Studies show that adolescents' exposure to the suicide of a family member or peer can trigger new-onset or recurrent major depressive disorder, posttraumatic stress disorder, and suicidal ideation, especially within the month following the suicide (Brent et al., 1993c). Youth who were already at risk for depression because of family history, a prior episode of depression, or recent interpersonal conflict were found to be at increased risk for suicidal ideation following a suicide, as were those who knew about the victim's plan, felt responsible for the death, or had a conversation with the victim within 24 hours of the suicide. Although the study by Brent and colleagues cited above did not find evidence of increased risk for suicide attempts among such youth, studies of the contagion effect of suicide (Gould et al., 1994; Gould, Wallenstein, & Kleinman, 1990) also report increased suicidal ideation among exposed youth, as was discussed in Chapter 21. It may be that contagion effects are most pronounced in adolescents who are not closely linked with the suicide victim.

The assumption of programs targeting youth exposed to suicide, referred to as “postvention,” is that suicide exposure carries increased risk for suicidal ideation, and possibly suicidal behavior, in a school or community where a recent suicide has occurred. Postvention within schools generally seeks to support those grieving the loss, to identify and assist those at risk for developing depression or posttraumatic stress disorder in response to the suicide, and to return the community or school to its normal routines.

One well-described postvention program is the Services for Teens at Risk (STAR) Center Outreach program implemented in Pennsylvania (Kerr, Brent, & McKain, 1997). This program provides a protocol that identifies specific steps to be taken by school staff, community officials, stu dents and parents in the event of a suicide. Central to the protocol is the development of a school-based crisis team to coordinate postvention activities. The STAR-Center Outreach program provides free training to crisis teams, upon request by school districts throughout the state. Such training consists of an initial 6–12 hr that includes designation of a postvention coordinator, assignment of tasks to team members, simulations and problem-based learning activities, team-building exercises, preparation of Crisis Team Members Kits that include needed documents and supplies, and “dry runs” to test the postvention response. The crisis team then meets for a monthly refresher at the school. This postvention effort emphasizes the importance of including information about warning signs for suicidal behavior with students and staff and the need for ongoing monitoring of at-risk students and staff following implementation. The program specifically discourages school and local officials, family members, and friends from having direct contacts with media in the aftermath of a suicide.

Many other less comprehensive postvention efforts have been implemented in schools across the country (Hazell & Lewin, 1993), as well as abroad (Poijula, Wahlberg, & Dyregrov, 2001). The limited nature of the interventions that were implemented, limited articulation of the intervention models, and the small samples that were studied preclude meaningful conclusions about their impact.

Although there has been a proliferation of postvention programs in recent years, there are no published studies that systematically assess the impact of these programs or identify specific components that are particularly helpful or potentially harmful. Guidelines for postvention responses by schools have been in existence for some time (CDC, 1988), but the interventions implemented by individual school districts and communities are varied. The Substance Abuse and Mental Health Services Administration (SAMHSA) is currently funding a project to de

velop research-based guidelines for schools to help them to implement timely and effective postvention programs (Gould, 2000).

Staffing for postvention programs and follow-up can be costly for schools both financially and emotionally, and this may be a significant impediment to their implementation. Conducting formal evaluations of the impact of such programs within schools is fraught with difficult ethical issues such as parental consent and confidentiality of data regarding students' emotional and behavioral responses to suicide.

As summarized in Table 23.1, several different programs have been developed to encourage restriction of access to firearms by children and adolescents. The key assumption underlying such programs is that accessibility is a primary risk factor for suicide. Programs of this type have been directed primarily at parents.

A core strategy of firearms restriction programs has involved firearm safety counseling to parents that encourages removal or safe storage of firearms from homes where children reside. One such effort, entitled Love our Kids: Lock your Guns, was developed by Coyne-Beasley, Schoenbach, and Johnson (2001), following research that documented the presence of unlocked and loaded weapons within many households in which children and adolescents live (Azrael, Miller, & Hemenway, 2000; Coyne-Beasley et al., 2002; Schuster, Franke, Bastian, Sor, & Halfon, 2000; Senturia, Christoffel, & Donovan, 1994, 1996; Stennies, Ikeda, Leadbetter, Houston, & Sacks, 1999). Prior research by Coyne-Beasley and colleagues (2002) established that firearm storage practices were frequently lax even among parents who demonstrated high safety consciousness of other potential hazards in the home.

