Suicide remains a leading cause of death among youth in the United States, with disproportionately elevated risk in rural communities. Schools represent a critical and underutilized setting for suicide prevention, offering a practical avenue to overcome barriers related to access, workforce shortages, and service fragmentation. This special issue is informed by decades of school-based clinical and research experience and highlights the need for a comprehensive, multi-tiered approach to suicide prevention in schools and underscores the urgent need to expand research and practice at the tertiary level. Strengthening partnerships among schools, researchers, and community mental health systems will be essential to advancing effective, equitable, and scalable interventions. Collectively, the contributions in this issue aim to catalyze continued progress in addressing youth suicide within K–12 settings.

OBJECTIVE:The specific influence of individual characteristics on antidepressant efficacy and tolerability in pediatric major depressive disorder (MDD) remains unclear. This study aimed to characterize subgroup-specific treatment efficacy and to establish a preliminary scientific foundation for precision psychiatry in pediatric MDD management based on available data. METHOD:An individual participant data (IPD) analysis of double-blind randomized trials (RCTs) was conducted to compare antidepressants with placebo for the acute treatment of MDD in children and adolescents. Subgroup analyses identified treatment outcome differences by participant characteristics, with mixed-effects models used to examine effect modifiers. Primary outcomes were efficacy (depressive symptom change, mean difference [MD]) and tolerability (adverse event-related withdrawals, odds ratio [OR]). Secondary outcomes included deterioration and suicide-related outcomes. The protocol is registered with PROSPERO (CRD42016051657). RESULTS:IPD from 10 of 40 eligible RCTs (2,584 participants) on 5 antidepressants (fluoxetine [n = 475], imipramine [n = 95], paroxetine [n = 413], desvenlafaxine [n = 358], duloxetine [n = 341]), and placebo [n = 902] were analyzed. Most trials had "some concerns" for risk of bias. There was also substantial missing data for key covariates (eg, 53% for family history of psychiatric disorders). Inconsistencies in the reporting and collection of suicide-related outcomes (ideation and attempts) limited our analyses. In the individual participant meta-analysis, subgroup analysis showed that fluoxetine was the only agent significantly more effective than placebo (MD = -2.43). Imipramine (OR = 5.43) and paroxetine (OR = 1.85) showed poor tolerability. In terms of subgroup analyses based on individual participant characteristics, fluoxetine demonstrated superior efficacy in children, female participants, White participants, healthy weight participants, and those with severe symptoms (MDs = -3.90 to -2.60). Fluoxetine also showed less deterioration in female participants (OR = 0.55, 95% CI = 0.37 to 0.83). No significant differences in suicide-related outcomes were observed across subgroups based on individual characteristics. CONCLUSION:These provide a preliminary understanding of one possible precision medicine framework for pediatric MDD, indicating that individual characteristics (age, sex, ethnicity, body mass index [BMI], symptom severity, family history) may influence treatment outcomes. Exploratory subgroup analyses suggest fluoxetine's efficacy may be more pronounced in certain populations: children, female participants, White individuals, healthy weight participants, and those with severe symptoms. These findings should be interpreted with caution as IPD was only available from a quarter of eligible clinical trials, introducing data availability bias. These findings also require further validation in more diverse cohorts. Universal suicide-related outcome assessment across all subgroups (regardless of individual characteristics) remains essential. Broader data sharing is needed to improve representativeness in future IPD analyses. STUDY REGISTRATION INFORMATION:Comparative efficacy and tolerability of new-generation antidepressants for major depressive disorder in children and adolescents: protocol of an individual patient data meta-analysis; https://www.crd.york.ac.uk/PROSPERO/view/CRD42016051657.

AbstractIndividuals who live in rural communities face health challenges, including a higher risk of suicide and opiate dependence, and relatively fewer healthcare resources compared to those found in urban communities. The most prominent barriers to effective suicide prevention in rural areas include limited availability of healthcare providers, transportation limitations, economic disparities, a lack of broadband access, and reluctance to seek professional treatment. Despite these barriers, school mental health partnerships and telehealth models of care have shown promise in addressing several of these barriers in practice. These two innovations will be discussed in detail and how they help overcome some of the known barriers to effective suicide prevention in rural communities.

