This Manual Was Created by the American Foundation for Suicide Prevention

INTERACTIVE SCREENING PROGRAM MANUAL 2011-2012

This Manual was created by the American Foundation for Suicide Prevention.

Copyright © 2011 by the American Foundation for Suicide Prevention

For additional information, contact:

The American Foundation for Suicide Prevention

120 Wall Street, 29th Floor

New York, New York 10005

Phone: 888-333-2377

1

INTERACTIVE SCREENING PROGRAM MANUAL 2011-2012

Table of Contents

Acknowledgements 4

Introduction 5

Section 1. The Interactive Screening Program (ISP) 6

Purpose of ISP 6

How ISP Works 6

Data Reports 8

Website and Data Security 9

Required Resources 9

Legal Considerations 11

ISP Evaluation Results 12

Section 2. Is the ISP Right for My Campus? 13

Can the ISP Fill a Gap in our Suicide Prevention Strategies? 13

Do We Have the Clinical Resources to Staff the ISP? 13

Can We See How the ISP Online Screening Process Works? 14

What Happens Next? 14

Section 3. Preparing to Implement the Interactive Screening Program 15

Assign or Secure Needed Clinical Personnel 15

Plan Desired Program Evaluation Activities 15

Identify Available Mental Health Services for Student Referrals 15

Customize the ISP Website 16

Develop the Student Invitation Process 16

Tailor the Demographic Items on the Stress & Depression

Questionnaire 18

Section 4. Suggestions for Site-Based ISP Evaluation 19

Conclusion 20

Appendices 21

Acknowledgements

The American Foundation for Suicide Prevention (AFSP) wishes to acknowledge the generous support for the initial development and testing of the Interactive Screening Program (ISP) from the Kristin Rita Strouse Foundation, the Johnny Foundation, Eli Lilly and Co., Janssen Pharmaceuticals Inc., Solvay Pharmaceuticals Inc., and Wyeth Pharmaceuticals. We also gratefully acknowledge the support of the Rainier Foundation for implementation of the program in the state of Washington, and the ongoing support of the Johnny Foundation for the ISPin several colleges and universities in Georgia.

We wish to especially note the generosity and support of the ISP by the AFSP Chapters across the country. Through their fundraising efforts, especially the Out of the Darkness Community Walks, the AFSP Chapters have played an essential role in expanding the number of colleges and universities that are able to offer this unique program on their campuses.

We also acknowledge our partnership with Entech, Inc., which has provided not only the expertise to develop the ISP technology, but also the creative vision that has guided its continued enhancement. Finally, we are deeply grateful for the partnerships we have developed with the colleges and universities where theISP has been implemented. Their commitment to providing effective outreach to students in need has inspired our efforts, and this Manual is based in large part on what we have learned together.

Introduction

In 2001, the American Foundation for Suicide Prevention (AFSP) began the development of an anonymous, Internet-based method of outreach to college students with serious depression or other suicide risk factors who were not currently receiving treatment. This effort was rooted in the recognition that, despite the availability of counseling centers and other mental health facilities on most U.S. college and university campuses, an estimated 80% of students who die by suicide each year had not used these services.[1] Our hunch was that this was not just because at-risk students were unaware that campus services were available, but also because something in their life experiences, ways of thinking or fears and concerns prevented them from asking for help. What was needed, we felt, was a simple, convenient and safe way for troubled students to connect with an experienced, caring mental health counselor, who could help them more clearly identify the problems they were experiencing and work through their barriers to help-seeking.

In the spring of 2002, AFSP launched what was initially called the College Screening Project at Emory University in Atlanta, Georgia. Soon after, the University of North Carolina at Chapel Hill joined the pilot project. Between 2002 and 2005, a comprehensive evaluation of the screening initiative was conducted with undergraduates on these two campuses that led to several enhancements of program methods and technology. In 2006, we expanded the initiative to graduate students at the Massachusetts Institute of Technology, and in 2007, to medical students at the University of Pittsburgh. During the 2008-09 year, we welcomed four other universities to the program: The University of Maine at Orono, the University of California at San Diego, and two schools in Washington State: the University of Puget Sound and Heritage University.

In early 2009, we changed the name to the Interactive Screening Program (ISP), and launched a broader dissemination effort that resulted in 10 new schools deciding to implement the program in the 2009-10. In that same year, following review by outside experts appointed by the Suicide Prevention Resource Center (SPRC), the ISP was designated a Best Practice for Suicide Preventionand listed in the SPRC-AFSP Best Practices Registry.

