When silence can be fatal

The unthinkable happened in Clark County, Wash., at the start of the 2000-01 school year: A 16-year-old boy committed suicide. Few in this rural region near the Oregon border dared even speak about it publicly.

Over the course of the school year, however, the deaths eerily kept coming. Five more students took their own lives in what experts term a teen suicide cluster. As panic set in, pressure mounted for a solution, but every option seemed to risk doing more harm than good.

"The ongoing concern all along has been whether to say anything at all," says Karyl Ramsey, then coordinator of the county's suicide prevention campaign. "The fear was that talking about it might exacerbate the problem."

After convening a task force and weighing the risks, Clark County officials gambled that new public-service announcements and school programs addressing suicide might create a safer youth climate.

But across the nation, the same questions remain: What, if anything, can prevent youth suicide? Does education on the topic lead depressed students to get help? Or do discussions instead run the risk of pushing some students closer to attempting suicide?

Finding answers has become an urgent matter for public-health officials who focus on youth. Nearly 5,000 people between ages 15 and 24 take their own lives in the United States each year. Only motor vehicle accidents and homicides account for more deaths in this age group.

Although youth suicide rates have been dropping since 1994, researchers remain concerned as today's teen rates continue to be three times as high as those of the 1950s. This year, states are unfurling new initiatives to catch warning signs and raise public awareness of the problem.

Yet because experts generally say they aren't sure what's causing rates to drop, prevention efforts keep emerging in all shapes and sizes, with intense debates never far behind.

Example: the TeenScreen program from Columbia University in New York. In it, high school students in 95 communities don headphones, answer questions about their thoughts and feelings, and wait to see if evaluators encourage a meeting with a counselor.

The theory is simple: Screening for risk factors might save lives, while education about suicide might backfire.

"It's difficult to do direct education with youth that is safe and effective," says Laurie Flynn, director of the Carmel Hill Center at Columbia. "Just talking to kids about 'Don't do something' isn't terribly effective, since adolescents aren't especially responsive to adult admonition. Just having an assembly on suicide carries with it a possibility of stirring up those few young people who are very depressed and at risk. We just don't know enough yet about how to do [suicide education] well."

But officials for the state of Wisconsin strongly disagree. For them, edu- cation is a must. Since the mid-1980s, state law has required that every Wisconsin public school student receive instruction in suicide prevention.

"These kids are just suffering in silence," said Nic Dibble, a consultant to Wisconsin's department of public instruction. "We can't guarantee there won't be a student who reacts negatively [to suicide-prevention classes]. But on balance, we'd be doing more harm by not doing anything."

The roots of youth suicide remain mysterious. But social alienation in large schools and unrooted families, coupled with more substance abuse at younger ages, and easier access to guns have all been cited as factors in rising teen suicide rates in recent decades, says Lucy Davidson, director of education and prevention practice at the American Foundation for Suicide Prevention in New York.

Warning signs, such as loss of interest in activities and muffled cries for help, are almost always present in teen suicides, say experts. The challenge with youth is to identify those most at risk and get them promptly into treatment. But the question is: What type of treatment?

"Just raising general awareness can be dangerous because it tends to normalize the idea of suicide," says Ms. Davidson. "Awareness tends to disproportionately impact the population most at risk. It makes troubled youth aware of [suicide] as an option."

The volatile disposition of suicidal teens calls for education on the subject to be far more nuanced than efforts to raise awareness of health issues, such as smoking or pregnancy, according to Davidson. She believes educators have inherited a delicate task. They must reinforce the cultural taboo on suicide; that is, to say it's never OK. At the same time, though, they must remove the imbedded cultural stigma associated with getting help for mental illness.

In regions plagued by high rates of youth suicide, however, leaders on the prevention front are doing all they can to spark fresh public discussion. Virginia and Maine, for instance - two rural states where scant counseling resources have been connected to higher-than-average youth suicide rates - are concentrating new prevention efforts on training a cross-section of people to recognize warning signs and to persuade youth to seek help.

With help from a three-year, $900,000 grant from the Centers for Disease Control, Maine is developing one of the nation's most comprehensive approaches. School staff are trained to spot suicidal behavior, students in a series of health classes learn how to cope with depression, and counselors take calls to a 24-hour crisis hotline.

Adults in Maine are also encouraged to broach the subject with students who show warning signs.

But adults everywhere are apt to bristle at being nudged to raise a topic they fear might be harmful, say experts. Those delivering prevention programs to rural Virginia, where youth suicide rates are nearly three times the national average, say the group most opposed to discussing suicide are parents.

"A lot of parents, when you bring [a child's risk factors] to their attention, say, 'Oh, that's nothing. They've always been like that,' " says Calvin Nunnally, suicide prevention training coordinator at the Virginia Department of Health. "Most think kids are going through a phase when these things could be warning signs of suicide. Parents are pretty much in denial."

"Most parents tell me, 'Don't talk about it,' " says Kathleen Wakefield, a Virginia Beach mother who lost a 21-year-old son to suicide in 2001 and now talks to schools and parents about prevention. "It's that same backward idea that if you try to educate kids about drugs or sex then they'll start using drugs and having sex."

To date, most prevention efforts developed since the crisis peaked in the mid-1990s are too new or too unstudied for any consensus to have developed as to what works. Nevertheless, early studies have their tentative supporters.

Flynn at TeenScreen, for instance, finds encouragement in a 2003 Columbia University study suggesting that access to antidepressant medication might account for declining suicide rates since the mid-1990s.

Conversely, she says, surveys suggest hotlines don't work because suicidal teens seldom obtain help or treatment on their own.

Studies are currently being done of the programs in place in Maine and Virginia to determine if either is demonstrably effective or worthy of replication in other states.

But prevention leaders say the potential for more suicides looms too large to sit back and wait for conclusive results.

"People still have a hesitancy to call it suicide when that's exactly what it is," said Mr. Nunnally, noting that many local newspapers don't report suicides as such. "It's better to put it on the table and deal with it than to push it under the rug and keep losing lives."