Historically, the suicide rates in rural and Indigenous communities have been disproportionately high. Since the COVID-19 pandemic, stigma, mental health workforce shortages, and the diminished health care infrastructure in rural and remote regions have only amplified this trend. Fortunately, several innovative and culturally responsive approaches have been developed in the context of these communities to address these persisting mental health disparities. Two specific approaches, embedded school mental health partnerships and telehealth solutions, are described in detail in this article. Both examples have shown considerable promise in stemming the tide of these sobering epidemiological trends in rural and Indigenous communities.

Background Educators in rural schools are uniquely situated to address youth mental health disparities, yet often face challenges in delivering mental health supports. This paper describes the process of adapting the evidence-based Coping Power program, a small group prevention program for youth with aggressive behavior problems, to be a two-tiered (Tier 1 and Tier 2), transdiagnostic intervention to improve fit and feasibility for rural upper elementary and middle schools. Method Identified challenges with the Coping Power program for rural areas included program length, substantial staffing and resource requirements, lack of universal programming, low caregiver engagement, and co-occurring problems. Initial adaptations included a classroom and small group format implemented by school staff, teacher consultations integrated into coaching and co-facilitation, and a technology-supported caregiver component. Implementer feedback forms, coaching notes, and individual interviews informed the iterative development and feasibility testing process. Results Between 2019 and 2023, thirteen schools across six rural districts implemented the program. Student curriculum revisions included order and relative emphasis of content, classroom and small group overlap, necessary simplification of concepts, improved contextualization to the rural setting, and the addition of student workbooks. Supports for implementers included fully developed lesson plans and slides, a comprehensive implementation manual, video lesson overviews, action-focused training, and a 3-session coaching model to support implementer preparation and sustain motivation. Teacher and caregiver infographic text “nudges” were improved to promote generalization of concepts across settings. Discussion By partnering with school-based implementers, the adapted program holds promise to be more feasible and appealing for rural schools than the original model. This fully developed program is now ready for larger-scale testing in rural schools.

Background: Data are scarce on assessing the impact of the COVID-19 pandemic on young people. Aim: To examine changes in crisis text patterns in the United States during the pandemic compared to the prepandemic period. Method: Nonintrusive data from a national digital crisis texting platform were analyzed using an interrupted time series design. Poisson regression with repeated-measures examined help-seeking patterns for stress, anxiety, depression, suicidal thoughts, and other mental health concerns in the pandemic (March 13 to July 20, 2020) compared to the prepandemic period (March 13 to July 20, 2019). Results: An abrupt increase in national crisis response texts occurred during the pandemic for stress and anxiety, substance abuse, bereavement, isolation, and abuse compared to the prepandemic period. Similar trends of excess texts for isolation and abuse were reported among children (relative risk [RR]abuse: 1.16, CI: 1.03, 1.31; RRisolation: 1.15, CI: 1.09, 1.21) and adolescents (RRabuse: 1.17, CI: 1.11, 1.24; RRisolation: 1.08, CI: 1.05, 1.11), bereavement among Black (RR: 1.31, CI: 1.12, 1.54) and Hispanic (RR: 1.28, CI: 1.10, 1.49) texters, and isolation and bereavement in female (RRisolation: 1.09, CI: 1.06, 1.11; RRbereavement: 1.21, CI: 1.13, 1.28) or nonconforming youth (RRisolation: 1.19, CI: 1.08, 1.32; RRbereavement: 1.50, CI: 1.08, 2.09) texters. Conversely, the risks of reporting bullying, depression, relationship issues, and suicidal thoughts as reasons for texting were significantly lower during COVID-19. Limitations: Results may underestimate crisis support-seeking in some groups because demographic data were not captured on all texters. Conclusion: Findings illuminated the real-time crisis response of young people across the United States and can inform more responsive interventions to alleviate the mental health consequences brought on by the COVID-19 pandemic.

