{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T03:41:05Z","timestamp":1787888465313,"version":"build-2784847793"},"reference-count":140,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2026,2,9]],"date-time":"2026-02-09T00:00:00Z","timestamp":1770595200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000025","name":"National Institute of Mental Health","doi-asserted-by":"publisher","award":["L30 MH120575"],"award-info":[{"award-number":["L30 MH120575"]}],"id":[{"id":"10.13039\/100000025","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100001455","name":"American Foundation for Suicide Prevention","doi-asserted-by":"publisher","award":["PRG-1-108-23"],"award-info":[{"award-number":["PRG-1-108-23"]}],"id":[{"id":"10.13039\/100001455","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Behavioral Sciences"],"abstract":"<jats:p>Despite decades of research, suicide risk factors predict outcomes at chance levels, and there is a dearth of protective factor and resilience research, which limits the utility of risk-based approaches. Further, suicide prevention interventions primarily consist of individual psychotherapies and treating individuals after suicide-related outcomes occur. Unfortunately, there is a lack of upstream suicide prevention interventions targeting known suicide risk factors and aiming to increase well-being and resilience in the U.S. Thus, we discuss these problems in the field and the U.S. health care system and provide a possible solution. We propose using low-intensity, universal, and upstream prevention interventions, such as Stress Control. Stress Control is a classroom-style, Cognitive Behavior Therapy-based program shown to reduce \u201crisk,\u201d stress, anxiety, and depression and boost well-being and resilience as part of a stepped-care model. Although Stress Control\u2019s suicide prevention effectiveness has not yet been directly assessed, we discuss how it could be a promising suicide prevention strategy with additional testing. A proposed mechanism for this reduction is building resilience to common risk factors and suicide ideation via evidence-based coping skills, thereby decreasing future suicide risk. We review current limitations and discuss how upstream, scalable, universal prevention interventions can help improve psychological resilience and reduce suicidal thoughts and behaviors, lowering the U.S. suicide rate. Implications and recommendations are discussed.<\/jats:p>","DOI":"10.3390\/bs16020243","type":"journal-article","created":{"date-parts":[[2026,2,9]],"date-time":"2026-02-09T09:41:02Z","timestamp":1770630062000},"page":"243","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Beyond Risk Prediction: Considering Upstream Universal Suicide Prevention to Decrease Risk and Increase Resilience"],"prefix":"10.3390","volume":"16","author":[{"given":"Sarah","family":"Sparks","sequence":"first","affiliation":[{"name":"Department of Psychological Services, Texas Tech University, Lubbock, TX 79409-2051, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cole","family":"Marvin","sequence":"additional","affiliation":[{"name":"Department of Psychological Services, Texas Tech University, Lubbock, TX 79409-2051, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-4624-9930","authenticated-orcid":false,"given":"Regan","family":"Sweeney","sequence":"additional","affiliation":[{"name":"Department of Psychological Services, Texas Tech University, Lubbock, TX 79409-2051, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-3396-7186","authenticated-orcid":false,"given":"Destiny","family":"Rojas","sequence":"additional","affiliation":[{"name":"Department of Psychological Services, Texas Tech University, Lubbock, TX 79409-2051, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3729-7368","authenticated-orcid":false,"given":"Sean M.","family":"Mitchell","sequence":"additional","affiliation":[{"name":"Department of Psychological Services, Texas Tech University, Lubbock, TX 79409-2051, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,9]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1007\/s11920-018-0969-9","article-title":"Social determinants of mental health: Where we are and where we need to go","volume":"20","author":"NeMoyer","year":"2018","journal-title":"Current Psychiatry Reports"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1007\/s11121-021-01265-0","article-title":"Protective