Examining Gender Differences in Risk Factors for Suicide Attempts Made 1 and 7 Years Later in a Nationally Representative Sample

ObjectivesThis study examined the prospective risk factors for making a nonfatal suicide attempt and whether they varied by gender.MethodsWe used data from the National Longitudinal Study of Adolescent Health. A nationally representative sample of 10,828 youth was assessed over three different time points spanning 7 years. We conducted multivariable logistic regression to examine the main and interactive effects on the odds of making a suicide attempt 1 and 7 years later.ResultsRegardless of an individual's gender, multivariable analyses indicated unique risk factors including suicidal ideation, depressive symptoms, a friend's past history of attempted and completed suicide, and a family member's past history of attempted suicide that were significantly associated with increased odds of suicide attempts made 1 and 7 years later. Parental loss predicted likelihood of suicide attempt 1 year later but not 7 years later. Moderational analyses indicated that gender did not interact with most of the risk factors. However, post hoc probing of two significant interaction terms indicated that young age was a risk factor for making a nonfatal suicide attempt 1 year later for females but not for males, and that females with high somatic symptoms had a greater risk for making a nonfatal suicide attempt as compared with those with low somatic symptoms and with males with low or high somatic symptoms.ConclusionThese results indicate similar risk factors for nonfatal suicide attempts among males and females. However, younger age and somatic symptoms were reported to be risk factors for females but not for males, suggesting the need for targeted interventions with young females with somatic complaints.     

Pediatric Emergency Consultations: Prior Mental Health Service Use in Suicide Attempters

This study investigated the relationship between presenting complaints and prior mental health encounters in youth seen for emergency psychiatric consultation. Records of youths aged 9–17 years old receiving a psychiatric consultation in a pediatric emergency department from 2002 to 2007 were examined (N = 1,900). Youth were classified by presenting complaint: suicide attempt, suicidal ideation, and behavioral problems. Nearly half of the youth presented with behavior problems, and 39% presented with suicidal ideation and/or attempt. Those presenting with both suicide attempt and behavior problems were most likely to have made a prior suicide attempt. Those presenting with suicide attempt alone were least likely to report current mental health treatment, while youth presenting with behavior problems alone were the most likely to report current mental health treatment. Further research is needed to better understand the role that emergency departments play in the course of care and to maximize the opportunity to make lasting and effective community-based care connections.     

家庭矛盾与青少年自杀行为关系的队列研究

目的 分析家庭矛盾与青少年自杀行为间的关系。方法 在山东省3个县（市）采用方便整群抽样的方法共选取8所中学作为调查学校，选取7、8和10年级的学生进行基线和随访调查，包括一般人口学、自杀行为、家庭矛盾和抑郁等信息，研究共纳入7 072名研究对象。采用多因素logistic回归模型分析家庭矛盾和自杀行为的关系。结果 7 072名研究对象的基线年龄为（14.58±1.45）岁，有任何自杀行为的有750人（10.6%），其中自杀意念、自杀计划和自杀未遂的人数（报告率）分别为707人（10.0%）、258人（3.6%）和190人（2.7%）。有自杀行为者的家庭矛盾得分高于没有自杀行为者。调整其他因素后，logistic回归结果显示，家庭矛盾与自杀行为（OR=1.05，95%CI：1.01~1.10）、自杀意念（OR=1.05，95%CI：1.00~1.09）、自杀计划（OR=1.08，95%CI：1.01~1.16）和自杀未遂（OR=1.10，95%CI：1.02~1.19）的风险增加有关。进一步对性别进行分层后，分析结果显示，女生的家庭矛盾和自杀行为无统计学关联；男生的家庭矛盾和自杀行为有统计学关联，尤其是自杀意念和自杀计划，且男生家庭矛盾对于自杀计划的预测作用大于自杀意念。敏感性分析显示该结果对于男生稳定。结论 家庭矛盾可能会增加青少年自杀行为的风险，尤其是男生。和谐的家庭环境、良好的家庭氛围对预防和控制青少年自杀行为的发生具有重要意义。     