The intervention aimed essentially to reach male gun owners who lived with children, and thus was implemented in an outdoor community setting. Program developers provided firearm safety counseling, distributed free gunlocks, and demonstrated their use on a community-wide basis. Politicians, law enforcement personnel, and the media participated in the program along with youth and their parents; T-shirts and certificates were presented to participants. A 6-month follow-up evaluation found improved safe storage habits among gun owners who had participated in the program. Participants with children, who overall were more likely than other gun owners to store weapons unlocked and loaded at baseline, were found in the posttest to be more likely to have removed guns from the home and to lock the guns that remained. Those who had participated in the counseling were also more likely to report talking with friends about safe storage practices.

A few attempts have been made to deliver firearms and other means restriction education in mental health settings. One such effort involved education for parents of children who made a visit to an emergency room mental health department of a rural, Midwestern hospital (Kruesi et al., 1999). At 6-month follow-up, these investigators found that the education led to decreased youth access to guns, prescription medications, and over-the-counter medication but not alcohol. Firm conclusions were limited, however, by the high attrition rate at follow-up.

A similar effort was made with parents of depressed adolescents who participated in a randomized clinical trial of psychotherapy (Brent, Baugher, Birmaher, Kolko, & Bridge, 2000). Parents who reported the presence of firearms in the homes of these adolescents received an intervention designed to encourage gun removal. Although compliance with recommendations was more likely in the homes of adolescents with active suicidality and in single-parent homes, overall, less than one third of the targeted parents removed their guns from the home. Urban families and families in which there was marital discord or a father with a drinking problem were less likely to remove guns. The investigators emphasized the need to talk directly with the parent who owned the gun. In addition, 17% of parents

who reported no gun in the home at intake and therefore were not targeted by the intervention purchased a gun during the study. This points to the advisability of weapons restriction interventions for all parents and not just those who own a gun at the outset of the intervention.

The policy statement on firearm safety of the American Academy of Pediatrics (2000) has urged parents to remove guns from the environment where children live and visit, and if guns remain in the home, to store them unloaded and locked, with ammunition stored separately. One attempt to apply this policy in an intervention program (although not specifically a suicide prevention program) is the Steps to Prevent Firearms Injury Program (STOP) of the American Academy of Pediatrics and the Center to Prevent Handgun Violence. This intervention provides counseling to parents in primary care clinics. Evaluations have not found the program to be effective in reducing firearm safety and removal (Grossman et al., 2000; Oatis, Fenn Buderer, Cummings, & Fleitz, 1999), possibly because it has reached primarily mothers, whereas fathers and other males in the household are more often responsible for the presence and storage practices of the guns in the home.

In assessing the effectiveness of firearms restriction programs on reducing youth suicide, it is important to note that the activities described here have been implemented during a period of declining use and ownership of firearms in U.S. homes, notable since 1980. Thus, care must be exercised in drawing conclusions about the role of specific interventions in removing guns from American households.

Assessment of the impact of firearms removal and firearms safety on youth suicidal behavior is likewise a difficult task. It is not surprising that young people who use guns for self-injury live in a house where there are firearms, and where the firearms are accessible. This does not mean, however, that the presence of firearms has set in motion the lengthy and complex process that leads to suicide. The methodological challenge ultimately facing firearms restriction programs is to demonstrate that suicide-prone youth survive in firearms-free homes, but not in homes where firearms are accessible. As was noted in Chapter 21, it is not clear the extent to which a decrease in youth suicide deaths from firearms may be offset by increases in the use of other lethal methods (Beautrais, 2001; De Leo et al., 2003), and this possibility needs to be considered in evaluating the impact of firearms restriction programs.

Although comprehensive evaluations of this sort have not yet been undertaken, existing programs suggest the potential of community-based programs that provide firearms restriction education to males within households in which children and youth live. It should be noted that means restriction programs have not received widespread funding, in part because of political pressures and in part because they address a more limited audience than universal interventions that can be easily incorporated into public school systems.