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Archives of Suicide Research

ISSN: 1381-1118 (Print) 1543-6136 (Online) Journal homepage: https://www.tandfonline.com/loi/usui20

Feasibility and Acceptability of the Youth Awareof Mental Health (YAM) Intervention in USAdolescents

Janet C. Lindow, Jennifer L. Hughes, Charles South, Luis Gutierrez, ElizabethBannister, Madhukar H. Trivedi & Matthew J. Byerly

To cite this article: Janet C. Lindow, Jennifer L. Hughes, Charles South, Luis Gutierrez, ElizabethBannister, Madhukar H. Trivedi & Matthew J. Byerly (2019): Feasibility and Acceptability ofthe Youth Aware of Mental Health (YAM) Intervention in US Adolescents, Archives of SuicideResearch, DOI: 10.1080/13811118.2019.1624667

To link to this article: https://doi.org/10.1080/13811118.2019.1624667

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Accepted author version posted online: 04Jun 2019.Published online: 04 Jul 2019.

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Feasibility and Acceptability ofthe Youth Aware of MentalHealth (YAM) Intervention inUS AdolescentsJanet C. Lindow , Jennifer L. Hughes, Charles South,Luis Gutierrez, Elizabeth Bannister,Madhukar H. Trivedi�, and Matthew J. Byerly�

Suicide is the second leading cause of death among US adolescents, and ratesof suicide among youth have been increasing for the past decade. This studyassessed the feasibility and acceptability of the universal, school-based YouthAware of Mental Health (YAM) program, a promising mental health pro-motion and suicide primary prevention intervention, in US youth. Usingan uncontrolled design, the feasibility and acceptability of delivering andstudying YAM were assessed in Montana and Texas schools. Thirteen of 16(81.3%) schools agreed to support YAM delivery, and five Montana and 6Texas schools were included in analyses. Facilitators delivered YAM in 78classes (1,878 students) as regular high school curriculum. Of the totalnumber of students who received YAM, 519 (27.6%) provided parentalconsent and assent. 436 (84.0%) consented students participated in pre-and post-surveys. Students, parents, and school staff found YAM highlyacceptable based on satisfaction surveys. In summary, this study found YAMfeasible to implement in US schools. Results also suggest students, parents,and school staff supported school-based programs and were highly satisfiedwith the YAM program. A randomized controlled trial is warranted to testthe efficacy of YAM in promoting mental health and preventing suicidalthoughts and behaviors in US adolescents.

Keywords Youth Aware of Mental Health, YAM, suicide prevention intervention, adolescents,mental health promotion, suicide, feasibility

Suicide is second only to accidental deathsin causing fatality in adolescents aged12–18, and is a growing public healthproblem (Centers for Disease Control andPrevention, 2017c). While suicide attemptrates are similar across the US (8.6%), in

some states, like Montana, fatal suiciderates among adolescents aged 12–18 yearsare well above the national average (16.5/100,000 versus 5.9/100,000) (Centers forDisease Control and Prevention, 2017a,2017b). Texas has a higher suicide attemptrate (10.1%) according to results from themost recent Youth Risk Behavior�These authors contributed equally to this work.

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Archives of Suicide Research, 0:1–17, 2019# 2019 International Academy for Suicide ResearchISSN: 1381-1118 print/1543-6136 onlineDOI: 10.1080/13811118.2019.1624667

Surveillance System survey (Centers forDisease Control and Prevention, 2017a),but a similar fatal suicide rate to thenational average (5.7/100,000) (Centersfor Disease Control and Prevention,2017b). Since 2010, the suicide rate hasbeen increasing nationwide, and representsthousands of adolescent deaths each year(Centers for Disease Control andPrevention, 2017b).

Youth suicide prevention consists of 3tiers: universal (primary), selected (second-ary), and indicated (tertiary) (Miller,Eckert, & Mazza, 2009). Primary preven-tion interventions, delivered to all youthbefore the onset of suicidality, often focuson social skill-building, reducing stigma,and increasing suicide awareness, help-seeking, and mental health knowledge(Miller, 2011; Wilcox & Wyman, 2016).Primary preventive interventions are costeffective, can be delivered to all youth, anddo not require screening (Brent, 2019).The goal of primary suicide prevention isto reduce incident cases of suicidality(Miller et al., 2009). Selected interventionsoften focus on identifying and linking at-risk youth to services, and increasing socialsupport to prevent suicidal behaviors(Miller et al., 2009). These interventionsoften use strategies, such as treatingdepression with psychotherapy or pharma-cological interventions, reducing access tolethal means, and modifying media cover-age of suicides (Mann et al., 2005).Finally, indicated interventions aredesigned for youths with current or a his-tory of suicidal behaviors. Evidence-basedinterventions, such as dialectical behavioraltherapy or cognitive behavioral therapy,can be used to reduce suicidal behaviorsin indicated youth (Miller et al., 2009).Most youth-based suicide prevention inter-ventions have focused on individuals incrisis, though a growing number of

universal suicide prevention interventionshave been developed and evaluated inrecent years (Wilcox & Wyman, 2016).