Workplace bullying and risk of suicide and suicide attempts: A register-based prospective cohort study of 98 330 participants in Denmark

ObjectivesThe aim of this study was to analyze whether individuals reporting exposure to workplace bullying had a higher risk of suicidal behavior, including both suicide attempt and death by suicide, than those not reporting such exposure.MethodsUsing a prospective cohort study design, we linked data from nine Danish questionnaire-based surveys (2004–2014) to national registers up to 31 December 2016. Exposure to workplace bullying was measured by a single item. Suicide attempts were identified in hospital registers and death by suicide in the Cause of Death Register. Among participants with no previous suicide attempts, we estimated hazard ratios (HR) and 95% confidence intervals (CI), adjusting for sex, age, marital status, socioeconomic status, and history of psychiatric morbidity.ResultsThe sample consisted of 98 330 participants (713 798 person-years), 63.6% were women, and the mean age was 44.5 years. Of these participants, 10 259 (10.4%) reported workplace bullying. During a mean follow-up of 7.3 years, we observed 184 cases of suicidal behavior, including 145 suicide attempts, 35 deaths by suicide and 4 cases that died by suicide after surviving a suicide attempt. The fully-adjusted HR for the association between workplace bullying and suicidal behavior was 1.65 (95% CI 1.06–2.58). The HR for suicide attempts and death by suicide were 1.65 (1.09–2.50) and 2.08 (0.82–5.27), respectively. Analyses stratified by sex showed a statistically significant association between workplace bullying and suicidal behavior among men but not women.ConclusionsThe results suggest that exposure to workplace bullying is associated with an elevated risk of suicidal behavior among men.     

Prospective Associations between Delinquency and Suicidal Behaviors in a Nationally Representative Sample

PurposeWe examined the prospective associations between delinquency and suicidal behaviors among adolescents using a nationally representative sample.MethodsThe National Longitudinal Study of Adolescent Health was used to assess the prospective associations between delinquency at ages 12–17 years and suicidal behaviors (ideation, attempts, treatment for attempts) 1 and 7 years later.ResultsControlling for demographic variables, delinquency was prospectively associated with an increased risk for all three suicidal behaviors 1 year later, and to ideations and attempts 7 years later. After controlling for other risk factors (i.e., depression, self-esteem, problem drinking, impulsivity, religiosity), delinquency was still significantly related to an increased likelihood for suicidal ideation 1 and 7 years later, and to suicide attempts 1 year later. Further, delinquency was significantly related to suicidal ideation for girls more than for boys.ConclusionsThese findings suggest that delinquent youth, particularly delinquent girls, should be targeted in interventions to reduce suicidal behaviors.     

Socioeconomic and Clinical Characteristics Associated With Repeat Suicide Attempts Among Young People

PurposeRepeat suicidal behaviors in young people are a critical public health concern. The study investigates individual socioeconomic and episode-dependent clinical factors predicting repeat suicide attempts among youth by gender.MethodsUsing a retrospective cohort study, we identified a total of 4,094 male and 3,219 female youths who had the index suicide episode at the ages of 15–24 years from the 1996–2007 National Health Insurance Research Database in Taiwan. The recurrence of suicide attempt was assessed within 1 year after the index suicide. Information pertaining to suicide management and postsuicide treatment was obtained from healthcare records. Repeated event survival analyses were used to estimate episode-dependent risk of suicide attempt.ResultsThe occurrence of repeat suicide attempts was more common in males, yet the phenomenon of risk aggravation appears more prominent in females. The estimate for peak hazard of the second repeat attempt was 2-fold higher than that of the first repeat event in males, and approximately 6-fold in females. Socioeconomic (e.g., labor market participation: adjusted Hazard Ratio [aHR] = 1.14, 95% CI = 1.01–1.28) and index suicide management characteristics (e.g., receiving treatment at clinic, aHR = 1.54, 95% CI = 1.19–1.99) were found to play important roles for repeat suicide attempts in males. For females, postsuicide treatment of mental disorders appears more influential.ConclusionsThe relationships between socioeconomic and clinical factors with repeat suicide attempts in young people vary by gender. School/workplace-based post suicide attempt consultation and clinical management for youth may be planned and delivered on a gender-appropriate basis.     

