Prioritizing Prevention

In modern contexts, preventative mental health care is rarely prioritized and extremely poorly resourced as a component of an integrated health care system in accordance with it's value to communities.

Social network health research has found that prevention is, in fact, the most effective way to prevent many mental health issues, including suicidal ideation. One reason this is the case is that, in the absence of universal indicators available through diagnosis, broad based prevention can reach an entire community, reduce risk factors, and increase protective factors. The side effects of focusing on prevention are, in sum, hugely positive for community mental health.

Social Network Health approaches, which emphasize community relationships, are perfectly suited to prevention by design. The other Theory:Actions:#key action findings in social network health have been studied in the context of prevention.

NOTES:

Upstream prevention is necessary.

Existing military suicide intervention programming focuses on detecting and remediating risk after suicidal individuals are identified.  Although undoubtedly saving lives, this approach is insufficient on its own.

Wingman-Connect addresses an urgent need for preventions that are effective in reducing suicide risk across broad populations – particularly where stigma and concerns about negative career impacts remain major barriers to disclosing suicidal thoughts/behaviors.

Wingman-Connect (Wyman et al., 2020 & 2022) uses a network health theoretical framework to strengthen two suicide-protective functions of social networks: 1) Strengthening positive social bonds, and 2) Building healthy norms that incentivize adaptive coping.

This expanded focus on modifying “upstream” risk and protective processes—before the emergence of suicidal behavior—stands in contrast to current youth suicide prevention programming focused on identifying and treating individuals who are already suicidal or at high risk by training adult gatekeepers and screening. (Wyman 2014)

Childhood and adolescence are key suicide “prevention window” periods. Approximately one half of emotional and behavioral disorders that are well-defined risk factors for suicide have onset of symptoms by age 14 years.2 Many effective programs for children and adolescents prevent or reduce the severity of these mental, emotional, and behavioral problems, according to a recent National Academy of Sciences review.2 In addition to being a critical period for preventing disorders, childhood and early adolescence are important periods for preventing the onset of suicidal behaviors (Wyman 2014)

Interventions delivered in social systems are needed for broad impact Children develop through interactions within social systems (e.g., families, schools), and interventions in these systems can influence emotional and behavioral developmental processes of large youth populations essential to reduce suicide rates. (Wyamn 2014)

Upstream interventions delivered through social systems in childhood and early adolescence have the potential for reducing population-level suicide rates by decreasing the number of adolescents with mental emotional and behavioral problems, as well as creating social environments that expose adolescents to positive coping norms, increase youth-adult connections, and reduce adverse experiences such as bullying. (Wyman 2014)

Wyman PA. Developmental approach to prevent adolescent suicides: research pathways to effective upstream preventive interventions. Am J Prev Med. 2014 Sep;47(3 Suppl 2):S251-6. doi: 10.1016/j.amepre.2014.05.039. PMID: 25145747; PMCID: PMC4143775.

Treatment:

Peer-adult network structure and suicide attempts in 38 high schools: implications for network-informed suicide prevention (10,291 students)  

In 38 US high schools, 10,291 students nominated close friends and trusted adults to construct social networks. Network interventions addressing these processes, such as maximizing youth-adult connections schoolwide and heightening influence of youth with healthy coping, could create more protective schools. Lower peer network integration and cohesion increased likelihood of SI and SA across individual and school-level models. Two factors increased SA: student isolation from adults and suicidal students' popularity and clustering.

Journal of Child Psychology and Psychiatry *: * (2019), Peter A. Wyman, Trevor A. Pickering, Anthony R. Pisani, et al.

To date, suicide prevention has focused primarily on individual-level psychiatric risk factors and on strategies to refer and treat high-risk youth. Yet researchers and policymakers recommend strengthening positive social bonds because social integration can reduce suicidal behavior in youth

To our knowledge, this is the first study of any adolescent health problem, including suicidal behavior, that integrates adult connections into friendship networks at a school population level.

Network interventions addressing these processes, such as maximizing youth–adult connections schoolwide and heightening influence of youth with healthy coping, could create more protective schools. The present study is the first empirical evidence linking more integrated youth–adult networks (i.e., students sharing trusted adults with friends) to lower Suicide Attempts.

Effect of the Wingman-Connect Upstream Suicide Prevention Program for Air Force Personnel in Training.  A Cluster Randomized Clinical Trial

JAMA Open Network, October, 2020

Group training that builds cohesive, healthy military units is promising for upstream suicide prevention.