Universal, school-based interventionsare attractive candidates for reducing sui-cide among youth because they offer twoimportant benefits as a suicide preventionstrategy. First, school-based interventionscan be delivered in a critical developmentalperiod: before or early in the onset of men-tal illnesses, which develop in 50% ofaffected individuals by age 14 and 75% byage 24 (Kessler et al., 2005; Merikangaset al., 2010), and are a major risk factorfor suicidal behaviors (Brent, Baugher,Bridge, Chen, & Chiappetta, 1999;Kessler, Borges, & Walters, 1999; Shafferet al., 1996). Second, delivering preventioninterventions in schools allows access tonearly all youth in a population, especiallywhen delivered as part of the regularschool curriculum (Miller, 2011).

Evidence supporting the efficacy ofschool-based suicide prevention interven-tions has been increasing. The GoodBehavior Game (GBG), a universal pri-mary prevention intervention delivered inearly elementary school, has demonstratedreductions in suicidal thoughts and behav-iors in participants through age 30 (Wilcoxet al., 2008). A randomized controlled trial(RCT) of Family Checkup, a stepped inter-vention, also showed a reduction in suiciderisk through age 28–30 years among thosereceiving this selected intervention(Connell, McKillop, & Dishion, 2016).Other school-based interventions haveshown positive outcomes over shorter time-frames (3–18months). RCTs of Signs ofSuicide (SOS) showed reductions in sui-cide attempts over 3months (Aseltine &DeMartino, 2004; Aseltine, James,Schilling, & Glanovsky, 2007; Schilling,Aseltine, & James, 2016). Lastly, Sourcesof Strength showed positive perceptions of

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adult helpfulness, particularly among youthwith history of suicide and non-significantreductions in suicidal ideation 4monthspost-intervention (Wyman et al., 2010).

The Youth Aware of Mental Health(YAM) intervention is a promising univer-sal, school-based mental health promotionand suicide primary prevention interven-tion for adolescents (Wasserman et al.,2015). YAM is designed to raise mentalhealth awareness about risk and protectivefactors associated with suicide, includingknowledge about depression and anxiety,and to enhance the skills and emotionalresiliency needed to deal with adverse lifeevents, stress, and suicidal behaviors(Wasserman et al., 2010). The format ofthe YAM intervention, which includes stu-dent role plays, empowers youth to thinkabout, verbalize, and discuss importantstressors and mental health concerns, suchas depression and suicide, in a context thatis meaningful to them. YAM was recentlyevaluated in an RCT of �11,000 9th

graders in 10 European countries(Wasserman et al., 2015). The YAM groupexperienced significantly reduced suicidal-ity, including 55% fewer incident suicideattempts and 50% fewer cases of severesuicidal ideation, compared to control,over 1 year (Wasserman et al., 2015).

While schools receiving YAM demon-strated marked decreases in suicidalthoughts and attempts in Europe, it hasnot been adapted for or tested in US youth.All countries have distinct cultural andsocial attributes, which can affect attitudestoward mental health. Cultural adaptationsof mental health interventions and treat-ments are needed, particularly when thereare specific risk and protective factorswithin a population (Hall, Ibaraki, Huang,Marti, & Stice, 2016). For example, indi-viduals with mental disorders are morelikely to use mental health services and

seek other forms of help when informationand assistance are provided in culturallyrelevant contexts (Bhui & Bhugra, 2004;Carter, Read, Pyle, & Morrison, 2017;Rathod, Kingdon, Phiri, & Gobbi, 2010).In multiple studies, adapting mental healthinterventions and treatments so languageand content are targeted for specific ethnicand cultural backgrounds resulted inimproved efficacy relative to usual care orother interventions (Degnan et al., 2018;Hall et al., 2016), with a direct associationbetween efficacy and the level of adapta-tion performed (Degnan et al., 2018).While the superiority of adapted overunadapted interventions and treatmentshas not been established definitively, evi-dence is growing that cultural adaptationsof mental health interventions mayimprove outcomes (Chowdhary et al.,2014; Degnan et al., 2018; Hallet al., 2016).

Feasibility studies aim to measure fac-tors important for intervention implemen-tation (recruitment, data collection) anddelivery (fidelity) to inform the design offuture, larger-scale RCTs, which thendefinitively test the efficacy of the inter-vention (Bowen et al., 2009; Leon et al.,2011). As an initial step towards evaluat-ing the impact of YAM in the US, the pre-sent study determined the feasibility andacceptability of the intervention whenadapted for and delivered as part of theregular school curriculum in primarily 9th

grade classrooms in Montana and Texas.

