Looking at Global Mental Health Models to Prevent Youth Suicide in the United States

Introduction

Reducing population-based youth suicide rates among ethnoracially minoritized youth requires us to reevaluate the traditional ways of delivering mental health care in the United States and look globally at models that have successfully reduced barriers to care. Despite national efforts to reduce youth suicide, in the United States, suicide is the second leading cause of death for adolescents 10 to 14 years old and the third for those 15 to 24 years old.¹ Suicide ideation and attempts, the strongest predictors of death by suicide,² have increased in the last decade for the US adolescent population, particularly for ethnoracially minoritized youth.^3–5 In the United States, we face similar challenges to other countries regarding increased demand for child mental health services⁶ and a mental health workforce shortage, which increases the gap between need and access.

Task-shifting to Address Adolescent Mental Health

In low-resource countries, task-shifting evidence-based mental health interventions have been used to increase access to mental health care and decrease depression symptoms, such as sadness and hopelessness.^7–9 The task-shifting approach was first implemented as a global response to health workforce shortages and increased demand for services to ameliorate the HIV burden.¹⁰ Task-shifting is the distribution of tasks from specialized providers in specialized settings to non-specialized providers (cf. lay providers) in community settings to address the service provision gap.¹⁰ Evidence suggests that task-shifting improves access to mental health services and reduces negative mental health outcomes^11–13 and is a promising, just, and equitable solution to improve youth mental health burden.¹⁴ An important aspect of task-shifting is that trained and supported non-specialized providers are individuals who share lived experiences, including sharing language, ethnicity, gender, mental health conditions, or socioeconomic conditions with those who they serve, which reduces stigma and increases trust.^15,16 Several examples from the global literature on task-shifting suggest the potential of this strategy to address adolescent mental health. One example is a brief model called Interpersonal Counseling (IPC), derived from Interpersonal Therapy (IPT), delivered by lay providers in the community, has shown robust efficacy in reducing depression symptoms and increasing access to care among adults.^9,17,18 Although there are fewer studies with adolescents, one key study in Uganda has demonstrated that task-shifting IPT-Adolescent (IPT-A; group format) delivered by trained lay providers was effective in reducing depression symptoms compared to the control group.⁸ Another study in India shows that a brief problem-solving transdiagnostic intervention delivered by lay providers in school settings improves the overall psychosocial functioning of adolescents with diverse mental health problems.¹⁹

Task-shifting for Adolescent Suicide Prevention.

Task-shifting presents a unique opportunity for suicide prevention in community-based organizations where youth and their families may feel more comfortable receiving mental health services. Schools are ideal for mental health support and suicide prevention; however, the lack of multicultural and multilingual school staff continues to be a barrier to implementing school-based programs.²⁰ Youth community centers also offer an opportunity for task-shifting suicide prevention. Youth community centers are support systems widely used by youth from disadvantaged backgrounds²¹ and offer equitable and non-stigmatized access for low-resourced youth.²² In several countries, including Canada, Australia, and New Zealand, community-based integrated youth service hubs for mental health have been effective in providing rapid and comprehensive care to adolescents.²³ In our work in the US, we have seen the desire and the need among trusted adults and community health workers in community organizations to be trained in suicide prevention. Moving suicide interventions from specialized clinical settings to community settings and lay providers has the potential for adolescents and their families to be supported where they are and to be heard by those they trust, and avoid long waiting lists to be seen by a mental health professional.

Still, published work on the evidence of lay provider-delivered mental health prevention programs is limited.¹⁶ Most evidence of its effectiveness is shown in family strengthening programs, health prevention and intervention, and postpartum depression.¹⁶ Specifically in suicide prevention, there are some examples of health prevention and family strengthening programs that do not rely on licensed providers. For example, youths supported by trained, trusted adults in the community show a lower incidence of self-injury mortality than those who are not.²⁴ Parents and caregivers can also benefit from support to maintain youth safety and strengthen protective factors. In one of our projects, we are developing a model of training Community Health Workers in a brief intervention focusing on key risk factors for youth suicide behaviors and delivered to Latinx parents via primary care settings,²⁵ indicating the potential relevance of these models in suicide prevention with Latinx youth and families.

