A significant area of need highlighted in Minnesota’s five-year comprehensive needs assessment was a reduction in the number of youth who take their own life, making Adolescent Suicide the adolescent health priority area for Minnesota.

Minnesota has seen higher rates of suicide among youth than the national average for a long time.[1] Suicide is the second leading cause of death among people ages 10-24, and is not experienced equally across age groups, genders, sexual orientations, race/ethnicities, or geography in Minnesota.

There is not one single path that leads to suicide. Many factors can increase the risk of suicidal thoughts and behaviors, such as childhood trauma and adversity, serious mental illness, physical illness, alcohol or other substance abuse, a painful loss, exposure to violence, social isolation, and easy access to lethal means. Factors such as meaningful relationships, coping skills and safe and supportive communities can decrease the risk of suicidal thoughts and behaviors.[2] Adolescent suicide prevention efforts require improving access to comprehensive mental health services and building communities that support the mental well-being of youth and their families.

In Minnesota, we see large race/ethnicity disparities in adolescent suicide. Historical trauma, living in poverty, childhood adversity, lack of access to culturally relevant mental health services, and experiencing interpersonal violence are all experienced at higher rates among American Indian populations and are all associated with an increased risk of suicidal behavior. The disparities seen among American Indian youth in Minnesota is something we can’t ignore (see Figure 1).

Figure 1. Suicide Rate by Race/Ethnicity among Minnesota Adolescents (10-24 years old), 2015-2019

Evidence shows most suicides are preventable; mental illness is treatable; and recovery is possible with appropriate supports and intervention. The strongest suicide prevention efforts are multifactorial, requiring a combination of familial support, community connection, and behavioral health treatment. Annual average data from 2011 to 2015, show an estimated 13% of adolescents living in Minnesota experienced at least one major depressive episode in the past year and 46% of these adolescents who were struggling with their mental health did not receive treatment.[3]

The COVID-19 pandemic has likely magnified many of the barriers youth experience when trying to access the help they need. Limited access to mental health services and treatment may lead to self-harm, challenges with emotional regulation, and adaptive coping. As a result of COVID-19, children and adolescents have experienced unprecedented interruptions to their daily lives and some recent findings indicate that COVID-19 restrictions have impacted youth mental health due to lack of peer contact, social support, and activities, familial stress, and economic hardship within the family. A Kaiser Family Foundation (KFF) analysis of data from the Census Bureau’s Household Pulse Survey shows that during the pandemic, more than half of young adults (ages 18-24) reported symptoms of anxiety and/or depressive disorder (56%).[4] Compared to all adults, young adults were significantly more likely to report suicidal thoughts (26% vs. 11%). The pandemic has only exacerbated these issues – even prior to the pandemic, young adults were already at higher risk of poor mental health, though many did not receive treatment.

Five-Year Strategies and Activities Moving Forward

A Strategy Team was assembled to identify a set of strategies for the Minnesota Title V program to help reduce the number of young people who take their own life. There are demonstrable strategies to address adolescent suicide prevention. The strategies investigated by the Strategy Team were targeted towards the prevention of adolescent suicide. Many of the discussions were around how we can specifically address the disparities of the LGBTQ youth, as well as people of Native American heritage and resiliency building for those suffering from trauma.

The Strategy Team agreed that in order to be able to adequately implement any of the strategies, there were a set of guiding principles that must be considered for any activity, program, or plan (see Figure 2).

Figure 2. Adolescent Suicide Priority Guiding Principles

A logic model has been developed to visualize our planned work and intended results (see Figure 3). A larger version of the logic model is included with the supporting documents for this application. This logic model, along with the five-year action plan table, provide a broad picture of Minnesota’s strategies aimed at reducing the number of young people who take their own life. The discussion below includes Minnesota’s plans for implementing the strategies during FY2022 specifically.

Figure 3. Minnesota Adolescent Suicide Logic Model

Strategy A. Empower Youth, Young Adults, Families, and Communities to Meaningfully Engage in Creating Solutions to Prevent Suicide

The first strategy aims to empower youth, young adults, families, and communities to meaningfully engage in creating solutions to increase protection from suicide risk, while seeking to create a supportive environment that promotes general health of young people in Minnesota and reduces the risk for suicidal behaviors and related problems.