METHODS

Study Design

An uncontrolled, within-subjects studywas conducted to determine feasibility andacceptability of delivering and studying the

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YAM intervention in Montana andTexas schools.

Participants and Settings

Students were recruited from five pub-lic schools in Montana, and one publicand six charter schools in Texas(Supplemental Figure S1). Students wereeligible to participate in questionnaires iftheir principals gave permission for theschool to receive YAM, they and theirparents provided written informed assent/consent, and they attended a class in whichYAM was delivered. Schools wereapproached based on convenience, butwith an emphasis on inclusion of large andsmall schools fitting multiple geographicregions (Montana), and schools with afocus on diversity and demographics(Texas). YAM was delivered as part of theregular school curriculum primarily to stu-dents in 9th grade. However, some classescontained students in multiple grades. Thedemographics of the study population areshown in Supplemental Tables S1, S2,and S3.

Ethical Considerations. The InstitutionalReview Boards of Montana StateUniversity and the University of TexasSouthwestern Medical Center approvedthe study.

School Recruitment. Schools were initiallyapproached with emails describing theYAM program and research project, and arequest to meet if the school had interest.Larger school systems were approachedfirst at the administration level, then at theschool level. In-person meetings were usu-ally 45–60minutes and typically includedthe state site PI or Co-I, key school admin-istrators, teachers, and counselor(s). Afterschools agreed to participate, 60–90-

minute community meetings were held inall communities. In all but two Montanaschools, additional 20–30-minute meetingswere held with the entire teaching faculty.Advertising targeted parents of those stu-dents who would be receiving YAM,though all were welcomed.

Consent and Assent. Informed consent andassent forms were sent home with studentsin participating classes, and/or mailed oremailed to parents. Research staff gave ver-bal and written instructions about thestudy and students’ rights immediatelyprior to survey administration. Studentswere provided a $5 incentive for returningsigned consent and assent forms inMontana, regardless of whether they ortheir parents declined participation. Texasstudents were offered: a homework pass, afree dress day, breakfast to the class withmost returned consents, or no incentive.For parents and school staff, satisfactionsurveys contained an informed consentstatement, and survey return was consid-ered granting of consent. Consent rateswere calculated as the percentage of stu-dents for whom parental consent and stu-dent assent were granted.

Intervention

The YAM intervention has beendescribed previously (Wasserman et al.,2010, 2015). Briefly, YAM consists offive� hourly sessions, which include threerole-play sessions, two mental health inter-active lectures, an information booklet forstudents, and six posters. All students inparticipating classes received YAM, butonly those providing consent/assent com-pleted surveys. YAM facilitators weretrained in a 5-day course designed by theYAM developers. The course includedreview of all materials, practice sessions to

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deliver YAM content, theory behindYAM, and practice moderating role playswith discussion and feedback. YAM help-ers received 3–4 hours of training by certi-fied YAM facilitators.

US Adaptation. Because YAM was devel-oped and tested in European students, itrequired some cultural adaptations for USyouth. Prior to the study delivery of YAM,two separate groups of five students, com-prised of 10th and 11th graders, wererecruited in Montana to aid the adaptationof YAM. Written informed consent/assentwas received from parents/students foryouth who participated in the culturaladaptation. Adaptation consisted of 7steps: 1) YAM facilitators delivered anentire course of YAM to each of the 2 stu-dent groups; 2) youth provided writtenand verbal detailed feedback about theYAM program and materials; 3) the USstudy team summarized feedback and rec-ommended adjustments to the originalYAM manual and materials; 4) recom-mended adjustments were reviewed by theYAM originators (C. Wasserman, V.Carli), and in collaboration with the USteam, initial revisions were proposed; 5)written and verbal detailed feedback wasobtained from a single group of 6 students(who participated in the initial 2 studentgroups) on the proposed revisions; 6) asecond set of recommended adjustmentswere developed based on the feedbackfrom the single group of 6 students; and7) the second set of adjustments werereviewed by the YAM originators, and incollaboration with the US team, a finalversion was developed and approved bythe YAM originators.

YAM Delivery. Facilitators trained by theYAM developers, delivered the five YAMsessions to individual classes over 3 to

5weeks, guided by a detailed manual(modified for US youth) as described pre-viously (Wasserman et al., 2010). A YAMhelper assisted each facilitator. YAM deliv-ery occurred between October 2016 andMay 2017.

Measures

Feasibility. Feasibility was evaluated as fol-lows. School participation was specified asthe percentage of schools that imple-mented YAM delivery and assessments.Consent rates were defined as the percent-age of students in participating classes(total study population) who providedwritten assent/consent. Youth participationwas determined by the percentage of con-sented students who completed �80% ofany scale on baseline and 3-month follow-up surveys. Survey completion was definedas responses to �80% of items on all sur-vey scales. For each scale, the number ofstudents who completed �80% of itemswas also quantified.