factors as a unifying framework for strength-based intervention and culturally responsive American Indian and Alaska native suicide prevention","volume":"23","author":"Allen","year":"2022","journal-title":"Prevention Science"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"115854","DOI":"10.1016\/j.psychres.2024.115854","article-title":"Social determinants of mental health in major depressive disorder: Umbrella review of 26 meta-analyses and systematic reviews","volume":"335","author":"Alon","year":"2024","journal-title":"Psychiatry Research"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1002\/da.22711","article-title":"Treatment gap for anxiety disorders is global: Results of the world mental health surveys in 21 countries","volume":"35","author":"Alonso","year":"2018","journal-title":"Depression and Anxiety"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"422","DOI":"10.1176\/appi.ajp.21101001","article-title":"Structural racism and suicide prevention for ethnoracially minoritized youth: A conceptual framework and illustration across systems","volume":"179","author":"Alvarez","year":"2022","journal-title":"The American Journal of Psychiatry"},{"key":"ref_6","unstructured":"American Psychological Association (2025, December 28). Building your resilience, Available online: https:\/\/www.apa.org\/topics\/resilience."},{"key":"ref_7","first-page":"96","article-title":"A qualitative evaluation of the impacts of a strength-based and youth-driven approach to suicide prevention in rural and minority communities in Hawai\u2019i","volume":"79","author":"Antonio","year":"2020","journal-title":"Hawai\u2019i Journal of Health & Social Welfare"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"838","DOI":"10.1016\/j.beth.2016.11.005","article-title":"Toward a unified treatment for emotional disorders\u2014Republished article","volume":"47","author":"Barlow","year":"2016","journal-title":"Behavior Therapy"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1359","DOI":"10.1017\/S0033291799002950","article-title":"Unequal access and unmet need: Neurotic disorders and the use of primary care services","volume":"30","author":"Bebbington","year":"2000","journal-title":"Psychological Medicine"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"642","DOI":"10.1001\/jamapsychiatry.2019.0174","article-title":"Prediction models for suicide attempts and deaths: A systematic review and simulation","volume":"76","author":"Belsher","year":"2019","journal-title":"JAMA Psychiatry"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"445","DOI":"10.1016\/j.amepre.2015.09.029","article-title":"Improving suicide risk screening and detection in the emergency department","volume":"50","author":"Boudreaux","year":"2016","journal-title":"American Journal of Preventive Medicine"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1192\/bjp.186.1.11","article-title":"Stepped care in psychological therapies: Access, effectiveness and efficiency: Narrative literature review","volume":"186","author":"Bower","year":"2005","journal-title":"British Journal of Psychiatry"},{"key":"ref_13","first-page":"21","article-title":"Making decisions about patient progress: The application of routine outcome measurement in stepped care psychological therapy services","volume":"4","author":"Bower","year":"2006","journal-title":"Primary Care Mental Health"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1016\/j.jpsychores.2005.06.074","article-title":"The perseverative cognition hypothesis: A review of worry, prolonged stress-related physiological activation, and health","volume":"60","author":"Brosschot","year":"2006","journal-title":"Journal of Psychosomatic Research"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"S186","DOI":"10.1016\/j.amepre.2014.06.008","article-title":"Evidence-based psychotherapies for suicide prevention","volume":"47","author":"Brown","year":"2014","journal-title":"American Journal of Preventive Medicine"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"100","DOI":"10.31887\/DCNS.1999.1.2\/mbruce","article-title":"Designing an intervention to prevent suicide: PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial)","volume":"1","author":"Bruce","year":"1999","journal-title":"Dialogues in Clinical Neuroscience"},{"key":"ref_17","first-page":"680","article-title":"Does suicide risk screening improve the identification