months after program implementation, students who had participated in the SOS intervention reported significantly lower rates of suicide attempts and greater knowledge and more adaptive attitudes about depression and suicide (Aseltine & DeMartino, 2004).

Educational efforts in the Dade County, Florida, Public School System provide an example of universal programs applied on a community-wide level. This program, which began in 1989, included related curricula across kindergarten through 12th grade, although only 10th graders received direct discussion of suicide and suicide prevention. In addition to the instructional components, it also included intervention and postvention activities by school-based crisis teams.

A 5-year longitudinal study of the Dade County program examined rates of suicide deaths and suicide attempts by youth in the county in the years during which the program was operative (1989–1994), comparing them to comparable rates over the 8-year period preceding the program (Zenere & Lazarus, 1997). The annual suicide rate was reported to have decreased from an average of 12.9 deaths per 100,000 youth prior to the program to 4.6 per 100,000 during the 5 years of program operation. Known suicide attempts were reported to have dropped from 87 to 37 per 100,000 youth. No significant change was reported in rates of suicidal ideation.

The lack of a contemporaneous local control group in this study makes it difficult to determine the linkage between the educational program and the reported decline in suicide rates. Although this report concludes that the comprehensive educational program contributed to the declines, it should be noted that youth suicide rates were declining nationally during the 5-year period of the program's implementation, although not as sharply as were reported in this particular county. In addition, the county under study was quite small (330,000 students), so that relatively large fluctuations in suicide rates are not as meaningful as they would be for the national population.

Many states are currently implementing universal youth suicide prevention programs that, in addition to student education, frequently include parent and gatekeeper training. Like other programs of this type, controlled evaluation studies have not yet been reported. In an internally published report (Eggert, Karovsky, & Pike, 1999), positive results have been reported for one of the most fully developed such programs, the Youth Suicide Prevention Program (YSPP) in Washington State.

Some efforts to address suicide prevention on a universal level have concentrated specifically on gatekeeper training. These programs are summarized in Table 22.2. The Suicide Options, Awareness and Relief (SOAR) program, for example, trains school counselors to identify students at risk of suicide and increase the likelihood and effectiveness of their interventions. This program has been reported to result in improved knowledge and increased comfort and confidence in dealing with at-risk students. More positive results were found among the most recently trained counselors, suggesting the need for ongoing training (King & Smith, 2000).

The broadest and most frequently applied gatekeeper training program, the Applied Suicide Intervention Skills Training (ASIST), has been developed by LivingWorks Education for application in a wider community setting (Ramsay, Cooke, & Lang, 1990; Rothman, 1980). Developed over the last 20 years, ASIST is a 2-day workshop for teachers, counselors, youth leaders, and other community caregivers that seeks to increase their awareness and understanding of suicide, address the associated stigma and taboos, develop their readiness and ability to use “first-aid” actions to prevent suicidal behavior, and network with other gatekeepers to improve communication and continuity of care. An estimated 25,000 caregivers participate in the program each year, and to date more than 300,000 have been trained worldwide.

Pre-to postevaluations of participants suggest increased knowledge about suicidal behavior, greater willingness to intervene, and improved competence in dealing with suicidal individuals (Eggert et al., 1999; Tierney, 1994). In one evaluation report of training programs in Australia, more than three quarters of ASIST workshop participants reported using their knowledge and intervention skills directly during the 4 months following their participation in the program (Turley & Tanney, 1998). There is some evidence

of an increase in referral to treatment as a result of gatekeeper training (Turley, 2000; Walsh & Perry, 2000).

A second component of LivingWorks' efforts is the Training for Trainers (T4T) program. This 5-day course, offered worldwide, trains and certifies gatekeepers to provide the ASIST training in their local communities. A CD-ROM program has recently been developed by LivingWorks to provide posttraining retention and reinforcement of intervention skills through virtual simulation of interactions with suicidal individuals.

Less proactive training strategies for school personnel and parents have used audiovisual materials to enhance suicide awareness and encourage early identification of youth at risk. Preliminary evaluations of two such efforts (Fendrich, Mackesy-Amiti, & Kruesi, 2000; Maine, Shute, & Martin, 2001) suggest that while most of those who view CD-ROMs and films about suicide prevention react positively, lack of time and inaccessibility of computer equipment may limit the effectiveness of such efforts, particularly within schools.

Another approach to gatekeeper training has involved educating general practitioners to more effectively identify suicidal patients. One such intervention was a youth suicide prevention workshop for general practitioners in Australia, which sought to encourage screening of young patients for psychological distress, depression, and suicidal behavior. The workshop was reported to have resulted in increased identification of distressed, depressed, and suicidal adolescents; no changes were reported, however, in physicians' management of such patients (McKelvey, Davies, Pfaff, Acres, & Edwards, 1998; McKelvey, Pfaff, & Acres, 2001).

In comparison with programs addressed to high school students and the adults who have frequent contact with them, suicide awareness and education programs for college students are far less cohesive and identifiable (Haas, Hendin, & Mann, 2003). One of the few programs that involve more than a single campus is Finding Hope and Help, developed by the National Mental Health Association in 2001. This program facilitates partnerships between a local mental health association and a university to develop and implement campus educational programs on suicide and related mental health problems. These “campus coalitions” typically work with residence hall advisers, campus counseling centers, relevant academic departments, campus ministries, and other student affairs personnel to design trainings for students and staff, peer counseling programs, and other activities to increase knowledge and awareness of mental health concerns (National Mental Health Association, 2005).

Another effort that targets colleges and universities is the recently produced film developed by the American Foundation for Suicide Prevention (AFSP), “The Truth About Suicide: Real Stories of Depression in College.” The film is accompanied by a Facilitator's Guide that includes recommendations for its use in classrooms, orientation sessions, and dorm meetings and at other student activities, as well as educational materials to assist faculty and other facilitators in guiding student discussions and answering specific questions about suicide. Although no formal evaluation of the film's effectiveness is currently planned, AFSP is gathering feedback data from viewers and facilitators.

Most suicide awareness and suicide education programs involve one or a limited number of relatively brief sessions focused on suicidal behavior, frequently as part of a larger curricular effort aimed at reducing multiple high-risk behaviors. Although pre-to postevidence suggests that such programs can increase students' knowledge and awareness of suicide risk and improve their help-seeking behaviors, little attention has been paid to determining the scientific accuracy of program content. Examination of curricular materials used by some of these programs reveals considerable variation in regard to their portrayal of suicide risk factors, in particular, the relationship between suicide and mental illness, as well as suicide demographics.

Generalizable conclusions about the efficacy and effectiveness of suicide education programs for both high school and college students are further limited by the lack of control or comparison groups that would make it possible to differen