Quality Control of YAM Delivery. Prior todelivery, facilitators completed a qualitycontrol questionnaire adopted from theSEYLE RCT of YAM (Wasserman et al.,2010) assessing the preparedness of eachsite for the intervention. It included:names of school’s principal and counselor;method of consent distribution; consentform return rates; number of baselinequestionnaires distributed and completed;whether school had any prior student sui-cidal behavior; if another mental health/suicide educational program had been orwas currently being provided; class periodduration; mean number of students/class-room; and whether teachers/principals hadprovided students with scripted informa-tion about the YAM study.

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YAM fidelity. Fidelity to YAM includedtwo components: intervention adherenceand dose (Proctor et al., 2011). Adherenceto the YAM intervention was measured bya fidelity form which facilitators completedat the close of each session (Wassermanet al., 2010). The form included the fol-lowing: facilitator and helper names; ratingof availability/accessibility of school con-tacts; date with any deviations noted; dur-ation, content, and location of session;whether all students received the YAMbooklet; YAM poster locations and avail-ability; participation in role plays withmention of any students left out; attend-ance of participants and reasons for absen-ces if known (Montana only); and adverseevents with a description of how each washandled. To support fidelity to the YAMmodel, facilitators participated in twice-monthly and as-needed group consultationby phone (Montana) or in-person (Texas).Facilitators from both states were in con-tact throughout the study to discuss ques-tions impacting delivery.

The second fidelity component, doseof the intervention, was defined by thenumber of sessions attended by students.In Montana, facilitators logged the attend-ance of consented students for each ses-sion. In Texas, facilitators recorded thetotal number of students who attendedeach session. Both states recorded attend-ance of consented students during surveyadministration.

Determination of Acceptability. Students,parents, teachers, and school staff/adminis-trators were asked to complete anonymousquestionnaires assessing their satisfaction ofthe YAM intervention. Student satisfactionsurveys (8 items) were administered aspart of the 3-month follow-up survey(Supplemental Table S4). Parental surveys(12 items) were sent home with

participating students or mailed at the timeof the 3-month follow-up (SupplementalTable S5). Teacher and staff/administratorsurveys (8-items and 9-items, respectively)were delivered in-person or via mail nearthe end of the final semester in whichYAM was delivered (Supplemental TablesS6 and S7). All surveys contained fiveitems (Likert-like scale with 1¼ stronglydisagree to 5¼ strongly agree) askingYAM-related satisfaction questions, andincluded additional questions specific foreach group (Supplemental Tables S4–S7).

Outcomes

Feasibility and acceptability of theYAM intervention were the co-primaryoutcomes of the study.

Data Analyses

The sample of interest was defined asthose students (286 from Montana, 150from Texas) who participated in both sur-veys (i.e., completed at least 80% of thequestions on one of the scales at each timepoint). Descriptive statistics were used todescribe all demographic data and the pri-mary outcomes. Tests for differencesbetween states were completed for demo-graphic items of interest in SupplementalTable S1, as well as the acceptability ques-tions. For continuous outcomes, eithertwo-sample t-tests or the Mann WhitneyU test were used, depending on the evalu-ation of model assumptions. For categor-ical outcomes, the Fisher’s exact test wasused due to the inclusion of small counts.In all cases, two-sided tests were per-formed, and p values were not adjusted formultiple comparisons. For the two qualita-tive questions requiring written responses,word clouds were generated to identify the

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most frequently used words. All analyseswere completed using R 3.4.3 (R CoreTeam, 2017).

RESULTS

Participant Characteristics

Characteristics of participants whocompleted both research evaluations arepresented in Supplemental Table S1.Proportionally more female students par-ticipated. Montana and Texas had signifi-cantly different proportions of students ineach grade, with more Montana studentsin grades 7th, 8th, and 9th, and more Texasstudents in 10th and 12th grades (p¼ 0.002), though the numbers of youth not in9th grade were small. Significantly, moreTexas students reported not being born inthe USA and being non-native Englishspeakers (p< 0.001 for both). Lastly, moreTexas students lived with both parentscompared to their Montana counterparts(p¼ 0.015).

Consent, Participation, and Drop-outRates for Montana and Texas Combined

Thirteen of 16 schools (81.3%)approached via email agreed to meet inperson for further consideration of YAMimplementation. Of these, 71.4% inMontana and 66.7% in Texas participatedin YAM delivery and evaluation. Two ofthe 7 schools approached in Montanadeclined participation because they werealready involved in a suicide preventiongrant. Of the 9 Texas schools approached,1 declined, 1 was lost to follow-up prior tointervention implementation, and 1 par-ticipated in baseline surveys and YAM ses-sions, but follow-up surveys were notcollected the same school year and resultswere therefore excluded from analyses.