自杀行为暴露与青少年非自杀性自伤关系的纵向研究

目的 青少年群体中,非自杀性自伤（non-suicidal self-injury,NSSI）行为较为普遍且受多种因素影响。本研究旨在探究中国青少年自杀行为暴露与其自身NSSI之间的关系。方法 研究对象来自山东省青少年行为与健康队列研究。选取参与了2015年基线调查和2016年第一次随访调查,并且基线调查中不存在NSSI行为史的5 154名学生为研究对象。研究内容通过自填式问卷收集,包括基本人口学信息、社会心理学信息、终生及过去一年NSSI情况、自杀行为暴露史等。采用多因素logistic回归模型分析基线自杀行为暴露与一年后NSSI间的关系。结果 5 154名研究对象的基线年龄为（14.49±1.48）岁,女性占48.5%。9.0%的青少年报告曾暴露于自杀行为,其中6.0%暴露于自杀未遂,4.9%暴露于自杀死亡,7.3%暴露于朋友/熟人的自杀行为,3.1%暴露于亲属的自杀行为。自杀行为暴露组的过去一年NSSI发生率高于非暴露组,差异有统计学意义（P<0.05）。多因素logistic回归分析显示,与非暴露组相比,暴露于自杀死亡（OR=1.91,95% CI：1.22~3.01）和暴露于亲属自杀行为（OR=1.79,95% CI：1.02~3.12）与NSSI风险增加有关。结论 暴露于自杀死亡或亲属自杀行为可能会增加青少年NSSI行为风险。自杀事件发生后,针对高危人群进行心理疏导和健康教育可促进青少年身心健康、预防自我伤害。     

Adolescent Alcohol Use,Suicidal Ideation,and Suicide Attempts

PurposeTo examine the association between self-reported alcohol use and suicide attempts among adolescents who did and did not report suicidal ideation during the past year.MethodsScreening data from 31,953 students attending schools in the United States that implemented the Signs of Suicide (SOS) program in 2001–2002 were used in this analysis. Two types of alcohol use were investigated: heavy episodic drinking, and drinking while down. Self-reported suicide attempts were regressed on suicidal ideation and both measures of alcohol use, controlling for participants’ levels of depressive symptoms, and demographic characteristics.ResultsLogistic regression analyses indicated that both drinking while down and heavy episodic drinking were significantly associated with self-reported suicide attempts. Analyses examining the conditional association of alcohol use and suicidal ideation with self-reported suicide attempts revealed that drinking while down was associated with significantly greater risk of suicide attempt among those not reporting suicidal ideation in the past year. Heavy episodic drinking was associated with increased risk of suicide attempt equally among those who did and did not report suicidal ideation.ConclusionsThis study identified the use of alcohol while sad or depressed as a marker for suicidal behavior in adolescents who did not report ideating prior to an attempt, and hence, may not be detected by current strategies for assessing suicide risk. Findings from this study should provide further impetus for alcohol screening among clinicians beyond that motivated by concerns about alcohol and substance use.     

北京50家综合医院门诊患者自杀意念及自杀未遂调查

目的 了解北京市综合医院门诊患者的自杀意念和自杀未遂出现率及其危险因素.方法 采用自制量表对随机抽取的北京市50家各级综合医院2877例门诊患者进行调查,通过logistic分析筛选出其危险因素.结果 自杀意念和自杀未遂终生发生率分别为6.08%和1.18%;多因素分析显示两者的共同危险因素为近一年有绝望感、年纪轻、熟人有过自杀行为、女性.结论 北京市综合医院门诊就诊患者经常有自杀危险、抑郁等心理问题;应培养普通门诊医务人员识别、评估和处理这类问题的技能.     