Partner with the MDH Suicide Prevention Unit to Implement Identified Strategies from the Minnesota Suicide Prevention State Plan

The MDH Suicide Prevention Unit (SPU), part of the Health Promotion and Chronic Disease Division at MDH, is responsible for the state’s Suicide Prevention State Plan (https://www.sprc.org/sites/default/files/Minnesota%20SuicidePreventionStatePlan2015.pdf) and its deliverables. Released in 2015, Minnesota’s Suicide Prevention State Plan has five main goals:

• Support healthy and empowered individuals, families and communities to increase protection from suicide risk.
• Coordinate the implementation of effective programs by clinical and community preventive service providers to promote wellness, build resilience, and prevent suicidal behaviors.
• Promote suicide prevention as a core component of health care services.
• Increase the timeliness and usefulness of data systems relevant to suicide prevention and improve the ability to collect, analyze, and use this information for action.
• Sustain suicide prevention efforts.

During this next five-year block grant cycle, the Title V program will work with the SPU to develop a cohesive statewide approach to adolescent and young adult suicide prevention. This cohesive approach is needed because the Suicide Prevention State Plan often overlaps with the work of the Minnesota Partnership for Adolescent and Young Adult Health (described in more detail below). More specifically, during FY2022 Title V staff will connect with the SPU team to better align the Suicide Prevention State Plan with the State Plan of the Minnesota Partnership for Adolescent and Young Adult Health. By creating this alignment, we will be able to better work together to intentionally empower young people to engage in creating solutions to prevent adolescent suicide.

Focus, Partner, and Implement Supportive Action Steps from the Minnesota Partnership for Adolescent and Young Adult Health Strategic Plan

The Minnesota Partnership for Adolescent and Young Adult Health (MNPAH), convened by MDH, is a group of stakeholders representing state, county, schools, community agencies, faith organizations, and those working for and with young people. The MNPAH helps address Minnesota’s overarching adolescent health goals, which are to:

• Improve the health and well-being of all adolescents and young adults (ages 10-25 years old)
• Build and maintain strong partnerships with those interested in the health and well-being of young people.

In order to address these goals and inspire action, the MNPAH developed a Strategic Plan (https://www.health.state.mn.us/docs/people/adolescent/youth/mnpartnership.pdf) with a unifying vision and set of priorities. The priorities include ensuring access to high-quality teen-friendly health care; a safe and secure place to live, learn, and play; positive connections with supportive adults; opportunities for youth to engage; and adolescent and family-centered services. If addressed, the priorities of the Strategic Plan help to achieve the MNPAH’s vision of Minnesota being a “place where all young people thrive.” Young people who are thriving are less likely to complete suicide.

In addition to aligning the Suicide Prevention and Partnership Strategic Plans, over the next five-year cycle, we will work to implement steps to address the priorities established in the MNPAH Strategic Plan. During FY2022, we will particularly focus on the following activities:

• Increasing access to high-quality, teen-friendly health care by sharing best practices and partnering with agencies to strengthen youth’s overall resiliency and well-being.
• Working with partners who focus on adolescent mental health to highlight the need for positive connections with supportive adults.

Increase Help-Seeking Behaviors in Youth

Increasing help-seeking is a key strategy for effective suicide prevention. According to the Suicide Prevention Resource Center, “By teaching people to recognize they need support – and helping them to find it – you can enable them to reduce their suicide risk.” In order to help young people, increase help seeking behaviors, we need to decrease barriers to accessing supports. During FY2022 and in subsequent years, Minnesota’s Title V program will work with partners to lower barriers youth experience when trying to obtain help by promoting self-help tools and campaigns. We also will work with partners to address social and structural environmental barriers – which might include social/emotional learning to foster peer norms around help-seeking and working to make sure that youth-serving providers (such as primary care providers) are more culturally-appropriate, welcoming, and convenient for teens.