Supplemental Tables S2 and S3show thedemographic data for participating schoolsand classes.

YAM was delivered as part of theschool curriculum to 1,878 students in 78classes. Similar numbers of students (975and 903) and classes (41 and 37) receivedYAM in Montana and Texas, respectively.Of the total students, 519 (27.6%) pro-vided parental consent and assent to par-ticipate in research surveys. Consent rateswere 37.3% (n¼ 364) in Montana and17.2%, (n¼ 155) in Texas.

Ninety-three percent (n¼ 484) of con-sented students participated in a baselinesurvey (�80% completion of at least oneinstrument), and 84.0% (N¼ 436) partici-pated in the 3-month follow-up. A total of345 consented students (66.5%) completedboth surveys (�80% completion of all 11scales), with an average of 76.9% (range65.9–80.0%) completing each of the 11scales. In Texas, nearly all participants par-ticipated in both surveys (96.8%), while inMontana, the rate was 78.6%. Reasons formissing surveys are described inSupplemental Table S8, of which schoolabsences were the most common.

Fidelity of Delivery

Intervention Adherence. Adherence to theYAM intervention by facilitators was�90% for all elements of the interventionexcept those listed in Table 1. Interventiondeviations were primarily due to changesin class period duration (29.5% of ses-sions) or absence of posters in classrooms(13.3% of sessions). Fidelity support offacilitators was done in person in Texasand via teleconference in Montana.

Completion of Scheduled InterventionSessions (Intervention Dose). ThirteenYAM facilitator-helper teams delivered the

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YAM program (5 sessions) in 3 to 5weeks(54 and 24 classes, respectively). Deliverydiffered by state in the number of YAMfacilitators (9 in Montana, 4 in Texas).Attendance was recorded for consentedstudents (Montana) or all students(Texas). In Montana, there were 1,820total planned YAM student sessions (num-ber of consented students [364] x numberof sessions [5]), of which 1,567 (86.1%) ofall possible sessions were attended, and85.4% (n¼ 311) of consented studentsreceived at least 4 sessions (SupplementalTable S9). Sessions were primarily misseddue to school absences or moving (8.8%or 4.2% of all scheduled sessions, respect-ively) (Supplemental Table S9).Attendance specific to students participat-ing in the research was not recordedin Texas.

Acceptability

Students. Students reported positive satis-faction with YAM and agreed they wouldrecommend the program to other schools(Figure 1A). Texas students had

significantly higher satisfaction with theYAM program (Figure 1A). Acceptabilitydid not differ significantly for studentsself-reporting as LGBTQ or as non-nativeEnglish speakers except more LGBTQ stu-dents signified the need for mental healthprograming in schools (Question 4;Supplemental Figure S2). Word clouds(Supplemental Figure S3) show studentwritten responses to two opin-ion questions.

Parents and School Staff. Parental satisfac-tion ratings were positive overall (N¼ 61)(Figure 1B). Similarly, surveys completedby 50 participating teachers, principals,and relevant school staff showed favorablesatisfaction with the YAM program(Figure 1C).

Safety. In Montana, nine adverse eventsoccurred during YAM delivery to the975 students who received YAM as partof the school curriculum. In four instan-ces, facilitators removed students fromclass because of behavioral problems thatimpacted sessions. For five students, thefacilitator notified the school counselor:

TABLE 1. YAM Session Protocol Deviations by State

StateaDelivery timeb

N (%)Rescheduledc

N (%)Contentd

N (%)Posterse

N (%)Facilitatorf

N (%)Helperg

N (%)Repeatedh

N (%)

Montana 80 (39.0) 9 (4.4) 12 (5.9) 32 (15.6) 2 (1.0) 16 (7.8) 20 (9.8)

Texas 35 (18.9) 0 (0.0) 1 (0.5) 20 (10.8) 12 (6.5) 12 (6.5) N/D

Total 115 (29.5) 9 (2.3) 13 (3.3) 52 (13.3) 14 (3.6) 28 (7.2) N/D

a205 (Montana) and 185 (Texas) total sessions were delivered. All students received the YAM booklet.bDue to early school/class release, 78 Montana sessions were shortened by 7.3 ± 1.0minutes. One session was10minutes longer. In Texas, 35 sessions were 20minutes longer due to 70-minute class periods at that school.cSessions were rescheduled due to an unexpected school closure.dFull content was not delivered in 4 (2.0%) of Montana classes due to time restrictions or equipment issues.Content was delivered in the subsequent session. Other changes: repeat of self-help skills/available resources fol-lowing a suicide at the school (1 session); repetition of the ice breaker/other materials (3 sessions). One Texas classmissed final session due to scheduling problems.eLocation was changed, and YAM posters were not present in the new classroom.fYAM facilitator was changed due to poor travel conditions or illness.gYAM helper was changed due to scheduling changes or absences.hFour students repeated YAM due to changes in their class schedules. N/D¼ not done.