Suicide, high-risk behaviors, and coping style in homeless adolescent males' adjustment.

PURPOSE: To evaluate the association among suicide behaviors, high-risk behaviors, coping style, and psychological adjustment (i.e., depressive symptomatology, internalizing and externalizing behavior problems) in homeless and non-homeless adolescent males (aged 16 to 19 years). METHODS: Data were obtained from 100 homeless youth accessing an emergency shelter (Ottawa, ON). The comparison group was comprised of 70 youth accessing local community drop-in centers that lived with their parent(s)/guardian(s) and had never stayed in a shelter. Data were analyzed using Chi-square, Student's t-tests, and regression statistics. RESULTS: Relative to non-homeless youth, homeless youth were more likely to report drug, alcohol, and tobacco use, legal problems, academic difficulties, and mental health problems. Homeless youth presented with a higher prevalence of suicidal ideation, past suicide attempts, depressive symptomatology, and internalizing and externalizing behavior problems. Disengagement coping was a predictor of suicidal ideation, past attempts, depressive symptoms and both internalizing and externalizing behavior problems in homeless youth. CONCLUSIONS: Relative to non-homeless youth, findings indicate that homeless youth reported greater use of a disengaging coping style and are at greater risk for high-risk behaviors, past suicide attempts, and clinically elevated levels of depressive symptoms and behavior problems.     

Self-harm and suicide attempts among high-risk, urban youth in the U.S.: shared and unique risk and protective factors

The extent to which self-harm and suicidal behavior overlap in community samples of vulnerable youth is not well known. Secondary analyses were conducted of the "linkages study" (N = 4,131), a cross-sectional survey of students enrolled in grades 7, 9, 11/12 in a high-risk community in the U.S. in 2004. Analyses were conducted to determine the risk and protective factors (i.e., academic grades, binge drinking, illicit drug use, weapon carrying, child maltreatment, social support, depression, impulsivity, self-efficacy, parental support, and parental monitoring) associated with both self-harm and suicide attempt. Findings show that 7.5% of participants reported both self-harm and suicide attempt, 2.2% of participants reported suicide attempt only, and 12.4% of participants reported self-harm only. Shared risk factors for co-occurring self-harm and suicide attempt include depression, binge drinking, weapon carrying, child maltreatment, and impulsivity. There were also important differences by sex, grade level, and race/ethnicity that should be considered for future research. The findings show that there is significant overlap in the modifiable risk factors associated with self-harm and suicide attempt that can be targeted for future research and prevention strategies.     

2所中专学校学生自杀行为及其人口特征学研究

目的了解中专生自杀行为的现状及其人口统计学特征,为中专学校学生心理健康教育提供依据.方法以某市2所中专学校共2 032名中专生为调查对象进行现况调查.自杀行为的定义与问卷设计与美国疾病控制中心(CDC)青年危险行为监测系统(YRBSS)相同.结果中专生总体自杀意念发生率为26.6%,自杀计划发生率为13.4%,自杀企图发生率为7.5%.各年龄分组比较,自杀意念发生率差异有显著性.17岁以下学生自杀意念发生率显著高于18岁以上组(P＜0.001),女生自杀意念发生率显著高于男生,非汉族中专生自杀意念发生率高于汉族学生.来自农村学生3种自杀行为的发生率均低于来自城市的学生.父母文化程度、是否在外工作(打工)对中专生的自杀行为无显著影响.多元非条件Logistic回归分析表明,年龄大为自杀意念的保护因素,非汉族、家住城镇和学习成绩差为自杀意念的危险因素;家庭所在地为城市、学习成绩差为自杀计划的危险因素;年级为自杀企图的保护因素,而家住城市为危险因素.结论中专生的自杀意念、自杀计划和自杀企图发生率较高,自杀行为的发生率受人口统计学特征的影响.应加强对中专生的心理健康教育.     