By June 2011, a total of 30 colleges and universities had adopted the ISP, and we set the goal of having the program in 50 schools by the end of the 2011-12 academic year. As we were completing the 2011-12 edition of the Interactive Screening Manual, we learned that the 10 campuses of the University of California system will be implementing the ISP during 2011-12 as part of a major statewide student mental health initiative. We look forward to welcoming these campuses, as well as additional schools, to the program during the coming months.

This Manual is designed for colleges and universities that wish to learn more about how the Interactive Screening Program can augment their campus’s student mental health services. It describes how the program works, what it can achieve, what it costs and the key implementation procedures. After reviewing the Manual, interested schools are urged to submit a Request for Further Information Form, which can be completed on the AFSP website ( Our staff will then contact you to talk in depth about bringing the ISP to your campus.

Thank you for your interest in the ISP. We hope to hear from you shortly.

Ann P. Haas, Ph.D., Senior Program SpecialistMaggie Mortali, Education Manager

American Foundation for Suicide PreventionAmerican Foundation for Suicide Prevention

120 Wall Street, 29th Floor120 Wall Street, 29th Floor

New York, NY 10005New York, NY 10005

(207) 236-2475(212) 363-3500, ext. 2034

1. The Interactive Screening Program(ISP)

Purpose of ISP

The purpose of the Interactive Screening Program (ISP) is to identify, engage and refer to treatment students with serious depression or other conditions that put them at risk of suicide.

How ISP Works

Although there are variations that a college or university may choose in implementing the ISP, this section presents an overview of how the program works on most campuses (specific options are discussed in a later section of the Manual).

Each school decides which students to target through the program, and these students receive an email invitation to make use of a uniquecampus service aimed at helping students assess whether depression or other mental health problems may be interfering with their academic or personal functioning. (See Appendix A for the copy of theinvitational email). Only those students who have reached the age of 18 are invited to participate, and the invitations are usually staggered throughout the academic year to avoid overburdening clinical personnel and resources.

The invitational emails are sent from a designated university official and directed to students via their campus-registered email addresses. The email contains a link to a secure website which further explains the program, provides students an opportunity to sign up with a self-assigned UserID and password and complete an onlineStress Depression Questionnaire. The questionnaire incorporates the PHQ-9, a 9-item standardized depression screening scale that has been validated in two large multi-site studies,[2],[3] and found to be strongly predictive of major depressive disorder. In addition to the depression items, the Stress Depression Questionnaire contains questions about suicidal ideation and attempts, problems related to depression such as anger and anxiety, alcohol and drug abuse, and eating disorder symptoms. The questionnaire contains 35 questions and normally takes less than 10 minutes to complete. (See Appendix B for screen shots of the questionnaire as it appears online and Appendix C for a Word document copy).

At the end of the questionnaire, students are asked to provide an email address so that they can be notified when a counselor has prepared a personalized response and posted it to their attention on the program website. Students are assured that their email address will be encrypted into the computer system to protect their identity, and will not be made available to anyone, including the counselor who will be responding to them.

Immediately after the student submits the questionnaire, it is computer analyzed and, based on specific answers, the student is classified into one of four tiers; 1a, 1b, 2, or 3, with 1a suggesting highest risk and 3 lowest risk. (See Appendix D for the tier designation criteria). The computer system then generates an email to the counselor, which indicates the student’s tier level and provides a link to the student’s record on the secure website.

Program guidelines call for all Tier 1 students to be answered within 24 hours, Tier 2 students within 36 hours and Tier 3 students within 48 hours. Within the appropriate time frame, the counselor reviews the student’s questionnaire and writes a response, using a template specific to the student’s tier. (See Appendix E for counselor response templates). Each response begins with a brief self-introduction which includes the counselor’s name, position at the college or university, office location and phone number. Although much of the response is standardized on the template, key problems indicated in the student’s questionnaire are addressed on an individual basis. All tier 1 and tier 2 students are urged to contact the counselor to arrange an in-person meeting. All students, regardless of tier designation, are offered the option of using the website’s “Dialogue” feature to communicate online with the counselor while remaining anonymous. The counselor’s key aims in the response are to convey interest, support and availability, and to encourage engagement, whether in-person or through the anonymous online dialogues.

Once the counselor has posted the response on the website, the computer system accesses the student’s encrypted email address and sends a notification that the response is ready. This email provides a link back to the program website, where the student can log in and open the counselor’s response. Two additional emails are automatically sent to tier 1 and tier 2 students, 15 and then 30 days after the counselor’s response has been posted. The reminders urge these students to access the counselor’s response if they haven’t already done so, and to follow the recommendations for follow-up. (See Appendix F for the copy of the email reminders). The second and final reminder contains a link to a brief Update Questionnaire that students who have not yet had contact with the counselor are asked to complete. Items inquire about how the student has been doing in recent weeks, and elicit reasons for not contacting the counselor as well as the student’s perception of what would be most helpful at this time. (See Appendix G for the copy of the Update Questionnaire).