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FIGURE 1. Student, parent, and school staff satisfaction with the YAM intervention. A) Total students, B) par-ent, and C) school staff YAM satisfaction ratings. All surveys included the following questions (withresponses on a 5-point Likert-like scale: 1¼ strongly disagree to 5¼ strongly agree). Q1) I liked/waspleased/satisfied with the YAM project that my/my child's school took part in; Q2) I would suggestparticipating in this program to other schools; Q3) I would want my/my child's school to participateagain in the YAM project; Q4) I think it is a good idea to provide young people with a mentalhealth promotion and risk behavior prevention program in schools; and Q5) Most students/youthwould find the program implemented in your/your child's school appropriate. Data represent themean ± SD. Bars signify Montana (gray), Texas (light gray), and combined (stippled). The min-imum number of responses completed for all 5 questions is reported in the legends. Differences

between state groups are denoted by �(p< 0.05) and ��(p< 0.01).

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one student disclosed possible parentalabuse to the facilitator; one studentbecame angry during class and left; twostudents, who had personal ties to a stu-dent (not in a grade receiving YAM)who recently died by suicide, becameupset when hearing of the depression/suicidality focus of the third role playsession were excused from the session;and one student gave the facilitator anote about “wanting to die.”

In Texas, nine adverse events occurredwhile delivering to 903 students: a facilita-tor removed a student from the room dueto behavioral problems that impacted thesession; four students left the room duringthe session, stating they were “upset” (fol-low-up by the facilitator after the sessionindicated the students’ moods hadimproved); three students reporting signifi-cant depression or suicidal thoughts wereescorted to the school counselor by thefacilitator; and one student chose not toattend the first two sessions of YAM, butlater joined the class.

DISCUSSION

Results of this study indicate that theYAM intervention was feasible to deliverand evaluate in US school settings as deter-mined by school and student recruitment,intervention fidelity, and assessment com-pletion rates. Surveys of students, parents,and school staff showed high satisfactionof YAM. This study provides key insightsfor addressing challenges of future deliveryand research of YAM in urban andrural settings.

The recruitment of schools was feasiblein both states, with high proportions ofschools agreeing to participate. The overallschool recruitment rate (81.3%) is similar tothat observed in the only 3 RCTs of

adolescent school-based mental health pro-motion/suicide prevention interventionsreporting school recruitment data (50%,75%, and 72%) (Schilling, Lawless,Buchanan, & Aseltine, 2014; Swartz et al.,2017; Wasserman et al., 2015). Future USschool recruitment is unlikely to be a barrierto YAM implementation and evaluation:both states have a waiting list of schools forYAM delivery. Three Montana schools arecurrently paying for continued YAM deliv-ery; a health care system is funding YAM ina Montana urban center (Bozeman HealthFoundation, 2018); Montana state legislativefunding will support a follow-up feasibilitystudy of YAM (Montana State University,2018); and Texas expanded YAM deliveryto 20 schools during the 2017–2018 aca-demic year (Ellege et al., 2018; Hugheset al., 2018; Trivedi, Hughes, South,Lindow, & Byerly, 2018).

Optimal delivery requires rigorousintervention fidelity monitoring (Proctoret al., 2011). The current study found thatYAM was delivered with a high degree offidelity to the program’s content.Standardized fidelity assessments providedby YAM facilitators and helpers indicatedall but class period duration and missingmaterials were �90% in accordance toprotocol. Post-session assessments and bi-weekly “debriefing” meetings involvingstudy leaders and facilitators likely sup-ported adherence to the protocol. TheSEYLE RCT of YAM included a series ofmonitoring visits and quality control ques-tionnaires for facilitators, which alsoshowed no or small differences among sites(Carli et al., 2013). Other analogous ado-lescent school-based intervention studieshave reported 75%-87.6% delivery fidelity(Schilling et al., 2014; Wyman et al.,2008, 2010). A future study of YAMmight benefit from a quality assurancemeasure rating facilitator fidelity to the

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program; currently, Texas is piloting ameasure (Trivedi, 2018).

Intervention attendance, which likelysupports program efficacy, is anotherimportant fidelity measure (Proctor et al.,2011). Attendance of 86% of available ses-sions in Montana was considerably higherthan in the only 3 similar interventionstudies, involving indicated depression oruniversal interventions, reporting similardata (35%, 30%, and 65%) (Connellet al., 2016; Hart et al., 2018; Silverstoneet al., 2015). Other universal interventionslikely delivered to a majority of targetedpopulations, though no data were reported(Schilling et al., 2014, 2016; Swartz et al.,2017; Wyman et al., 2010).