of primary care patients who will attempt suicide versus depression screening alone?","volume":"49","author":"Bryan","year":"2023a","journal-title":"Joint Commission Journal on Quality and Patient Safety"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1176\/appi.ps.202100611","article-title":"Weighing the costs and benefits of universal suicide risk screening in primary care: An evidence-based approach","volume":"74","author":"Bryan","year":"2023b","journal-title":"Psychiatric Services"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"148","DOI":"10.1037\/a0011141","article-title":"Managing suicide risk in primary care: Practice recommendations for behavioral health consultants","volume":"40","author":"Bryan","year":"2009","journal-title":"Professional Psychology: Research and Practice"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1037\/a0022290","article-title":"Circumventing mental health stigma by embracing the warrior culture: Lessons learned from the defender\u2019s edge program","volume":"42","author":"Bryan","year":"2011","journal-title":"Professional Psychology: Research and Practice"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1016\/j.jad.2022.06.070","article-title":"Scores on the suicide cognitions scale-revised (SCS-R) predict future suicide attempts among primary care patients denying suicide ideation and prior attempts","volume":"313","author":"Bryan","year":"2022","journal-title":"Journal of Affective Disorders"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1177\/0145445514553094","article-title":"The unified protocol for transdiagnostic treatment of emotional disorders: Preliminary exploration of effectiveness for group delivery","volume":"39","author":"Bullis","year":"2015","journal-title":"Behavior Modification"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"431","DOI":"10.1017\/S1352465815000491","article-title":"\u201cStress Control\u201d as a large group psychoeducational intervention at step 2 of IAPT services: Acceptability of the approach and moderators of effectiveness","volume":"44","author":"Burns","year":"2016","journal-title":"Behavioural and Cognitive Psychotherapy"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1136\/injuryprev-2017-042366","article-title":"Comprehensive, integrated approaches to suicide prevention: Practical guidance","volume":"24","author":"Caine","year":"2018","journal-title":"Injury Prevention"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.psychres.2019.05.024","article-title":"Suicidal ideation disclosure: Patterns, correlates and outcome","volume":"278","author":"Calear","year":"2019","journal-title":"Psychiatry Research"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"229","DOI":"10.1027\/0227-5910\/a000558","article-title":"Suicide risk assessment: Risk stratification is not accurate enough to be clinically useful and alternative approaches are needed","volume":"39","author":"Carter","year":"2018","journal-title":"Crisis: The Journal of Crisis Intervention and Suicide Prevention"},{"key":"ref_27","unstructured":"Centers for Disease Control and Prevention [CDC] (2025, December 28). 1999\u20132018 Wide Ranging Online Data for Epidemiological Research (WONDER), multiple cause of death files [Fact sheet], Available online: http:\/\/wonder.cdc.gov\/ucd-icd10.html."},{"key":"ref_28","unstructured":"Centers for Disease Control and Prevention [CDC] (2025, December 28). Prevalence of depression among adults aged 20 and over: United States, 2013\u20132016, Available online: https:\/\/www.cdc.gov\/nchs\/products\/databriefs\/db303.htm."},{"key":"ref_29","unstructured":"Centers for Disease Control and Prevention [CDC] (2025, December 28). Suicide data and statistics [Fact sheet], Available online: https:\/\/www.cdc.gov\/suicide\/facts\/data.html?CDC_AAref_Val=https:\/\/www.cdc.gov\/suicide\/suicide-data-statistics.html."},{"key":"ref_30","unstructured":"Centers for Disease Control and Prevention [CDC] (2025, December 28). U.S. uninsured rate dropped 18% during the pandemic [Fact sheet], Available online: https:\/\/www.cdc.gov\/nchs\/pressroom\/releases\/20230516.html?CDC_AAref_Val=https:\/\/www.cdc.gov\/nchs\/pressroom\/nchs_press_releases\/2023\/202305.htm."