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EARLY INTERVENTION IN YOUTH SUICIDE PREVENTION AND COMMUNITY ENGAGEMENTThere is concern about the mental health of children and young people and a possible rise in suicidal behaviour in this group. Suicide is the second leading cause of death in 15-29-year-olds worldwide and the rates seems to be increasing (WHO 2014). Numerous factors contribute to the sharp rise in suicide in the late teens. Several of the risk factors like self-harm, mental illness, alcohol or drug misuse and social isolation are common to all age groups. However, some factors such as family adversity, bullying, and the role of internet sites and social media, educational stress and relationship break- up are youth – specific (Cathryn et al., 2016). Suicide has a devastating and far-reaching pact on families, friends and communities. The stigma, criminalization in some countries and weak surveillance systems associated with it means that many people are unable to seek help. These striking facts and the lack of implemented timely interventions make suicide a serious global public health problem that needs to be tackled imperatively. Young people require specific attention when it comes to suicide. This pattern of cumulative risk and so-Called final straw phenomena provides opportunities to intervene prevention of future deaths by suicide depends on society-wide awareness of risks, as well as actions by particular services (Cathryn et al., 2016).On 10th October 2018 World Mental Health Day, British Prime Minister appointed Jackie Doyle- Price as minister for suicide prevention, a step to improve mental health particularly suicide. World Health Organization have committed themselves in the Mental Health Action Plan 2013-2020 to work towards the global target of reducing the suicide rate in countries by 10% by 2020. This target can be achieved only when communities are actively engaged in efforts for early intervention in suicide prevention especially in youth (WHO, 2014).Early intervention programs are an integral component of basic healthcare. Mental healthcare has traditionally been reactive and palliative, largely adult-focused and youth-specific community-based early intervention services have been overlooked. Young people aged between 12 and 25 years are less likely than any other age group to access mental health services for a number of reasons such as stigma, reduced mental health literacy, poor access to appropriate services and inadequate health system structures (McGorry & Mei, 2018).In the last decade the progress made in redesigning early intervention services for youth mental health has gained tremendous momentum. Headspace, an innovative integrated model of youth mental health care created in Australia, is a government-funded initiative that provides youth-friendly, stigma-free early intervention services in a ‘one-stop shop’ location to 12–25 year olds with emerging mental health. Youth participation and engagement form the central pillar of the model (McGorry & Mei, 2018). Providing non-judgmental, youth-friendly service in a non-stigmatizing environment headspace was found to be accessible by a range of young people with high levels of psychological distress that included vulnerable groups such as those who are marginalized and at risk. Headspace was effective in significantly reducing suicide ideation and self-harm, and in decreasing the number of absent school or work days.20 (McGorry & Mei 2018). Similar culturally appropriate models have been adopted by UK, Ireland, Canada, USA, Europe and Asia . In the UK, the creation of Youthspace, a youth-based mental health service in Birmingham, has led to the commissioning of an integrated care pathway for individuals aged 12–25 years.“Preventing Suicide in England: A cross-government outcomes strategy to save lives” was published by the Coalition government in September 2012. Developed after consultations with experts, including members of the National Suicide Prevention Strategy Advisory Group (NSPSAG) (Mackley, 2018). The key objectives of this Strategy: “a reduction in the suicide rate in the general population in England; and better support of those bereaved or affected by suicide” (Mackley, 2018) . In January 2017 the “Third Progress Report”, entitled Preventing suicide in England: Third progress report of the cross-government outcomes strategy to save lives was published. This report renewed focus on patients identified as being at higher risk of suicide, such as young and middle aged men, also a new focus on support for bereaved families as well as on education and young people mental health was included ( Mackley 2018).The Mental Health Commission of Canada launched grassroots initiative #308conversations in which each of Canada’s 308 Members of Parliament and other community leaders held a conversation in their community about suicide prevention. The World Health Organization has worked collaboratively with the Mental Health Commission of Canada to adapt this participatory approach for global use (WHO 2014).Early intervention programs may be grouped according to three very broad criteria: individual or ‘indicated’, group or ‘selective’ and ‘universal’ interventions (Ch 3.1, 2011).Individual or ‘indicated intervention the most commonly understood methods treats individuals displaying suicide-related behaviors. It aims