Participant recruitment is a key elem-ent of research feasibility as greater partici-pation limits selection bias.(Ghaemi,2009) Adolescent recruitment rates inschool-based mental health promoting/sui-cide prevention studies have varied widely,with two studies not requiring consentreporting higher participation (>90%)(Aseltine & DeMartino, 2004; Aseltineet al., 2007; Hart et al., 2018) than threeother studies requiring consent for youth(35–69%) (Schilling et al., 2014, 2016;Wyman et al., 2010), the current study(27.6%), and one other not requiring con-sent (19% and 10%) (Wyman et al.,2008). Incentivizing students may increaseyouth consent rates in school-based inter-ventions (Wolfenden, Kypri, Freund, &Hodder, 2009). In a replication study ofone adolescent school-based mental healthpromotion/suicide prevention interven-tion, higher consent rates were achieved(50% vs. 35%) when students were offereda gift card and raffle for consent formreturn (Schilling et al., 2014, 2016). Inthe current study, the difference betweenthe recruitment rates in Montana andTexas was potentially due to incentivizing

strategies: Montana, which had higherrecruitment rates (37% vs. 17%), usedmonetary incentives, while Texas offeredno or non-monetary incentives. Theseresults suggest that future research ofyouth school interventions requiring con-sent should consider incorporating mater-ial incentives to enhance participation.

Another challenge is achieving highrates of assessment completion, which isimportant for limiting sampling bias(Ghaemi, 2009) In this study, 93% of con-sented students participated in baseline sur-veys and 84% participated in both surveys,indicating low attrition rates. Similar studiesreported a wide range of student survey par-ticipation, which depended on interventiontype and consent requirements. Gatekeeperinterventions had lower student rates ofassessment completion (10%, 19%)(Wyman et al., 2008) relative to universalinterventions (24–93%) (Aseltine &DeMartino, 2004; Aseltine et al., 2007;Hart et al., 2018; Schilling et al., 2014,2016; Swartz et al., 2017) or indicatedinterventions (63–79%) (Connell et al.,2016; Wyman et al., 2010). In general, uni-versal and indicated interventions requiringconsent/assent had lower student assessmentparticipation rates (29–79%) (Connellet al., 2016; Schilling et al., 2014, 2016;Swartz et al., 2017) than those using opt-out methods (58, 92, and 93%) (Aseltine& DeMartino, 2004; Aseltine et al., 2007;Hart et al., 2018). A recent meta-analysissuggested requiring active parental consentmay lead to significant sample bias, andopt-out methods, which still protect minors,should be considered when possible (Liu,Cox, Washburn, Croff, & Crethar, 2017).

Positive acceptability of a school-basedintervention is an additional characteristicneeded for widespread implementation ofsuch programs (Bowen et al., 2009). Thesingle study of a similar intervention that

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collected quantitative satisfaction datareported high student and adult satisfac-tion with presentation of materials, know-ledge gained, and content (Hart, Mason,Kelly, Cvetkovski, & Jorm, 2016). Thepositive satisfaction ratings of YAM, andfor similar programs, suggest there wouldbe continued stakeholder support forfuture YAM delivery and testing.

Limitations

While feasibility and acceptabilityoutcomes of this study were promising,there were several limitations. The enroll-ment of students from limited regionswithin two states was relatively low(27.8%) and had proportionally morefemale participants than in participatingclasses (61% vs. 51%), which reducesthe generalizability of findings. Using anuncontrolled design potentially maskedthe effect of randomization on recruit-ment rates, especially that of schools.Different measures of fidelity were usedbetween sites. Distal outcomes of suicide(attempts and suicidal thoughts) werenot measured. The quality of YAMdelivery, a component of interventionfidelity often assessed by outside observ-ers, was not measured. Finally, YAMdelivery requires trained, paid facilitatorsrather than school staff, and fidelitymonitoring, increasing cost and logisticalchallenges. While using teachers or otherschool staff would enhance generalizabil-ity, an important design element ofYAM is delivery by non-school person-nel. The use of outside facilitators isintended to create a “safe place” inwhich students can discuss stigmatizedtopics and stressful life situations. Thisstudy was supported by multiple fundingsources, but strategies for providing

widespread delivery of YAM have onlybeen partially determined. In urban, butnot rural settings, YAM can be deliveredby a core group of facilitators with lim-ited travel, as demonstrated in Texas.Using fewer facilitators increases deliveryexperience, thereby optimizing facilitatorskill development. Providing YAM inrural regions represents a greater chal-lenge. A model using multiple commu-nity facilitators would reduce travel, butlimit YAM delivery experience, while oneusing a small core of facilitators wouldincrease delivery experience but requireextensive travel. Thus, optimizing meth-ods for widespread delivery of YAM,should it prove effective, should beincluded in future studies.