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"458","DOI":"10.1001\/jamapsychiatry.2018.0185","article-title":"Association of an early intervention service for psychosis with suicide rate among patients with first-episode schizophrenia-spectrum disorders","volume":"75","author":"Chan","year":"2018","journal-title":"JAMA Psychiatry"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1186\/s13033-020-00356-9","article-title":"Prevention and early intervention in youth mental health: Is it time for a multidisciplinary and trans-diagnostic model for care?","volume":"14","author":"Colizzi","year":"2020","journal-title":"International Journal of Mental Health Systems"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"683","DOI":"10.1177\/1077558718780592","article-title":"A review of mental health and mental health care disparities research: 2011\u20132014","volume":"76","author":"Cook","year":"2019","journal-title":"Medical Care Research and Review"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"100847","DOI":"10.1016\/j.ssmph.2021.100847","article-title":"Barriers to healthcare access among U.S. adults with mental health challenges: A population-based study","volume":"15","author":"Coombs","year":"2021","journal-title":"SSM\u2014Population Health"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"614","DOI":"10.1037\/0003-066X.59.7.614","article-title":"How stigma interferes with mental health care","volume":"59","author":"Corrigan","year":"2004","journal-title":"American Psychologist"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1177\/1529100614531398","article-title":"The impact of mental illness stigma on seeking and participating in mental health care","volume":"15","author":"Corrigan","year":"2014","journal-title":"Psychological Science in the Public Interest"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1089\/vio.2020.0087","article-title":"Gender differences in male depression and suicide risk","volume":"8","author":"Cui","year":"2021","journal-title":"Violence and Gender"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"334","DOI":"10.7326\/M19-0869","article-title":"Treatments for the prevention and management of suicide","volume":"171","author":"Uhl","year":"2019","journal-title":"Annals of Internal Medicine"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"894","DOI":"10.15585\/mmwr.mm6534a2","article-title":"CDC grand rounds: Preventing suicide through a comprehensive public health approach","volume":"65","author":"Crosby","year":"2016","journal-title":"Morbidity and Mortality Weekly Report"},{"key":"ref_40","first-page":"e20210316","article-title":"The impact of mindfulness on suicidal behavior: A systematic review","volume":"44","author":"Bilhalva","year":"2022","journal-title":"Trends in Psychiatry and Psychotherapy"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"65S","DOI":"10.1177\/0033354918800019","article-title":"An integrated public health approach to interpersonal violence and suicide prevention and response","volume":"133","author":"Decker","year":"2018","journal-title":"Public Health Reports\u00ae"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1016\/j.brat.2016.09.010","article-title":"A multi-service practice research network study of large group psychoeducational cognitive behavioral therapy","volume":"87","author":"Delgadillo","year":"2016","journal-title":"Behaviour Research and Therapy"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"940","DOI":"10.1111\/sltb.12778","article-title":"Social closeness and support are associated with lower risk of suicide among U.S. Army Soldiers","volume":"51","author":"Dempsey","year":"2021","journal-title":"Suicide and Life-Threatening Behavior"},{"key":"ref_44","first-page":"e2014070","article-title":"Assessment of selective and universal screening for suicide risk in a pediatric emergency department","volume":"2","author":"Ryan","year":"2019","journal-title":"JAMA Network Open"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"375","DOI":"10.1111\/bjc.12288","article-title":"Effectiveness of stress control large group psychoeducation for anxiety and depression: Systematic review and meta-analysis","volume":"60","author":"Dolan","year":"2021","journal-title":"British Journal of Clinical Psychology"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"921","DOI":"10.1176\/ps.2008.59.8.921","article-title":"Perceived barriers to medical care and mental health care among veterans with serious mental illness","volume":"59","author":"Drapalski","year":"2008","journal-title":"Psychiatric