at reducing risk factors and promoting protective factors in an individual with identified risk factor(s). This intervention is not necessarily restricted to the individual concerned, but may include family, friends, colleagues, teachers and others. A limitation of this approach is that it will not provide assistance to individuals who are at risk but cannot be identified. An additional barrier is so-called ‘help-negation’, where individuals in need avoid or withdraw from help, particularly in individuals experiencing depression. Another limitation inherent in indicated interventions concerns the continuity of care, especially after a hospitalization for a suicide attempt.Group or ‘selective’ intervention focuses on specific groups and communities within society believed to be at higher risk of suicide. These groups include LGBT, Indigenous youth, and youth from remote area, young people bereaved by suicide; and young people with history of a mental illness or previous suicide attempt or engage in self-harm. However it does not necessarily mean that these individuals will necessarily contemplate suicide. Selective intervention programs are tailored to the particular group and operate at nationwide and local levels. They include community based youth-friendly services, such as drop-in centers, recreational activities, sporting groups, school-based workshops or courses and outreach services. These activities aim to increase at-risk young people’s social connectedness and sense of belonging, reduce isolation, and improve awareness, knowledge and attitudes towards suicide and mental health. In addition to building support networks and it provides avenues for referrals to other services, where necessary. A ‘universal’ intervention targets the entire population or a segment of it, on the basis that some individuals within the population may be at risk of suicide, but will not exhibit any risk factors or exhibit factors that not be identified by others. It does not respond to a particular event or group characteristic – that is, they do not ‘intervene’ in a specific way. Rather, these programs are targeted at the entire population or particularly age groups within that population. The universal approach is also important for increasing the general awareness of suicide risks and seek help for suicidal risk behavior in themselves and others.Most intervention strategies comprise a combination of elements that are aimed at reducing risk factors and promoting protective factors. And it is important to recognize that these risk and protective factors may be modifiable and non-modifiable. It is also recommended that interventions operate across a range of settings, including clinical, educational, workplace and community settings and more recently are 3,1delivered in digital, as well as face-to-face, settings [Ch 3.1 2011]. A meta-analysis by Robinson et al., (2018) identified a large number of studies testing the full spectrum of interventions including universal means restriction and educational interventions, selective interventions such as training programs, indicated interventions such as cognitive or dialectical behavior therapy, and multimodal interventions that combined education with either screening or gatekeeper training conducted across multiple settings such as clinical, educational/workplace and community settings. The meta-analysis found that interventions delivered in both clinical and educational settings appear to have an impact on suicide-related outcomes at post intervention and follow-up. It was found that some Interventions for example, brief contact interventions in clinical settings, and psycho-education combined with screening in school settings can reduce the frequency of self-harm and suicidal ideation, however the size of these studies determines the effects. In community settings, multifaceted, place-based approaches seem to have an impact on rates of suicide and self-harm. Although the number and range of studies was encouraging the study had certain limitation, there was an absences of studies were conducted in low-middle income countries or with demographic populations known to be at increased risk of suicide. Similarly, few studies were conducted in primary care, universities and workplaces. Also the study quality was limited because statistically, suicide is a relatively rare event, therefore it is often not feasible to obtain sample sizes necessary to demonstrate the impact of interventions on this outcome (Robinson et al., 2018). A study on the patterns of suicide rates based on age, gender and time across countries showed significant differences (Roh et al., 2018). It has been observed that the absolute number of completed suicides is higher among male adolescents than female adolescents, but suicidal ideation and attempts are more frequent among female adolescents, this is frequently referred to as the gender paradox of suicidal behavior (Roh et al., 2018). However in some Asian countries, including China and India, youth suicide rates for females exceed those for males, whereas, suicide rates for females aged 14 or younger have been reported to be increasing in Western countries. The gender gaps in most countries for suicide rates showed similar magnitude but the differences due to age and gender varied significantly by region. A decreasing trend in suicide rates among 10-19 year old