Adolescent depression and suicide risk: association with sex and drug behavior

BACKGROUND: Depression is common among adolescents, and suicide is the third leading cause of death among 15- to 19-year-olds. Although both health problems have been associated with drug use and early sexual intercourse, the relationship has not been systematically studied in a nationally representative sample. METHODS: Sixteen patterns of combined sex and drug use behaviors were obtained using cluster analysis of responses to Wave I of the National Longitudinal Study of Adolescent Health conducted from September 1994 through December 1995. Bivariate and multivariate analyses tested correlations between behavior patterns and current depression, serious suicidal ideation, and previous suicide attempt, controlling for gender, race/ethnicity, Hispanic ethnicity, family structure, and parent education. RESULTS: Compared to youth who abstain from risk behaviors, involvement in any drinking, smoking, and/or sexual activity was associated with significantly increased odds of depression, suicidal ideation, and suicide attempts. Odds ratios were highest among youth who engaged in illegal drug use. There were few differences between boys and girls who abstain from sex and drug behaviors. Girls were less likely than boys to engage in high-risk behaviors, but those who did tended to be more vulnerable to depression, suicidal ideation, and suicide attempt. CONCLUSIONS: Teens engaging in risk behaviors are at increased odds for depression, suicidal ideation, and suicide attempts. Although causal direction has not been established, involvement in any sex or drug use is cause for concern, and should be a clinical indication for mental health screening for girls; both boys and girls should be screened if engaging in any marijuana or illegal drug use.     

Les sources d’information sur les tentatives de suicide dans le Nord - Pas-de-Calais. Apports et limites

BackgroundThere are very few permanent indicators of mental health in France; suicidal behavior is often only understood on the basis of deaths by suicide.MethodThe epidemiological interest and methodological limits of four medico-administrative databases from which data on suicide attempts can be extracted have been the subject of a study in the Nord - Pas-de-Calais Region of France: telephone calls for emergency medical assistance after suicide attempt (2009 to 2011), admissions in emergency services with a diagnosis of suicide attempt (2012), medical-surgical hospital admissions as a result of suicide attempt (2009 to 2011), and psychiatric admissions with a diagnosis of suicide attempt (2011).ResultsUsable data were provided by one of two emergency medical assistance units, five of thirty emergency departments and all medical-surgical and psychiatric units; in data from the latter two sources, a unique anonymous identifier gave individual statistics, while the first two covered only suicide attempts. In 2011, the number of suicide attempt calls per 100,000 inhabitants was 304, whereas the number of hospitalisations with this diagnosis was 275; rates are highest in men between 20 and 49 years of age, and in women below 20 years of age and between 40 and 49. Sources are seen to be very homogeneous with regards to the average age at which suicide took place (between 37.8 and 38.5 years, depending on the source), and to the sex (55.0% to 57.6% of women). In 2011, the number of patients with a diagnosis of suicide attempt treated in psychiatry is 2.6 times lower than the number hospitalised for suicide attempt in medical-surgical units (3563 vs 9327).ConclusionPermanent gathering of data, and the large volume of data recorded, should encourage the use of these databases in the definition and assessment of mental health policy: an increased contribution from emergency call centers and emergency services, and the coding of the suicidal nature of intoxications by a few clearly under-declaring units, must however be achieved in order to improve this source of information.     

Suicidal Thoughts and Attempts Among U.S. High School Students: Trends and Associated Health-Risk Behaviors, 1991–2011