Services"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"703","DOI":"10.1016\/j.jad.2019.09.062","article-title":"Psychosocial protective factors and suicidal ideation: Results from a national longitudinal study of veterans","volume":"260","author":"Elbogen","year":"2020","journal-title":"Journal of Affective Disorders"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"88","DOI":"10.1016\/j.cbpra.2009.06.002","article-title":"Unified protocol for the transdiagnostic treatment of emotional disorders: Protocol development and initial outcome data","volume":"17","author":"Ellard","year":"2010","journal-title":"Cognitive and Behavioral Practice"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1192\/bjp.180.1.51","article-title":"Towards a standardised brief outcome measure: Psychometric properties and utility of the CORE-OM","volume":"180","author":"Evans","year":"2002","journal-title":"British Journal of Psychiatry"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"1117","DOI":"10.1037\/bul0000305","article-title":"Interventions for suicide and self-injury: A meta-analysis of randomized controlled trials across nearly 50 years of research","volume":"146","author":"Fox","year":"2020","journal-title":"Psychological Bulletin"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"187","DOI":"10.1037\/bul0000084","article-title":"Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research","volume":"143","author":"Franklin","year":"2017","journal-title":"Psychological Bulletin"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"1120","DOI":"10.1007\/s10608-021-10214-8","article-title":"Reappraisal and suppression each moderate the association between stress and suicidal ideation: Preliminary evidence from a daily diary study","volume":"45","author":"Franz","year":"2021","journal-title":"Cognitive Therapy and Research"},{"key":"ref_53","unstructured":"Goldsmith, S. K., Pellmar, T. C., Kleinman, A. M., and Bunney, W. E. (2002). Reducing suicide: A national imperative. Institute of Medicine (US) Committee on pathophysiology and prevention of adolescent and adult suicide, National Academies Press (US)."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1176\/appi.ps.202100625","article-title":"Universal suicide screening is feasible and necessary to reduce suicide","volume":"74","author":"Boudreaux","year":"2023","journal-title":"Psychiatric Services"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1017\/S1754470X20000380","article-title":"The impact of a Stress Control course delivered in partnership with a sports organisation on mental health outcomes in a general population","volume":"13","author":"Hayes","year":"2020","journal-title":"The Cognitive Behaviour Therapist"},{"key":"ref_56","doi-asserted-by":"crossref","unstructured":"Hedegaard, H., Curtin, S. C., and Warner, M. (2020). Increase in suicide mortality in the United States, 1999\u20132018, NCHS Data Brief No. 362.","DOI":"10.15620\/cdc:101761"},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1016\/j.genhosppsych.2019.04.011","article-title":"Effectiveness of suicide prevention interventions: A systematic review and meta-analysis","volume":"63","author":"Hofstra","year":"2020","journal-title":"General Hospital Psychiatry"},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1080\/13811118.2020.1774454","article-title":"Suicide risk and protective factors: A network approach","volume":"26","author":"Holman","year":"2022","journal-title":"Archives of Suicide Research"},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"1855","DOI":"10.11124\/JBISRIR-2017-003848","article-title":"Effectiveness of diaphragmatic breathing for reducing physiological and psychological stress in adults: A quantitative systematic review","volume":"17","author":"Hopper","year":"2019","journal-title":"JBI Database of Systematic Reviews and Implementation Reports"},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"123","DOI":"10.1016\/j.jad.2020.03.115","article-title":"Sociodemographic differences in barriers to mental health care among college students at elevated suicide risk","volume":"271","author":"Horwitz","year":"2020","journal-title":"Journal of Affective Disorders"},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"731","DOI":"10.1016\/j.jad.2020.01.171","article-title":"Are stressful life events prospectively associated with increased suicidal ideation and behaviour? A systematic review and meta-analysis","volume":"266","author":"Howarth","year":"2020","journal-title":"Journal of Affective Disorders"},{"key":"ref_62","doi-asserted-by":"crossref","first-page":"36","DOI":"10.1016\/j.jad.2016.06.054","article-title":"Factors associated with suicidal ideation disclosure: Results from a large population-based study","volume":"205","author":"Husky","year":"2016","journal-title":"Journal of Affective Disorders"},{"key":"ref_63","unstructured":"Mrazek, P. J., and Haggerty, R. J. (1994). Reducing risks for mental disorders: Frontiers for preventive intervention research, National Academies Press."