In summary, the current study pro-vides promising feasibility and acceptabil-ity results for YAM delivery in the US.The study identified addressable challengesto delivering and conducting research onYAM, including approaches for greaterrecruitment of schools and participants,and ensuring program fidelity. Futureresearch should focus on the efficacy ofYAM in promoting mental health out-comes and reducing suicidality, and relatedrisk factors, when delivered in US schoolsettings. If findings from a US RCT aresimilar to those observed in Europe(Wasserman et al., 2015), then YAMwould represent an effective method forhelping to reduce one of the leading causesof death in US youth.

AUTHOR NOTE

Janet C. Lindow, Center for MentalHealth Research and Recovery,Department of Cell Biology andNeuroscience, Montana State University,Bozeman, Montana, USA; Department of

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Psychiatry, University of Arizona,Biomedical Research and EducationFoundation of Southern Arizona,Southern Arizona VA Health CareSystem, Tucson, Arizona, USA.

Jennifer L. Hughes, Department ofPsychiatry, University of TexasSouthwestern Medical Center, Dallas,Texas, USA.

Charles South, Department ofPsychiatry, University of TexasSouthwestern Medical Center, Dallas,Texas, USA; Department of ClinicalScience, University of Texas SouthwesternMedical Center, Dallas, Texas, USA;Statistical Consulting Center, SouthernMethodist University, Dallas, Texas, USA.

Luis Gutierrez, Department ofPsychiatry, University of TexasSouthwestern Medical Center, Dallas,Texas, USA.

Elizabeth Bannister, Center forMental Health Research and Recovery,Department of Cell Biology andNeuroscience, Montana State University,Bozeman, Montana, USA.

Madhukar H. Trivedi, Department ofPsychiatry, University of TexasSouthwestern Medical Center, Dallas,Texas, USA.

Matthew J. Byerly, Center forMental Health Research and Recovery,Department of Cell Biology andNeuroscience, Montana State University,Bozeman, Montana, USA; Department ofPsychiatry, Southern Arizona VA HealthCare System, University of Arizona,Tucson, Arizona, USA.

Correspondence concerning this art-icle should be addressed to Janet Lindow,Biomedical Research and EducationFoundation of Southern Arizona, 3601 S.6th Ave. Bldg. 77, MC (0-151),Tucson, AZ 85723, USA. Email:jlindow@alum.mit.edu

ACKNOWLEDGMENTS

The study team is grateful to the partici-pating schools’ administration, students,parents, and communities for their sup-port of this study. The study team alsoappreciates the scientific guidance ofDanuta Wasserman MD PhD, CamillaWasserman PhD, Vladimir Carli MDPhD, as well as the efforts of all YAMfacilitators.

DISCLOSURE STATEMENT

Dr. Lindow, Dr. South, Ms. Bannister,and Dr. Byerly have no biomedical finan-cial interests or potential conflicts ofinterest. Dr. Hughes and Mr. Gutierrezhave served as Youth Aware of MentalHealth (YAM) trainers and consultants/advisory board members for MentalHealth in Mind International. Dr.Hughes receives royalties from GuilfordPress. Dr. Trivedi serves, or has served, asa consultant/advisory board member forAlkeremes Inc., Akili Interactive,Allergan harmaceuticals, ACADIAPharmaceuticals Inc., Ontario BrainInstitute Canada, Brintellix Global,Global Medical Education, HealthcareGlobal Village, Lundbeck Research USA,Medscape LLC, MSI MethylationSciences Inc., Nestle Health Science –

Pamlab Inc., Naurex Inc., Navitor, OneCarbon Therapeutics, Otsuka AmericaPharmaceutical Inc., Saatchi, and TakedaGlobal Research in the past two years,and performs research activities for theNational Institute of Mental Health, theNational Institute of Drug Abuse,Johnson and Johnson, and JanssenResearch and Development LLC.

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SUPPLEMENTAL DATA

Supplemental data for this article can beaccessed at publisher’s weblink.

FUNDING

This work was supported in part byMontana state legislative funding (MontanaResearch & Economic DevelopmentInitiative [Byerly MJ PI]), Montana StateUniversity research funds, MontanaINBRE [NIGMS P20GM103474], theRees-Jones Foundation (Trivedi MH PI),and the UT Southwestern Center forDepression Research and Clinical Care.The funders of this research had no role inthe study design, analysis, interpretation ofresults, or preparation of this article. Thecontent is the sole responsibility of theauthors and does not necessarily representthe official views of any of the funders.

ORCID

Janet C. Lindow http://orcid.org/0000-0003-3235-3698

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