Although there is no clear evidence yet of the criteria for task-shifting suicide interventions, the population health framework proposed by Evans & Mitchell²⁶ could inform the levels at which lay providers could intervene. This framework proposes three levels of public health intervention: 1) keeping healthy people healthy, 2) mitigating risk for those who are at risk or subclinical by providing early intervention, and 3) providing specialized clinical care for diagnosed individuals.²⁶ A successful example of suicide prevention and intervention by lay providers at all these levels is the White Mountain Apache Tribe’s Celebrating Life, a multi-level approach that includes surveillance, case management, community education, and culturally adapted interventions delivered by community mental health specialists and elders.²⁷ At the subclinical level, trained lay providers can effectively mitigate risk, and it is at this particular level that we want to bring attention to and advocate for an extension of resources through a task-shifting approach. Ideally, this approach also supports the existing mental health system by increasing the capacity for licensed providers to focus on specialized clinical care. Yet despite the task-shifting promise, there is limited use of this approach in youth behavioral health.¹⁶ We recognize that task-shifting suicide interventions for adolescents diagnosed and endorsing suicide behaviors may pose the highest challenge for lay providers because youth at risk for suicide are a high-risk population, and understandably, non-specialized providers may feel doubtful of their abilities to work with this population, or administrators may feel concerned about taking on responsibility for this work. Lay providers, however, can support youth who are already diagnosed by providing psychoeducation and community support (New Hope²⁷), navigation services to increase access to and engagement in quality care (Bridging the Gap²⁸), or supporting their parents with increased attention to psychoeducation, means restriction, and addressing barriers to health care access.²⁵

Task-shifted delivery of interventions in community-based organizations should not be a replacement for specialized mental health services but rather a strategy to enhance existing community resources and empower those already working with ethnoracially minoritized youth or youth in low-resource environments (e.g., poor family support, concentrated poverty, limited access to care, geographically remote, high crime and violence^29,30) regardless of race and ethnicity, as a way to ameliorate disparities in access to care and in suicide behaviors. Thus, we propose task-shifting evidence-based mental health interventions as an upstream approach (before suicide ideation and behaviors onset), where lay providers can be trained to identify those at risk and address key risk factors such as depressive symptoms and low social connectedness^31,32 before suicide behaviors occur, as well as a complementary (to specialty mental health care) approach to increase safety and promote access to mental health care for those who have already experienced suicidal behaviors. To do this, lay providers would need appropriate training and ongoing support; systems would need to be put in place that allow the responsibility of this work to shift to the community and to have ongoing reliable monitoring in place to ensure it is safe and works. Collaboration and coalitions between researchers, mental health providers, community leaders, parents, and youth are necessary to establish an infrastructure to support lay providers in the community, including a plan for training and supervision and structural support.³³ Finally, time constraints for training lay providers and incorporating the interventions into the agency or school programming must be considered, and funding for the sustainment of these interventions is an ongoing challenge and priority. The current state of the task-shifting youth behavioral health literature is underdeveloped. There is a need to understand what qualifications, training, experiences, and types of support lay providers need and what the potential mechanisms are through which lay providers’ work is effective.¹⁶

Conclusion

It is time to add new strategies that effectively extend resources and knowledge into communities. We proposed a more comprehensive approach to suicide, one that 1) considers the voices of the communities for whom evidence-based interventions would be delivered; 2) adopts global strategies (e.g., task-shifting) that are effective in reducing mental health outcomes (e.g., depression) and increasing culturally- and linguistically- congruent access to mental health services; and 3) strengthens community resources to implement and sustain suicide prevention efforts in low-resource settings. It is time for suicide researchers to approach youth mental health more comprehensively as a public health, social justice issue and to take bold, pragmatic, and non-traditional strategies to change suicide rates among youth in the United States.