J. B. (2008). Randomized trial of a gatekeeper program for suicide prevention: 1-year impact on secondary school staff. Journal of Consulting and Clinical Psychology, 76(1), 104–115.

Received April 19, 2011 Revision received October 18, 2011 Accepted November 29, 2011 Published online June 20, 2012

About the authors

Dr. Georgina Cox is a postdoctoral research fellow specializing in suicide prevention at Orygen Youth Health, University of Mel- bourne, Australia. She has undertaken work in the area of depres- sion in children and adolescents and is currently involved in im- plementing a web-based intervention for at-risk youths.

Jo Robinson is a research fellow at Orygen Youth Health Research Centre, University of Melbourne, Australia, where she leads a research program specializing in youth suicide prevention. She is also undertaking her PhD study with the University of Melbourne examining the effects of a web-based intervention on at-risk youths.

Michelle Williamson is a research fellow at the Centre for Health Policy, Programs, and Economics at the University of Melbourne, Australia. She has worked predominantly in the areas of suicide prevention and mental health research and has worked on a num- ber of large-scale government program evaluations.

Anne Lockley is a freelance consultant specializing in program design, evaluation, and community-based research. She has de- signed and managed multiagency programs in sectors such as HIV, youth development, initiate partner violence, and public health.

Yee Tak Derek Cheung is currently completing a PhD on suicide clusters under the supervision of Professor Jane Pirkis. He has practical experience in suicide surveillance and monitoring and has published a number of academic articles and evaluation re- ports related to suicide.

Jane Pirkis is Professor and Director of the Centre for Health Pol- icy, Programs, and Economics at the University of Melbourne, Australia. She has undertaken a broad program of work on the epidemiology of suicide and has conducted a number of large- scale evaluations of suicide prevention initiatives.

Georgina Cox

Orygen Youth Health Research Centre Centre for Youth Mental Health University of Melbourne Parkville, Victoria 3052 Australia Tel. +61 4 0-630-0558 Fax +61 3 9-342-2941 E-mail [email protected]

214 G. R. Cox et al.: Suicide Clusters in Young People

T hi

s do

cu m

en t i

s co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

tio n

or o

ne o

f i ts

a lli

ed p

ub lis

he rs

. T

hi s

ar tic

le is

in te

nd ed

s ol

el y

fo r t

he p

er so

na l u

se o

f t he

in di

vi du

al u

se r a

nd is

n ot

to b

e di

ss em

in at

ed b

ro ad

ly .