PurposeTo describe secular trends in suicidal thoughts and attempts and the types of health-risk behaviors associated with suicidal thoughts and attempts among U.S. high school students.MethodsData were analyzed from 11 national Youth Risk Behavior Surveys conducted biennially during 1991–2011. Each survey employed a nationally representative sample of students in grades 9–12 and provided data from approximately 14,000 students. Using sex-stratified logistic regression models that controlled for race/ethnicity and grade, we analyzed secular trends in the prevalence of suicidal thoughts and attempts. Adjusted prevalence ratios (APR) were calculated to measure associations between suicide risk and a broad range of health-risk behaviors.ResultsDuring 1991–2011, among female students, both suicidal thoughts (seriously considered suicide; made a plan to attempt suicide) and attempts (any attempt; attempt with injury requiring medical treatment) decreased significantly; among male students, only suicidal thoughts decreased significantly. During 2011, compared with students with no suicidal thoughts or attempts, the health-risk behaviors most strongly associated with suicide attempts among female students were injection drug use (APR = 12.8), carrying a weapon on school property (APR = 9.7), and methamphetamine use (APR = 8.7); among male students, the strongest associations were for IDU (APR = 22.4), using vomiting/laxatives for weight control (APR = 17.1), and having been forced to have sex (APR = 14.8).ConclusionsSchool-based suicide prevention programs should consider confidential screening for health-risk behaviors that are strongly associated with suicide attempts to help identify students at increased risk for suicide and provide referrals to suicide and other prevention services (e.g., substance abuse and violence prevention) as appropriate.     

Ethnicity and the relationship between adolescent alcohol use and suicidal behavior

Adolescent suicide is the 3rd leading cause of death in the United States and alcohol consumption is estimated to cause adolescent males to be up to 17 times more likely to attempt suicide, and females three times more likely to attempt suicide. Suicide and suicide attempt rates vary across different ethnicities. Also, associated psychopathology, stressors and substance use differ across ethnic groups in adolescents. In an exhaustive review of the literature, we found that depressed Asian-American youth were four times more likely to display suicidal behavior when compared to other Asian youths with other diagnoses; and depressed African-American females were more likely to report suicidal ideation than male adolescents. We also found that Asian-Americans who experience high parental conflict are 30 times more likely to engage in suicidal behavior when compared to Asian-American youths with low parental conflict. African-American adolescents are 6.4 times more likely to attempt suicide as a result of parental conflict. With respect to alcohol use and dependence, Caucasian adolescents were twice as likely as the African American victims to have used alcohol before committing suicide. Alcohol use among adolescents was associated with increased suicidal behavior. Cultural differences in alcohol consumption may account for disparities, however future research is needed to further examine cultural trends in suicidal behavior and alcoholism.     

Suicidal ideation and self-harm behavior in a community sample of preadolescent youth: a case-control study

ObjectiveResearch has focused on understanding risk factors associated with suicidal ideation and self-harm behaviors in older youth, but less is known regarding these behaviors in preadolescents. We examined characteristics associated with suicidal ideation and self-harm behavior in youth aged 10–13 years.Design/MethodsA community sample of 387 youth was enrolled in a prospective study assessing precursors of risk behaviors. Twenty-three subjects endorsing items regarding suicidal ideation or self-harm behaviors (Achenbach's Youth Self-Report) (endorsers) were matched with 23 non-endorsers. Groups were compared on problem behaviors, impulsivity, neurocognitive function, risk behaviors, and other variables.ResultsEndorsers had higher levels of impulsivity, were more likely in borderline/clinical range on 5 of 8 Youth Self-Report Syndrome scales, and reported more risk taking. Endorsers and non-endorsers were similar in neurocognitive function. More non-endorsers were on stimulants, but groups were similar in parental monitoring and parental report of behavioral/emotional issues, socioeconomic status, and marital status.ConclusionIn this study, preadolescent endorsers report significantly more problem behaviors than non-endorsers. However, parental monitoring and parent report of problems were similar between groups. Given these findings, we suggest that at-risk youth may be underrecognized at young ages.     