Train Providers on Adolescent and Young Adult Mental Health Screening

In any given year, 9% of MN school age children and youth experience severe emotional disturbance.[5] Identification of mental health problems improves with standardized screening.[6] Half of all lifetime cases of mental illness begin by early adolescence.[7] Substantial evidence shows that early mental health interventions help prevent behavior problems and poor school performance.

Mental health surveillance is required at all Child and Teen Checkups (C&TC) for all ages. This includes obtaining the child and family’s mental health history and the child’s history of exposure to trauma. Mental health screening using an approved, standardized instrument is required for age 12 through 20 years. It is critical that children with identified concerns receive or be referred for specialized services. C&TC staff play a critical role by supporting health care providers that perform well child checks with up-to-date information on evidenced based best practices screening recommendations and tools to successfully do screenings and refer children and adolescents to other services they need.

This support is provided through direct technical assistance to medical providers and clinics and through training that includes a component on mental health screening, diagnosis support and referral resources. The training is targeted to locally based C&TC coordinators for 87 counties and four Minnesota Tribes, who provide information and trainings to all of their local clinics, and medical providers and nurses who are contracted with the Minnesota Department of Human Services to provide C&TC screening services. Individual C&TC coordinators do community outreach and quality improvement projects that includes outreach to youth around recognizing mental health concerns and connecting to services.

Evidence-Based Strategy Measure

Although helping young people prevent depression, suicide, and other problems is a community-wide effort, primary care providers are well situated to discuss risks, provide screening, and offer interventions. Offering screening and follow-up at preventive visits helps ensure that young people receive mental health services and support from family and peers. Minnesota’s evidence-based strategy measure (ESM) for FY2022 is the percentage of well-visits where depression screenings are occurring for Adolescents enrolled in Minnesota Health Care Programs (MHCP). More information on the measure, data sources, and potential limitations is included on the ESM detail sheet.

Educating those that work with Justice Involved Youth in Community about the importance of Mental Health Screening and Referral to Services

In conjunction with the University of Minnesota School of Public Health, the C&TC program has developed a training intended for those who work with and or provide health care for adolescents especially those youth involved in the Juvenile justice system (JIY). C&TC will provide one or more trainings on the unique health challenges and needs of JIY and the importance of ensuring that Medicaid eligible youth receive appropriate screening including mental health screening during C&TC visits.

Partner with Minnesota Personal Responsibility Education Program and Sexual Risk Avoidance Education Program’s Grantees

The Minnesota Personal Responsibility Education Program (PREP) is a federally funded grant program that aims to create successful transitions from youth to adulthood through promoting healthy decisions and providing medically accurate, evidence-based quality sexual education to Minnesota young people (ages 14-21 years old). The PREP program primarily serves young people who are in or transitioning out of foster care or juvenile detention centers, LGBTQ youth, homeless youth, youth in alternative schools, and youth of color and American Indian youth – many of which are at higher risk of suicide. By partnering with the PREP Program’s grantees, we will be better able to reach youth who are more vulnerable to suicide with prevention and help seeking messaging.

The MN PREP curriculum implementation, curriculum training and technical assistance will continue for grantee sites in-person, virtually or hybrid as applicable. There will also be networking and professional development opportunities for all grantee staff in regard to the targeted populations served. The PREP State Coordinator will seek virtual professional development and curriculum training implementation opportunities if COVID-19 restrictions prevent future in-person training.

MCH staff will also continue to oversee the federally funded Sexual Risk Avoidance Education (SRAE) Program to support the Healthy Teen Initiative (HTI), formally State Title V Abstinence Education Grant Program (AEGP). HTI will target funding to at least four grantees in the state serving populations experiencing the greatest disparities in teen pregnancies and STIs through the implementation of high quality, medically accurate, evidence-based and informed programs to promote healthy youth development, abstinence, and to delay the onset of sexual activity in youth 10-14. This population also will benefit from prevention and help seeking messaging to decrease their vulnerability to suicide. In addition, the HTI will continue to implement evidence-informed programs that reach parents of youth 10-19, and adult mentors that interact and/or work with youth 10-19. Similar to PREP, the SRAE State Coordinator will need to pursue professional development opportunities to assist grantees in person, virtual or hybrid as necessary with technical assistance.

