August 2006, Vol 96, No. 8 | American Journal of Public HealthLetters | 1339 Letters | 1339
SCREENING FOR SUICIDE RISK
I read with great interest the article on
screening high-school students for suicide risk
by Hallfors et al.1The suicide prevention pro-
gram described by Hallfors et al. appeared to
be one of the best implemented and managed
programs possible. When it failed, the authors
looked at organizational factors at the school
level to suggest how the program could be
better implemented on a more consistent
basis. A more likely hypothesis is that this sui-
cide prevention program was not feasible in a
real-world school setting and a different ap-
proach should be adopted.
American Journal of Public Health | August 2006, Vol 96, No. 81340 | Letters
More than 10 years ago, our research team
faced a similar problem when studying home-
less youths.2,3Screening on statistically based
risk factors (e.g., past attempts, depression,
ideation) would yield statistically based rates
of suicide risk of more than 80% among
homeless youths. It would not be feasible to
base any suicide prevention program on the
results of such screening; to do so would re-
quire one full-time shelter staff member just
to take youths designated as at risk to the
emergency room for psychiatric intervention.
Screening is feasible only for imminent dan-
ger of suicide, not for risk. Screening for risk
is likely to identify all adolescents demonstrat-
ing multiple problem behaviors, not only
those who are likely to attempt suicide.
We proposed a screening strategy based on
behavioral characteristics incompatible with
suicidal behavior: being able to identify positive
events and personal attributes, being able to
specify situations that would elicit suicidal acts,
having a plan for dealing with suicidal feelings,
being able to verbalize one’s current mood,
being able to identify 3 persons to seek social
support from if suicidal feelings arose, and
contracting not to engage in suicidal behavior.
Screening based on these criteria yielded a
much smaller group—only 1.2% of the youths
screened were considered at risk and referred
for further screening by a backup professional.3
This was a feasible screening strategy.
When elegant research programs do not
work, it is incumbent on us to consider that our
approach may be wrong, not the organization
in which we try to mount our programs. Hall-
fors et al. are a great research team and could
address suicide risk with a different strategy.
Mary Jane Rotheram-Borus, PhD
About the Author
Requests for reprints should be sent to Mary Jane
Rotheram-Borus, PhD, Center for Community Health,
UCLA, 10920 Wilshire Blvd, Suite 350, Los Angeles,
CA 90024 (e-mail: firstname.lastname@example.org).
1.Hallfors D, Brodish PH, Khatapoush S, Sanchez V,
Cho H, Steckler A. Feasibility of screening adolescents
for suicide risk in “real-world” high school settings. Am
J Public Health. 2006;96:282–287.
2.Rotheram-Borus MJ. Evaluation of imminent dan-
ger for suicide among youth. Am J Orthopsych. 1987;
3. Rotheram-Borus MJ. Evaluation of suicide risk
among youths in community settings. Suicide Life
Threat Behav. 1989;19:108–119.