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1037\/rmh0000125","article-title":"A phenomenological study of clinicians\u2019 perspectives on barriers to rural mental health care","volume":"44","author":"Jensen","year":"2020","journal-title":"Journal of Rural Mental Health"},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"1005","DOI":"10.1080\/01634372.2023.2202729","article-title":"Resilience as a protective factor in older adult suicide: A rapid review","volume":"66","author":"Jeong","year":"2023","journal-title":"Journal of Gerontological Social Work"},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"346","DOI":"10.1017\/S104161022300443X","article-title":"A systematic review of psychosocial protective factors against suicide and suicidality among older adults","volume":"36","author":"Ki","year":"2024","journal-title":"International Psychogeriatrics"},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"58","DOI":"10.1002\/wps.21160","article-title":"The social determinants of mental health and disorder: Evidence, prevention and recommendations","volume":"23","author":"Kirkbride","year":"2024","journal-title":"World Psychiatry"},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"307","DOI":"10.1080\/09638230802052153","article-title":"A randomized controlled trial comparing an adult education class using cognitive behavioural therapy (\u201cstress control\u201d), anxiety management group treatment and a waiting list for anxiety disorders","volume":"18","author":"Kitchiner","year":"2009","journal-title":"Journal of Mental Health"},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"540","DOI":"10.1016\/j.jad.2013.01.033","article-title":"Social support as a protective factor in suicide: Findings from two nationally representative samples","volume":"150","author":"Kleiman","year":"2013","journal-title":"Journal of Affective Disorders"},{"key":"ref_70","first-page":"339","article-title":"Understanding suicide to prevent suicide","volume":"43","author":"Klonsky","year":"2020","journal-title":"The Behavior Therapist"},{"key":"ref_71","doi-asserted-by":"crossref","first-page":"37","DOI":"10.2105\/AJPH.94.1.37","article-title":"If suicide is a public health problem, what are we doing to prevent it?","volume":"94","author":"Knox","year":"2004","journal-title":"American Journal of Public Health"},{"key":"ref_72","first-page":"1376","article-title":"Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: Cohort study","volume":"327","author":"Knox","year":"2003","journal-title":"BMJ (Clinical Research Edition)"},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1111\/sltb.12708","article-title":"Is the outpatient mental health workforce ready to save lives? Suicide prevention training, knowledge, self-efficacy, and clinical practices prior to the implementation of a statewide suicide prevention initiative","volume":"51","author":"Labouliere","year":"2021","journal-title":"Suicide & Life-Threatening Behavior"},{"key":"ref_74","doi-asserted-by":"crossref","first-page":"390","DOI":"10.1177\/1039856214537128","article-title":"Suicide risk categorisation of psychiatric inpatients: What it might mean and why it is of no use","volume":"22","author":"Large","year":"2014","journal-title":"Australasian Psychiatry"},{"key":"ref_75","doi-asserted-by":"crossref","first-page":"j4627","DOI":"10.1136\/bmj.j4627","article-title":"Can we usefully stratify patients according to suicide risk?","volume":"359","author":"Large","year":"2017","journal-title":"BMJ"},{"key":"ref_76","unstructured":"Leahy, R. L. (2017). Cognitive therapy techniques: A practitioner\u2019s guide, Guilford Publications."