Support Schools to Identify and Partner with Community Resources to Access Appropriate and Timely Services for Youth

Because adolescents and young adults spend a great deal of time in educational-related activities, schools can play a vital role in adolescent suicide prevention efforts. The effectiveness of prevention efforts in the schools is often tied to partnerships with community partners, who are typically more familiar with signs and symptoms of suicidality in adolescents. Therefore, during FY2022 and moving forward, Minnesota’s Title V program will work to make connections between schools and community partners to promote suicide screening, assessment, and referral, and follow up in schools through partnership with the MN School Based Health Alliance, the Minnesota Department of Education and the MDH Schools Team.

MDH PREP & SRAE staff will continue to work in partnership and participate on the planning committee for the Adolescent Health Summer Institute (AHSI), Reproductive Health Update (RHU) and the Adolescent Health Summit (AHS) Conferences. MDH provides sponsorship and facilitate workshops with the sponsoring agencies of these events to offer topical expertise, planning and guidance.

Conference (AHSI, RHU, AHS) attendees are from around the state of Minnesota and sometimes the country. Individuals living in rural and urban areas, along with out of state participants partake in innovative teaching styles, hear from expert guest faculty, form relationships, and network with colleagues over the two-three days of the conferences. Participants gain understanding, learn strategies, and build skills to better serve the populations adolescents throughout the state.

These conferences offer opportunities to explore healthy youth development. Building on four decades of research, participants will explore how racial inequity, COVID-19, and mental health concerns are converging to affect young people’s health and healthy development. It will reflect on how COVID-19 has and will continue to transform the landscape of adolescent development. Keynotes and workshop presenters will delve into effective strategies and best practices for supporting adolescents’ mental health and healthy development. It will also examine the importance of engaging young people as problem solvers and powerful change agents in their families, peer groups, and communities.  

Promote and Train Communities and Agencies in “Making Authentic Connections”

During FY2022, in partnership with Saint Paul – Ramsey County Public Health, MDH will work to provide the “Making Authentic Connections (MAC)” training in the community. MAC helps adults learn the “why” and “how” to make positive connections with adolescents. Increasing social connections with caring adults helps adolescents feel better about themselves and make better choices impacting health and safety. MAC is based on The Wakanheza Project, a nationally recognized initiative developed by Saint Paul-Ramsey County Public Health to create more welcoming places and public environments for families, children and young people.

Strategy B. Expand and Improve Postvention Supports

Postvention supports are those interventions that occur after a suicide has taken place in the community to help reduce the risk of further deaths. Minnesota’s second strategy to address adolescent suicide focuses on the area of postvention supports. As stated earlier, within MDH, the Suicide Prevention Unit (within the Health Promotion and Chronic Disease Division) works on both prevention and postvention efforts related to suicide. Related to this strategy, Minnesota’s Title V program will support the work of MDH’s Suicide Prevention Unit related to postvention supports.

Partner to Provide Trainings and Technical Assistance to Communities Dealing with the Impact of a Death from Suicide

Postvention training and technical assistance is a proactive planning tool to promote healing and reduce risk in the event of a suicide or sudden death. The MDH Suicide Prevention Unit provides training and technical assistance to communities that are dealing with the impact of a death from suicide.

One example of a training that is sponsored by MDH is the Connect Suicide Postvention Training. Connect is a half day training that focuses on engaging and building capacity for key service providers who will be involved responding to a suicide or other sudden death in a community. More information on the Connect Suicide Postvention Training can be found on their website at: https://theconnectprogram.org/available-services/reduce-suicide-risk-and-promote-healing-suicide-postvention-training/. During FY2022, CFH will help the MDH Suicide Prevention Unit to promote this training (and additional technical assistance as needed) to providers and community leaders – especially as it relates to adolescents and young adults.

