though their analysis had only included nine specific drugs. The warning states that the increased risk of suicidal thinking and/or behavior occurs in a small proportion of youth and is most likely to occur during the early phases of treatment. Although the FDA did not prohibit the use of antidepressants by children and adolescents, it called upon physicians and parents to closely monitor youth who are taking the medications for a worsening in symptoms of depression or unusual changes in behavior.

On February 1, 2005, the American Psychiatric Association (APA) and a coalition of other leading health, mental health, and advocacy organizations released detailed fact sheets for physicians and parents on the use of medications in treating childhood and adolescent depression (American Psychiatric Association, 2005). The fact sheets were developed because of concern that the FDA black box warning could have the unintended effect of limiting necessary, appropriate, and effective treatment of depression and other psychiatric disorders in youth.

The APA fact sheets were particularly critical of the FDA's measurement of suicidality following antidepressant use among children and adolescents, which essentially used thoughts of suicide or potentially dangerous behaviors that had been spontaneously shared by the young participants and subsequently recorded in the researchers' “adverse events reports.” Although the FDA analysis showed more such spontaneous reports among those taking an antidepressant medication as compared to placebo (4% vs. 2%), this finding was not supported by data from 17 of the 23 studies examined that had systematically asked all participants about their suicidal thoughts and behaviors, using standardized forms. The FDA's analysis of these data concluded that medication neither increased suicidality that had been present before the treatment, nor induced new suicidality in those who were not thinking about suicide at the start of the study. All studies collecting such data reported a reduction in suicidality over the course of treatment. The APA critique noted that while the FDA reported both sets of findings, it did not comment on the contradiction between them. It further questioned the reliability of the 2% and 4% spontaneous report rates, noting findings from numerous community samples that as many as half of adolescents with major depression were thinking of suicide at the time of diagnosis and 16%–35% reported making a suicide attempt.

The fact sheets included suggestions for physicians and parents in monitoring youth receiving antidepressant medication, and called for the development of a readily-accessible registry of clinical trials that could aid in resolving the controversy and conflicting information surrounding the prescribing of antidepressants to children and adolescents.

Research has pointed to a lack of posthospital treatment adherence among the many youth who are hospitalized in inpatient psychiatric units following serious suicidal behavior (Cohen-Sandler, Berman, & King, 1982; Spirito, Brown, Overholser, & Fritz, 1989). One result is frequent rehospitalization for repeated suicidality (Greenfield et al., 2002; Stewart et al., 2001). The key assumption of posthospitalization programs is that providing consistent support and improving adherence to aftercare recommendations will help to prevent future suicidal behavior.

The only full-developed program of this sort is the Youth-Nominated Support Team (YST) intervention, developed by King and colleagues (King, 2003; King, Preuss, & Kramer, 2001). This program was an outgrowth of the developers' finding that family dysfunction and parental psychopathology significantly impact treatment adherence by suicidal youth after hospitalization (King, Hovey, Brand, Wilson, & Ghaziuddin, 1997). Concentrating on the high-risk period for suicidality immediately following psychiatric hospitalization, the program specifically targets poor treatment adherence and negative perceptions of family support and helpfulness.

Before leaving the hospital, program participants nominate specific adults from their home, school, or community to support them when they are released. The YST conducts a psychoeducation session with these adults, then engages them in weekly consultations designed to improve their understanding of the suicidal youngster and how he or she can be effectively supported. A social network is encouraged among the adults, who typically come from diverse settings. The program is designed to supplement usual treatments.

Response to YST by participating youth and the nominated adults has been positive (King, 2003), with 80% of those nominated actually participating in the program. Positive effects have been reported for adolescent females, including reduced suicidal ideation and mood impairment. Similar benefits were not evidenced among male participants, although some described YST as having beneficial effects.

Since this intervention has only recently been implemented, it is too early to know whether the positive effects found among the suicidal girls will be translated into reductions of suicide attempts and rehospitalizations. It will also be important to identify the reasons underlying the lack of clear effects among male participants and to incorporate the necessary programmatic changes. The fact that the program has been manualized will likely encourage its replication, while permitting independent assessment of specific program components.

As was noted in Chapter 22 there has been marked reluctance among college and university officials to specifically identify suicidal students or offer treatment services that specifically address this problem. One university-based treatment program has been identified, which is based on the assumption that students who en gage in suicidal threats or behavior will not voluntarily submit to a clinical assessment, and thus that such assessment must be mandated as a condition of the student's continued enrollment at the university.

For the last 17 years, the University of Illinois has had in place a policy that requires mandatory reporting of all suicide threats and attempts by students, and mandatory clinical assessment sessions for all students identified as engaging in such behavior. Specifically, identified students are required to attend four weekly sessions with a social worker or psychologist at the University Counseling Center, during which the student receives a comprehensive clinical assessment and referral to additional treatment if needed. Students who do not attend the mandated sessions can be suspended or expelled from the university.

The program's primary developer reported high compliance among students over the past 17 years, with only one student being involuntarily dismissed from the university for refusing to attend the mandatory sessions. A significant decrease in the suicide rate at the university as a function of this policy has also been reported (Joffe, 2003).

Although the program has claimed to be uniquely successful in reducing suicidal behavior at the one campus where it has been implemented, confirmatory evidence is lacking. Comparative statistics on suicide rates over the last 17 years from universities with a similar student body to that of the University of Illinois are lacking, and it is possible the reported reductions are reflective of a general trend toward decreasing numbers of suicides among adolescents and young adults during the time period described, rather than the result of this specific program. Further, it is not clear how many suicidal students voluntarily withdrew from the university prior to identification, or how many troubled students may have decided not to enroll at all because of this particular policy.

In spite of considerable research and program development focusing on youth suicide, there is much we do not yet know about the factors that cause or significantly influence suicidal behavior among youth and the interventions that must be made if this behavior is to be prevented or treated. Listed below are the key knowledge needs our review has identified that constitute a future research agenda for youth suicide. Clearly, the task that lies ahead for researchers and program developers is formidable.