Little research has examined the mental health risks of concurrent disasters. For example, disasters like wildfires have been shown to have a strong association with psychological symptoms-the 2020 U.S. Western wildfire season was the worst on record and occurred while the country was still navigating the COVID-19 pandemic. We implemented two quasi-experimental analyses, an interrupted time series analysis, and a difference-in-difference analysis to evaluate the impacts of wildfires and COVID-19 on mental health crisis help-seeking patterns. Both methods showed no statistical association between exposure to wildfires and the seeking of mental health support during the COVID-19 pandemic. Results highlighted that 2020 wildfires were not associated with an acute increase in crisis texts for youth in the two months after the events, likely due to an already elevated text volume in response to the COVID-19 pandemic from March 2020 throughout the fall wildfire season (Aug to Oct 2020). Future research is needed outside of the context of the pandemic to understand the effects of extreme and concurrent climatic events on adolescent mental health, and targeted interventions are required to ensure youth and adolescents are receiving adequate support during these types of crisis events.

BACKGROUND:Most suicide prevention programs focus on increasing knowledge regarding the problem of suicide, yet many fail to include information on the science and application of means reduction approaches. In an attempt to address this gap in practice, the Counseling on Access to Lethal Means (CALM) program was developed to educate clinicians on the importance of means reduction interventions.METHODS:In the current study, a gatekeeper CALM training was delivered to 167 resident assistants. Confidence levels regarding suicide prevention and means reduction skills were assessed at baseline, post-training, and after a 6-week follow-up.RESULTS:Results were suggestive of medium to large training effects. Though there was a small decay of training effects at follow-up, the effects were durable when compared to baseline levels.CONCLUSION:Given these findings, future gatekeeper trainings should be provided more consistently to help sustain the effects and data on the implementation of CALM principles should be measured during follow-up assessments.

Purpose: This study characterized the unobserved patterns in crisis response among youth in the U.S. from March to December 2020 and determined the characteristics of vulnerable subgroups who were at increased risk for suicide due to the pandemic. Methods: A latent class analysis of crisis support-seeking from a national text-based crisis platform, (n = 179,497, aged 24 years or younger) for 11 crisis concerns (e.g., depression, anxiety/stress, suicidal thoughts, isolation, abuse, bereavement, relationships) was performed on three study periods: (1) January 2017 to December 2020, (2) prepandemic: 1 January 2017 to 12 March 2020, and (3) pandemic: 13 March to 20 December 2020. Demographic characteristics (age, race/ethnicity, sexual orientation, and gender identity) were used as predictors for class membership using the three-step method. Results: Four latent classes were identified: (1) depression/isolation/self-harm (D/I/S) (18,694 texters, 10.4%), (2) interpersonal stress/mood-anxiety (I/M) (32,640 texters, 18.2%), (3) suicidal thoughts/depressed (S/D) (34,067, 19.0%), and (4) adjustment/stress (A/S) (94,096 texters, 52.4%). During the pandemic, an increase in suicidal thoughts and active rescues occurred in the D/I/S and S/D higher-risk subclasses. Characteristics of vulnerable groups in higher-risk classes since the pandemic included children, LGBTQ American Indian, White, Black, Asian, female, and gender-nonconforming youth. Conclusions: Results identified a strong association with class membership in more severe risk classes during the pandemic and an increase in suicidal help-seeking, particularly among children and LGBTQ youth. Low-cost and targeted crisis text-based platforms for support-seeking in youth may be one potential safety net strategy to address the effects of the COVID-19 pandemic on mental health in youth. (C) 2021 Society for Adolescent Health and Medicine. All rights reserved.