Strategy C. Reduce Access to Lethal Means

Minnesota seeks to create a wide array of support systems, services and resources that promote wellness and help individuals manage stressful challenges to prevent suicides and related behaviors. Reducing access to lethal means (firearms, medicines/poisons, keys, sharp objects, materials used in hangings or suffocation, etc.) makes it less likely that the person with suicidal ideation will engage in suicidal behaviors, as well as decrease injuries, unintentional overdoses and substance abuse. CFH will partner with the MDH Suicide Prevention Unit to implement reducing access to lethal means strategies from the Minnesota Suicide Prevention State Plan.

Partner with providers and others who interact with individuals at risk for suicide to routinely assess for access to lethal means

• Develop policies and procedures for providers to routinely assess for access to lethal means and educate clients/patients on safe storage (inside and outside the home) recommendations.
• Partner with substance abuse prevention programs on medication take-back events and messaging around safe storage of medications (and chemicals) as an overdose prevention strategy.
• Develop standard messaging around risk for suicide and the importance of being alert to signs of suicidal behavior in a loved one and safe storage of firearms.

National Performance Measure and Five-Year Objective

Minnesota has chosen to focus on increasing the percentage of adolescents who have a preventive medical visit in the year (NPM 10) for the next five-year block grant cycle starting in FY2022. An annual preventive well visit can help adolescents adopt or maintain healthy habits and behaviors, avoid health‐damaging behaviors, manage chronic conditions, and prevent disease, including mental health issues. Additionally, they can play a role in preventing adolescent suicides. According to the American Academy of Pediatrics:

“At well-adolescent visits, adolescents who show any evidence of psychosocial or adaptive difficulties should be assessed regularly for mental health concerns and also asked about suicidal ideation, physical and sexual abuse, bullying, substance use, and sexual orientation.”[8]

The 2018 National Survey of Children’s Health found that 69.9% of adolescents (ages 12 through 17) had a preventive medical visit in the past year. By 2025, Minnesota aims to increase the percentage of adolescents who received a preventative medical visit in the past year by 10%. Due to our current climate with the COVID-19 pandemic, we do expect there to be a reduction of adolescents attending their annual preventive medical visit but don’t expect the reduction to last much after the pandemic resolves.

[1] America’s Health Rankings. (2019). Teen Suicide in Minnesota in 2018. Retrieved from https://www.americashealthrankings.org/explore/annual/measure/Suicide/state/MN.

[2] Centers for Disease Control and Prevention. (2017). Preventing Suicide: A Technical Package of Policy, Programs, and Practices. Retrieved from https://www.cdc.gov/violenceprevention/pdf/suicidetechnicalpackage.pdf

[3] Substance Abuse and Mental Health Services Administration (SAMHSA). (2017). Behavioral Health Barometer: Minnesota, Volume 4. Retrieved from https://www.samhsa.gov/data/sites/default/files/Minnesota_BHBarometer_Volume_4.pdf.

[4] Panchal, N., Kamal R., Cox, C., & R. (2021). The Implications of COVID-19 for Mental Health and Substance Use. Kaiser Family Foundation. Retrieved from https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/.

[5]MMB. (2019). Children’s Mental Health Inventory and Benefit-Cost Analysis. Retrieved February 17, 2021, from https://mn.gov/mmb-stat/results-first/cmh-report.pdf

[6] SAMHSA. (2012, April). Identifying Mental Health and Substance Use Problems of Children and Adolescents: A

Guide for Child-Serving Organizations. Retrieved from https://store.samhsa.gov/product/Identifying-MentalHealth-and-Substance-Use-Problems-of-Children-andAdolescents-A-Guide-for-Child-ServingOrganizations/SMA12-4700

[7] Weitzman, C., & Wegner, L. (2015). Promoting Optimal Development: Screening for Behavioral and Emotional

Problems. Pediatrics, 135(2), 385-395.

[8] American Academy of Pediatrics (2016). Clinical Report: Suicide and Suicide Attempts in Adolescents. Retrieved from https://pediatrics.aappublications.org/content/pediatrics/138/1/e20161420.full.pdf.