The Wingman-Connect program used group skill building for cohesion, shared purpose, and managing career and personal stressors.  Wingman-Connect is the first universal prevention program to reduce suicidal ideation and depression symptoms in a general Air Force population. Group training that builds cohesive, healthy military units is promising for upstream suicide prevention.

Wingman-Connect is the first universal prevention program to reduce suicidal ideation and depression symptoms in a general Air Force population. Group training that builds cohesive, healthy military units is promising for upstream suicide prevention and may be essential for ecological validity.

Network health interventions target natural organizational groups to strengthen bonds, cohesion, and adaptive coping norms, all of which are logical targets for upstream suicide prevention.

Strong bonds reduce vulnerability to depression, and postenlistment depression is a specific factor associated with suicide attempts among military personnel.

Skills focused on growing and sustaining 4 core protective values: kinship (belonging and accountability), purpose (goals and motivating values), guidance (mentors and institutional resources), and balance (activities for well-being). Each class completed group exercises emphasizing cohesion, shared purpose, and the value of a healthy unit.

Wingman-Connect participants gained on all class protective factors: cohesion, morale, bonds to classmates, and perceptions that members support healthy behaviors

Wingman-Connect increased positive career behaviors and reduced anxiety and anger. Social impairments were reduced among participants

The magnitude of effects at 1 month (ES, −0.23 to −0.24) was equivalent to those of state-of-the-art prevention programs targeting broad adolescent and young adult populations where the majority are not at high risk.61 The beneficial impact on reduced depression symptoms was maintained at 6 months, including lower likelihood of elevated depression (OR, 0.80) over the full study period.

The dual benefits for occupational functioning and mental health underline a strength of upstream prevention implemented before the detection of serious suicidal behavior: skills that strengthened the trainee’s capability to meet job-related challenges also reduced depression

The study’s findings validate the underlying network health model: stronger bonds within a more cohesive healthy class reduced suicidal ideation and depression symptoms

These findings suggest that Wingman-Connect classes became increasingly unified around healthy norms and encouraged classmates who were vulnerable to mental health or occupational problems at a key juncture of military training, in addition to meeting their needs for belonging

PBIS:

Tier 1 systems, data, and practices support everyone across all settings. They establish the foundation for delivering regular, proactive support and preventing unwanted behaviors. Tier 1 emphasizes modeling, teaching, and acknowledging positive social, emotional, and behavioral (SEB) skills.

https://www.pbis.org/pbis/tier-1

Modern conceptions of mental health have transitioned from a predominantly problem reduction focus to a wellness promotion focus (Suldo & Shaffer, 2008). Thus, rather than exclusively targeting symptom reduction in individuals with mental illness, mental health services have gravitated towards prevention services that promote general wellness of the population (Prinz & Sanders, 2007). To attend to these issues, school-wide interventions based on the public health prevention model emerged in schools, most notably in the form of positive behavior interventions and support (PBIS; Smith, Molina, Massetti, Waschbush, & Pelham, 2007). PBIS is a framework or approach that provides the means of selecting, organizing and implementing [evidence-practices] by giving equal attention to (a) clearly defined and meaningful student outcomes, (b) data-driven decision making and problem solving processes, and (c) systems that prepare and support implementers to use these practices with high fidelity and durability. (Sugai & Horner, 2010, p. 4).

Instrumental mentoring can be a vehicle for evidence-based practice in a manner that allows for evaluations of independent and combined effects with other interventions. We propose that integration of SBM and school-wide supports systems can improve both programmes if stakeholder systematically ‘select, organize and implement’ instrumental programmes similar to the one described in this paper. For example, consider a middle school that has goals such as improving academic organization. The PBIS team could promote this goal at a primary prevention level (i.e. Tier 1) by setting school-wide expectations, encouraging universal classroom instruction and delivering rewards to students that maintain academic organization. A PBIS monitoring system could quickly identify at-risk students by measuring their response to the primary intervention. School support teams could then refer students not responding to the primary programme to an instrumental mentoring intervention, the mentoring programme being the Tier 2 or secondary intervention. By using volunteer mentors, school-based mental health teams could provide more Tier 2 intervention services to more students than they could using native school staff

https://www.researchgate.net/profile/Samuel-Mcquillin/publication/259176991_Innovation_in_school-based_mentoring_Matching_the_context_structure_and_goals_of_mentoring_with_evidence-based_practices/links/56bb5ede08ae0908186810d6/Innovation-in-school-based-mentoring-Matching-the-context-structure-and-goals-of-mentoring-with-evidence-based-practices.pdf