IMPORTANCE Crisis text lines have proven to be an effective and low-cost means for delivering texting-based mental health support to youth. Yet there has been limited research examining the use of these services in capturing the psychological impact on youth affected by a weather-related disaster. OBJECTIVE This ecologic study examined changes in help-seeking behavior for adolescents and young adults in North and South Carolina, USA, before and after Hurricane Florence (2018). DESIGN AND MAIN OUTCOMES A retrospective, interrupted time-series design was used to examine pre- and post-hurricane changes in crisis text volume among youth help seekers in the Carolinas for the following outcomes: (1) text for any reason; (2) stress & anxiety; (3) depression; and (4) suicidal thoughts. RESULTS Results showed an immediate and sustained increase in crisis texts for stress/anxiety and suicidal thoughts in the six weeks following Florence. Overall, an immediate 15% increase in crisis texts for anxiety/stress (SE = 0.05, p = .005) and a 17% increase in suicidal thoughts (SE = 0.07, p = .02) occurred during the week of the storm. Text volume for anxiety/stress increased 17% (SE = 0.08, p = .005) and 23% for suicidal ideation (SE = 0.08, p = .01) in the 6-week post-hurricane period. Finally, forecast models revealed observed text volume for all mental health outcomes was higher than expected in the 6 weeks post-Florence. CONCLUSIONS AND RELEVANCE A low-cost, crisis texting platform provided 24/7 mental health support available to young people in the Carolinas impacted by Hurricane Florence. These findings highlight a new application for text-based crisis support services to address the mental health consequences in youth following a weather-related disaster, as well as the potential for these types of crisis platforms to measure situational awareness in impacted communities.

Limited research has been conducted on the mental health concerns of frontline and essential workers and their children during the COVID-19 pandemic in the United States (U.S.). This study examined the association between working on the frontlines in the U.S. during the COVID-19 pandemic (March to July 2020) and personal crisis text concerns (e.g., self-harm, suicidal thoughts, anxiety/stress, and substance abuse) for frontline essential workers and the children of frontline workers. We used a novel data set from a crisis texting service, Crisis Text Line (CTL), that is widely used throughout the U.S. Generalized Estimating Equations examined the individual association between eight specific crisis types (Depression, Stress/Anxiety, Self-Harm, Suicidal Thoughts, Sub-stance Abuse, Isolation, Relationship Issues, and Abuse) and being in frontline work or being a child of a frontline worker during the early phase of the pandemic. Using CTL concerns as a proxy for the prevalence of mental health issues, we found that children of workers, specifically the youngest demographic (13 years and under), females, and non-conforming youth had a higher risk of specific crisis events during the COVID-19 pandemic. Additionally, Hispanic children of workers reported higher rates of stress/anxiety, whereas African American children of workers had higher rates of abuse and depression. Frontline workers had a higher risk of suicidal thoughts, and the risk of crisis events was generally highest for non-binary, transgender, and male users. In-creases in CTL usage among frontline workers were noted across 7-28 days after spikes in local COVID-19 cases. The research to date has focused on the mental health of frontline essential workers, but our study highlights troubling trends in psychological stress among children of these workers. Supportive interventions and mental health resources are needed not only for frontline essential workers, but for their children too.

Social anxiety disorder (SAD) is a highly prevalent and impairing mental disorder that often goes untreated. Because effective treatments exist but are not reaching many with SAD, it is important to investigate and design novel treatment delivery methods. To this end, our study set out to determine whether such a treatment could be effectively delivered through a new phone application featuring two novel mechanisms: (1) delivery of the treatment on a mobile smartphone and (2) the gamification of the treatment. Utilizing a single-subject multiple baseline across participants design, the efficacy of the treatment was evaluated on a sample of undergraduate students (N = 10) who endorsed significant levels of social anxiety on a self-report measure. Participants completed assessments every 4 days during a 12-, 16-, or 20-day baseline phase and a 44-, 40-, or 36-day treatment phase. At the study’s conclusion, participants showed a statistically significant mean decrease in scores on both the Brief Fear of Negative Evaluation Scale and the Liebowitz Social Anxiety Scale. In addition, the results evidenced high rates of completion, lending support for the acceptability of the treatment modality. Future research comparing purely self-guided interventions with minimal therapist contact interventions and traditional face-to-face treatment are needed, with further investigations into gamification as a potential mechanism for increasing adherence and motivation.