},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"273","DOI":"10.31887\/DCNS.2003.5.3\/slevine","article-title":"Psychological and social aspects of resilience: A synthesis of risks and resources","volume":"5","author":"Levine","year":"2003","journal-title":"Dialogues in Clinical Neuroscience"},{"key":"ref_78","doi-asserted-by":"crossref","first-page":"379","DOI":"10.1017\/S1352465800004070","article-title":"Multiple access points and levels of entry (MAPLE): Ensuring choice, accessibility and equity for CBT services","volume":"28","author":"Lovell","year":"2000","journal-title":"Behavioural and Cognitive Psychotherapy"},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1093\/brief-treatment\/mhh019","article-title":"Psychoeducation as evidence-based practice: Considerations for practice, research, and policy","volume":"4","author":"Lukens","year":"2004","journal-title":"Brief Treatment and Crisis Intervention"},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"611","DOI":"10.1176\/appi.ajp.2020.20060864","article-title":"Improving suicide prevention through evidence-based strategies: A systematic review","volume":"178","author":"Mann","year":"2021","journal-title":"American Journal of Psychiatry"},{"key":"ref_81","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1146\/annurev-publhealth-051920-123206","article-title":"The recent rise of suicide mortality in the United States","volume":"43","author":"Jiang","year":"2022","journal-title":"Annual Review of Public Health"},{"key":"ref_82","doi-asserted-by":"crossref","unstructured":"McCormack, H. M., MacIntyre, T. E., O\u2019Shea, D., Herring, M. P., and Campbell, M. J. (2018). The prevalence and cause(s) of burnout among applied psychologists: A systematic review. Frontiers in Psychology, 9.","DOI":"10.3389\/fpsyg.2018.01897"},{"key":"ref_83","doi-asserted-by":"crossref","unstructured":"McGillivray, L., Rheinberger, D., Wang, J., Burnett, A., and Torok, M. (2022). Non-disclosing youth: A cross sectional study to understand why young people do not disclose suicidal thoughts to their mental health professional. BMC Psychiatry, 22, (1).","DOI":"10.1186\/s12888-021-03636-x"},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"671","DOI":"10.1093\/pubmed\/fdab157","article-title":"Framing action to reduce health inequalities: What is argued for through use of the \u2018upstream\u2013downstream\u2019 metaphor?","volume":"44","author":"McMahon","year":"2022","journal-title":"Journal of Public Health"},{"key":"ref_85","unstructured":"Mental Health America (2025, December 28). 2022 key findings [Fact sheet], Available online: https:\/\/www.mhanational.org\/issues\/state-mental-health-america."},{"key":"ref_86","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1017\/ipm.2015.56","article-title":"Responding to mental health statutory drivers: Experience of a low intensity cognitive behavioural therapy programme","volume":"33","author":"Mills","year":"2016","journal-title":"Irish Journal of Psychological Medicine"},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"76","DOI":"10.1111\/sltb.12670","article-title":"Using categorical data analyses in suicide research: Considering clinical utility and practicality","volume":"51","author":"Mitchell","year":"2021","journal-title":"Suicide & Life-Threatening Behavior"},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"359","DOI":"10.1027\/0227-5910\/a000647","article-title":"Suicide-related training, self-efficacy, and mental health care providers\u2019 reactions toward suicidal individuals","volume":"41","author":"Mitchell","year":"2020","journal-title":"Crisis: The Journal of Crisis Intervention and Suicide Prevention"},{"key":"ref_89","doi-asserted-by":"crossref","first-page":"565","DOI":"10.1111\/jrh.12532","article-title":"A systematic review of factors impacting suicide risk among rural adults in the United States","volume":"37","author":"Mohatt","year":"2021","journal-title":"The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association"},{"key":"ref_90","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1176\/appi.focus.20190028","article-title":"Challenges and opportunities to meet the mental health needs of underserved and disenfranchised populations in the United States","volume":"18","author":"Mongelli","year":"2020","journal-title":"Focus"},{"key":"ref_91","doi-asserted-by":"crossref","first-page":"337","DOI":"10.1001\/jamapsychiatry.2024.4241","article-title":"Social determinants of health and suicide-related outcomes: A