was noticed in many countries. In several European countries there was a remarkable decrease in male suicide rates, but the female rates were either stable or increased (Roh et al., 2018). This was attributes to restrictions on firearms and some degree of improvement in global health. In contrast, Korea and Japan showed increasing suicide rates for both genders due to economic recession, inequality, and rapid changes in family structure (Roh et al., 2018). Suicide prevention cannot be accomplished by one person, organization or institution alone; it requires support from the whole community. Communities gives such individuals a sense of belonging , by providing social support to individuals who are vulnerable, engaging in follow-up care, raising awareness, fighting stigma and supporting individuals bereaved by suicide. In some cases, community members or representatives may take on the role of “gatekeeper” identifying people at risk of suicidal behaviour or emerging suicide clusters (Kral et al., 2009; Coppens et al., 2014).However, community engagement techniques often lack clear evidence and guidelines for their successful execution and design (Mendel et al., 2011). It may be difficult to know where or how to initiate action especially when dealing with a sensitive issue such as suicide prevention. Often, communities find they are inadequately prepared or are overwhelmed by the task of establishing successful suicide prevention strategies. Against this background the WHO toolkit provides practical suggestions that can be used by communities worldwide, regardless of the resources at their disposal or their current state of progress in suicide prevention efforts (WHO 2014).Suicide prevention efforts are effective when community engagements use a systematic, data-driven process to understand the suicide problem, set clear goals, and prioritize activities that are most likely to make a difference. It’s important that community members voice their concerns and opinion about the most pressing needs in suicide prevention in their community. This process helps in identifying gaps, resources and activities that may already be available in that particular community (WHO, 2014). It is also worth considering the scale of the community engagement, the population or region to be involved, available data and awareness of data limitations (WHO, 2014). Before starting community engagements, it is essential to understand the community and its relation to suicide and suicide prevention – e.g. by finding out suicide in the community- the number means and access to means, the sociocultural context namely stigma and cultural or religious beliefs, suicide prevention programmes are already in place, or most importantly how the community address suicide issue.Communities influence and shape policy and services by initiating activities that are comprehensive and combine multiple strategies that focus on key areas that are appropriate to their local context.Involving people from the community in planning and carrying out engagements paves way for successful suicide prevention strategy. A good way start community engagement is to create a steering committee of around 10 like-minded people from different background with different skills and ideas who share similar concerns and are motivated to engage in suicide prevention (Mental Health Commission of Canada, 2015; Capire Consulting Group, 2016; Suicide Prevention Australia, 2014). In a community there are formal and informal leaders (e.g. police, politicians, religious leaders) who play an important role in uniting the community and bringing people together to achieve a common goal. It is important to ensure that these leaders and other prominent members of the community (e.g. nurses, teachers, firefighters), who can act as gatekeepers, are educated about suicide prevention and play an active role in identifying persons at risk of suicide within the community (Kral et al., 2009). Gatekeeper training is an essential activity in suicide preventionTeamwork, open dialogue, and compromise are hallmark of successful community engagement and it is essential to establish at the beginning itself. Community engagement play an important role in restricting access to means of suicide. Awareness programmers and community education are important (WHO, 2016b) especially in context where suicides are impulsive. For instance, the easy and ready access to pesticides as a means of self-harm and suicide is a key problem in rural agricultural communities in low- and middle-income countries. Hence, in such communities potential activities should target farmers and their families (WHO, 2014). Suicide is shrouded in stigma and increasing dialogue about it to reduce the stigma is commonly employed in suicide prevention. This can be achieved through educational programmers conducted by a health professional or representative of a support group or a bereaved persons who have lost a loved one to suicide or have lived experience of self-harm (Mohatt et al., 2013).Suicide is a public health issue and the media has an important role to play in building public opinion and attitudes. It is important that the media act responsibly while reporting cases in order to avoid imitation of suicidal acts by vulnerable persons. Inappropriate reporting on suicide in the media may lead to a contagious effect or “Werther effect”””