摘要：Objectives: We examined whether a reduction in youth suicide mortality occurred between 2007 and 2010 that could reasonably be attributed to Garrett Lee Smith (GLS) program efforts. Methods: We compared youth mortality rates across time between counties that implemented GLS-funded gatekeeper training sessions (the most frequently implemented suicide prevention strategy among grantees) and a set of matched counties in which no GLS-funded training occurred. A rich set of background characteristics, including preintervention mortality rates, was accounted for with a combination of propensity score–based techniques. We also analyzed closely related outcomes that we did not expect to be affected by GLS as control outcomes. Results: Counties implementing GLS training had significantly lower suicide rates among the population aged 10 to 24 years the year after GLS training than similar counties that did not implement GLS training (1.33 fewer deaths per 100 000; P = .02). Simultaneously, we found no significant difference in terms of adult suicide mortality rates or nonsuicide youth mortality the year after the implementation. Conclusions: These results support the existence of an important reduction in youth suicide rates resulting from the implementation of GLS suicide prevention programming. Suicide is the 10th leading cause of death in the United States, the third leading cause of death among youths aged 10 to 14 years, and the second leading cause of death among youths aged 15 to 24 years. 1 As such, suicide prevention is a federal priority, and the Substance Abuse and Mental Health Services Administration has continually invested in long-standing programs such as the Garrett Lee Smith (GLS) Memorial Youth Suicide Prevention Program 2 to combat the problem. These federally funded programs are implemented in states, in tribes, and on campuses and are guided in part by the National Strategy for Suicide Prevention. The National Action Alliance for Suicide Prevention was formed in 2010 with partial support from the Substance Abuse and Mental Health Services Administration (SAMHSA) to revise and implement the National Strategy for Suicide Prevention through best-practice recommendations and a prioritized research agenda to advance the field and save lives. One of these research goals is to “prevent the emergence of suicidal behavior by developing and delivering the most effective prevention programs to build resilience and reduce risk in broad-based populations.” 3 (p47) Although many suicide prevention programs have been developed and implemented with a variety of embedded complementary activities and interventions, evaluating the connection between the proximal products of such programs and their intended long-term outcomes remains challenging. Community-based suicide prevention programs are often implemented for a short period of time and vary in their focus between more dispersed or more concentrated geographic areas. 4 These methods of implementation, as well as the relatively low base rate of suicide mortality, make examination of outcomes challenging. 5 Synthesizing what is known about the effects of gatekeeper training in particular, Isaac et al. 6 noted that studies have shown a positive impact on suicide prevention knowledge, skills, and attitudes. The broad scale and longevity of the GLS Memorial Youth Suicide Prevention Program provides a unique opportunity to examine the impact of community-based suicide prevention programs on youth outcomes. As of June 2014, 154 GLS grants had been awarded to 49 states and 48 tribes. (Twenty-six additional grants in 16 states and 10 tribes were awarded in September 2014. In addition, 144 grants have been awarded to college campuses since program inception. Data from the Campus GLS prevention program, however, were not included in this study.) Consistent with comprehensive public health suicide prevention planning, all GLS grantees include multiple activities in their prevention and early intervention programs to address the unique needs of their communities ( Figure 1 ). Open in a separate window FIGURE 1— Model of the comprehensive, community-based Garrett Lee Smith Memorial Suicide Prevention Program. Gatekeeper training has been a core part of all GLS programs, and grantees have consistently reported spending the largest proportion of their budget on this 1 strategy (32% on average). As such, training serves as a time- and region-stable proxy for GLS suicide prevention program implementation. Gatekeeper training sessions aim to teach specific groups of people to identify individuals at risk for suicide and refer them to appropriate support. 7 (p273) Gatekeepers include individuals who have contact with a large number of youths on regular basis, such as teachers, public school staff, peer educators, and physicians. The duration of training ranges from a few hours to a few days. A core component of all programs involves learning the warning signs of suicide and asking people identified as at risk whether they are thinking about killing themselves. Longer training sessions may aim at building skills to provide additional assistance such as collaboration with suicidal youths to develop a safety plan. Because of their focus on identifying and appropriately referring a large number of youths at risk—who might otherwise have not sought help—gatekeeper programs were recognized as having a potential impact on reducing suicide incidence 7 (p315) and explicitly incorporated as an area of emphasis in the GLS Memorial Act of 2004. Additional details on GLS-funded gatekeeper training implementation, including gatekeeper identification and referral behavior after participation in training, have recently been published. 8 GLS-funded gatekeeper training, however, is implemented not in isolation but rather in concert with other prevention strategies selected by grantees to be consistent with their locale and cultural context. These other activities are considered necessary comprehensive suicide prevention program components to effect change in suicidal behavior. Descriptions of the GLS program history, structure, and outcomes related to GLS grantees’ youth suicide prevention efforts have recently been produced. 9,10 We analyzed data collected through the SAMHSA–funded cross-site evaluation 9 and examined whether a reduction in youth suicide mortality occurred between 2007 and 2010 that could be reasonably attributed to GLS program efforts. Specifically, we compared youth mortality rates across time between counties that implemented GLS-funded training sessions and a set of matched counties in which no GLS-funded training occurred.