Figure 1: Schematic representation of the ISP process

Data Reports

On the website page where the counselor’s response is posted, a “Dialogue” button provides direct access to a page where the student can send a message to the counselor. Students may exchange messages with the counselor on an unlimited basis, although the counselor continues to urge students with significant problems to arrange an in-person meeting. The dialogues with the counselor play a critical role in the process of encouraging the student to seek help by facilitating the resolution of barriers to treatment. Barriers commonly identified in student dialogues include concerns about parental notification, confidentiality of treatment records or impact of treatment on future academic or career goals. In addition, the dialogues offer an opportunity for the student to begin to develop a trusting relationship with the counselor, which increases the likelihood that the student will ultimately accept the counselor’s invitation for a face-to-face meeting. In the event that a student agrees to meet with the counselor in person, all scheduling activities are encouraged to be done via phone or personal email so that no personally identifying information about the student is communicated (and stored) via the ISP website. (In the event that any such information is inadvertently communicated, it is deleted following regular review by AFSP).

During the in-person meeting, the student is further evaluated and treatment options are discussed. These may include counseling or other treatment services on or off campus, depending upon available resources and student needs. Students who may need medication are referred to a psychiatrist or another appropriate clinician for evaluation. The program counselor coordinates all clinical referrals, and as needed, meets with the student for additional sessions to make the transition to longer-term treatment.

Students may also be referred to a peer support program or other non-clinical programs or services offered by the college or university. Such referrals may strengthen students’ support networks and sense of connectedness within the college/university community.

Data Reports

All student and counselor-generated data transmitted over the ISP website are stored and organized in an administrative section that can be accessed by the counselors and other program personnel at each college or university. As shown in Figure 2 on the following page, the main administrative webpage displays and provides links to a variety of data reports. Reports can be generated for the full program period or for specific dates such as a given semester or academic year.

The most comprehensive is the Full Data report, which records individual answers to the Stress & Depression Questionnaire, listed by a computer-assigned ID number and the student-selected User ID. The Full Data report provides the dates and times the student submitted the questionnaire, the counselor posted the response to the student, and the student returned to the website and accessed the counselor’s response. The webpage displays these data in Excel format, which can be uploaded into a matching SPSS template for more detailed statistical analysis. Also included are answers to the Update Questionnaire for those tier 1 and tier 2 students who submit this form after not contacting the counselor within the 30-dayperiod after the counselor’s response is posted.

Other reports are designed to assist counselors and other program personnel in monitoring website communications to assure that all student questionnaires and dialogue messages are responded to in a timely fashion. All students whose questionnaires have not yet been reviewed and responded to by the counselor are listed in the Outstanding Responses report. Similarly, the students dialogues that have not yet been reviewed and responded to by a counselor are listed under the Outstanding Dialogue report. Both the Recently Completed Responses and the Recent Dialogues can be viewed by the counselor for the past 3 to 14 days. Collectively, these reports facilitate on-going administrative oversight of program activities, and are useful for year-end reporting of program accomplishments, as is discussed further in Section 4 of this Manual.

Figure 2: Administrative reports

Website and Data Security

Each college and university that uses the Interactive Screening Program has its own secure website that is backed by a Secure Sockets Layer (SSL) digital certificate. The SSL is an established industry standard cryptographic protocol that provides security and data integrity for communications over Transmission Control Protocol/Internet Protocol (TCP/IP) networks such as the Internet. By encrypting all data during the process of transmission, SSL prevents eavesdropping, tampering and message forgery, thus providing authentication and confidentiality to the website application.

When any changes are made to the website, file transfers are made through a Virtual Private Network (VPN). The VPN enhances the security of communications that take place over public networks by incorporating procedures that emulate those used in a private network, such as requiring User ID and password for access. This restricts the ability to access and alter database files to those individuals who are specifically authorized. The ISP website also has sophisticated access controls which allow users to access only those parts of the website they are permitted to see.

To further enhance security and confidentiality of the data transmitted over the website; the user's self-assigned password and the email address provided at the end of the Stress & Depression Questionnaire are encrypted in the system. Case-sensitive passwords, which are required to be between 8 and 12 characters and contain both letters and numbers, are stored in a separate database on the server.

Required Resources

The ISP is a relatively low cost method of identifying at-risk students and encouraging them to get treatment. Participating colleges/universities pay an annual program fee, and also provide the clinical personnel who perform the online and in-person services offered by the ISP. In addition, the college/university must be able to offer appropriate clinical services to students who are identified as needing them. The resources listed in Table 1 (p. 9) and described below are needed for successful program implementation.