Medical and Psychosocial Risk Profiles for Low Birthweight and Preterm Birth

ObjectivesLow birthweight and preterm birth are risk factors for infant mortality and persistent problems. This study uses representative data to assess whether distinct latent profiles of co-occurring medical and psychosocial factors have implications for preterm birth and low birthweight.MethodsData are from the Pregnancy Risk Assessment Monitoring System, a cross-sectional survey constituting representative data on pregnancies from 2012 to 2013. Latent class analysis derived classes of pregnant women potentially at risk for low birthweight and/or preterm birth.ResultsLatent class analysis identified five homogenous profiles of interrelated psychosocial and medical factors. Risk was greatest for the profile marked by high rates of medical factors, followed by a high risk for a profile marked by a combination of very low income and psychosocial factors. Two profiles involving low income and very low income also indicated greater risk for adverse birth outcomes related to socioeconomic status.ConclusionsMore attention should be paid to screening for and addressing psychosocial risk in concert with prenatal care. Women who show high-risk profiles can be monitored and supported by an interdisciplinary care team, when warranted.     

School-Based Screening for Suicide Risk: Balancing Costs and Benefits

Objectives. We examined the effects of a scoring algorithm change on the burden and sensitivity of a screen for adolescent suicide risk.Methods. The Columbia Suicide Screen was used to screen 641 high school students for high suicide risk (recent ideation or lifetime attempt and depression, or anxiety, or substance use), determined by subsequent blind assessment with the Diagnostic Interview Schedule for Children. We compared the accuracy of different screen algorithms in identifying high-risk cases.Results. A screen algorithm comprising recent ideation or lifetime attempt or depression, anxiety, or substance-use problems set at moderate-severity level classed 35% of students as positive and identified 96% of high-risk students. Increasing the algorithm''s threshold reduced the proportion identified to 24% and identified 92% of high-risk cases. Asking only about recent suicidal ideation or lifetime suicide attempt identified 17% of the students and 89% of high-risk cases. The proportion of nonsuicidal diagnosis–bearing students found with the 3 algorithms was 62%, 34%, and 12%, respectively.Conclusions. The Columbia Suicide Screen threshold can be altered to reduce the screen-positive population, saving costs and time while identifying almost all students at high risk for suicide.Adolescents commonly keep their thoughts about suicide to themselves and many suicide attempts go unrevealed to parents and other adults^1–4; furthermore, adolescents rarely seek treatment on their own. ^5,6 Proactive screening programs for adolescent suicidality rely on the identification of the principal risk factors for completed suicide (i.e., current suicidal ideation, previous attempt behavior, and the presence of a mood, anxiety, or substance use disorder). ^5,6One proactive screening program, the Columbia Teen Screen program, has employed a school-based screening approach, the Columbia Suicide Screen (CSS), that involves administering a self-completion form with questions about risk factors for suicide such as suicidal ideation, prior suicide attempts, depression, anxiety, and substance use. Students who screen positive (stage 1) are then seen by a clinician for a secondary confirmatory evaluation (stage 2) and, if indicated, the student is case managed to an appropriate referral. With its original algorithm, the CSS has been shown to identify 75% of students considered to be at high risk for suicide⁷and a third of students who had unspecified mental health problems that were not already known to school professionals.⁸ Criticisms that the approach generated many false positives were based on our previous reports⁷ that were limited to identifying high-risk cases^9–11 and ignored the fact that screening for suicidal ideation and behaviors will commonly reveal nonsuicidal mental illnesses that have never been disclosed.Much of the cost of screening comes from providing confirmatory evaluations to students identified during the initial part of a 2-stage procedure. Falsely identifying students who do not have a significant mental health problem adds to the cost of screening. To minimize this problem, these costs need to be weighed against the benefits of identifying students considered to be at high risk for suicide along with those who are not deemed to be at high risk for suicide but who do have an undiagnosed but significant, impairing, and treatable mental health condition. Second-stage evaluations that fail to confirm the need for clinical referral are therefore a necessary but at times onerous burden.We report, for the first time, how varying the items and threshold of the items that determine whether an adolescent screens positive affects the accuracy and the program burden of the CSS. Our research questions were: (1) What effect does altering the scoring algorithm of the CSS have on identifying adolescents at high risk for suicide? and (2) What effect does altering the scoring algorithm of the CSS have on reducing the burden of confirmatory evaluations for a screening setting?