Few studies in the Southeastern U.S. have examined county-level spatial patterning in suicide clusters, and no studies have examined clustering at the census block group. The objective of this retrospective ecological study is to identify high-risk suicide clusters and characterize the community-level factors associated with suicides inside and outside spatial clusters. We used the discrete Poisson SatScan statistic to identify spatial clusters in suicide for North Carolina, 2000–2017. A suicide cluster was defined as a statistically significant cluster of suicide events. Community-level determinants were obtained from the American Community Survey, and logistic regression models were used to examine the association between community-level determinants and suicide clusters. A total of 12 statistically significant high-risk spatial clusters were identified. Clusters were also identified for specific age-demographics, including adolescents (<25), the working-age population (25 to 64), and the elderly (65>). The risk ratios of suicide varied from 1.27 to 2.05 in high-risk clusters, and spatial clustering was positively associated with being male or residence in a rural area. Multivariable logistic regression found strong associations with income, population change, and educational attainment. Our results highlight the significant geographic heterogeneity in suicide across North Carolina and the need for more research that identifies localized suicide clusters for targeted public health interventions.

This article introduces a special issue on the school and life experiences of highly mobile students. In it, the phenomenology of high mobility is described as well as the current state of research on subpopulations of highly mobile students. In addition, the risk and resilience framework is invoked as a general theoretical crosscurrent that cuts across the articles included in the special issue that provide novel research on environmental instability, student homelessness, foster care experiences, relocation because of war, and trauma- and violence-informed care. Lastly, areas for future research are discussed as highly mobile students remain an understudied yet important and growing population in need of empirical investigation and supportive intervention.

In this issue of the North Carolina Medical Journal, youth mental health is the focus. The second half of the title of this issue brief, "creative innovations in challenging times," was designed to convey a sense of optimism and urgency for the readers. The optimism centers on the joys of birth, the wonderments of childhood and adolescence, and the discoveries and connections between families and cultures among and within North Carolina communities. The sense of urgency pertains to the current epidemiologic realities for youth between the ages of 10 and 21 and the growing economic and health care disparities impacting the vast majority of North Carolinians. The author lineup for the issue is nothing short of exceptional and includes contributions from experts in epidemiology, suicide prevention, policy and law, school mental health, telemedicine, the impact of technology and social media on youth, innovations in the dissemination of psychological science to the public, attention-deficit hyperactivity disorders, diagnostic disparities, substance misuse and abuse, K-12 education, and systems of care for families. Serving as guest editor of this issue on youth mental health for the North Carolina Medical Journal has greatly expanded the breadth and depth of my understanding of the aforementioned issues relevant for today's youth. I hope that this issue is as informative to your work, regardless of your role in serving and advocating for young people in the great state of North Carolina.

Beyond public health and economic costs, the COVID-19 pandemic adds strain, disrupts daily routines, and complicates mental health and medical service delivery for those with mental health and medical conditions. Bipolar disorder can increase vulnerability to infection; it can also enhance stress, complicate treatment, and heighten interpersonal stigma. Yet there are successes when people proactively improve social connections, prioritize self-care, and learn to effectively use mobile and telehealth.

There is considerable debate in the public arena and among the professional mental health community around the media's role in increasing suicide risk following exposure to suicide-themed media in youth. A recent example involves the concerning reaction to the release of Netflix's controversial hit teen-suicide drama 13 Reasons Why. This follow-up study examined the association between the release of 13 Reasons Why Season 2 (13RW2), which coincided with two celebrity suicides, and national trends in crisis-related text conversations. We implemented an interrupted time series design to examine changes in daily counts of crisis texts aggregated at the national level following two events: (1) the release of 13RW2 and (2) celebrity suicide deaths of Anthony Bourdain and Kate Spade. We also performed a sub-analysis of suicide-related crisis conversations following each event. Crisis conversation volume was 42% higher after the release of 13RW2 for 6 of the 18 days of the study period, while crisis text usage was 51% higher for 9 out of the 18 days after the publicized celebrity suicide deaths. Both the release of 13RW2 and the celebrity suicides in the summer of 2018 were followed by an abrupt, but transient rise in crisis help-seeking among adolescents. Media outlets should consider pairing suicide-themed content with crisis support services as a core best practice to reduce the risk of population-level adverse reactions to suicide portrayals or coverage.