review of meta-analyses","volume":"82","author":"Na","year":"2025","journal-title":"JAMA Psychiatry"},{"key":"ref_92","doi-asserted-by":"crossref","first-page":"l94","DOI":"10.1136\/bmj.l94","article-title":"Global, regional, and national burden of suicide mortality 1990 to 2016: Systematic analysis for the Global Burden of Disease Study 2016","volume":"364","author":"Naghavi","year":"2019","journal-title":"BMJ"},{"key":"ref_93","unstructured":"National Collaborating Centre for Determinants of Health (2014). Let\u2019s talk: Moving upstream, National Collaborating Centre for Determinants of Health, St. Francis Xavier University. Available online: https:\/\/nccdh.ca\/resources\/entry\/lets-talk-moving-upstream."},{"key":"ref_94","unstructured":"National Institute of Mental Health [NIMH] (2025, December 28). Suicide, Available online: https:\/\/www.nimh.nih.gov\/health\/statistics\/suicide."},{"key":"ref_95","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1016\/j.genhosppsych.2018.06.006","article-title":"Universal screening may not prevent suicide","volume":"63","author":"Nestadt","year":"2020","journal-title":"General Hospital Psychiatry"},{"key":"ref_96","doi-asserted-by":"crossref","first-page":"741","DOI":"10.7326\/0003-4819-158-10-201305210-00642","article-title":"Screening for and treatment of suicide risk relevant to primary care: A systematic review for the US Preventive Services Task Force","volume":"158","author":"Gaynes","year":"2013","journal-title":"Annals of Internal Medicine"},{"key":"ref_97","doi-asserted-by":"crossref","first-page":"207","DOI":"10.30773\/pi.2019.0171","article-title":"Understanding the complex of suicide in depression: From research to clinics","volume":"17","author":"Orsolini","year":"2020","journal-title":"Psychiatry Investigation"},{"key":"ref_98","doi-asserted-by":"crossref","unstructured":"Pickering, T. A., Wyman, P. A., Schmeelk-Cone, K., Hartley, C., Valente, T. W., Pisani, A. R., Rulison, K. L., Brown, C. H., and LoMurray, M. (2018). Diffusion of a peer-led suicide preventive intervention through school-based student peer and adult networks. Frontiers in Psychiatry, 9.","DOI":"10.3389\/fpsyt.2018.00598"},{"key":"ref_99","doi-asserted-by":"crossref","first-page":"720","DOI":"10.1016\/j.jpsychires.2010.11.015","article-title":"Suicidal ideation in treatment-seeking veterans of operations enduring freedom and Iraqi freedom: The role of coping strategies, resilience, and social support","volume":"45","author":"Pietrzak","year":"2011","journal-title":"Journal of Psychiatric Research"},{"key":"ref_100","doi-asserted-by":"crossref","first-page":"e787","DOI":"10.1016\/S2468-2667(24)00149-X","article-title":"Preventing suicide: A public health approach to a global problem","volume":"9","author":"Pirkis","year":"2024","journal-title":"The Lancet Public Health"},{"key":"ref_101","doi-asserted-by":"crossref","first-page":"432","DOI":"10.1093\/milmed\/usy296","article-title":"Suicide in the military: Understanding rates and risk factors across the United States\u2019 Armed Forces","volume":"184","author":"Pruitt","year":"2019","journal-title":"Military Medicine"},{"key":"ref_102","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1080\/13814788.2017.1284791","article-title":"Impact of educational interventions on primary prevention of cardiovascular disease: A systematic review with a focus on physical activity","volume":"23","author":"Oliveira","year":"2017","journal-title":"European Journal of General Practice"},{"key":"ref_103","doi-asserted-by":"crossref","first-page":"466","DOI":"10.1007\/s11920-014-0466-8","article-title":"Suicide risk in primary care: Identification and management in older adults","volume":"16","author":"Raue","year":"2014","journal-title":"Current Psychiatry Reports"},{"key":"ref_104","doi-asserted-by":"crossref","first-page":"602","DOI":"10.1002\/gps.466","article-title":"Treatment as usual (TAU) control practices in the PROSPECT study: Managing the interaction and tension between research design and ethics","volume":"16","author":"Reynolds","year":"2001","journal-title":"International Journal of Geriatric Psychiatry"},{"key":"ref_105","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1186\/1748-5908-7-3","article-title":"Delivering stepped care: An analysis of implementation in routine practice","volume":"7","author":"Richards","year":"2012","journal-title":"Implementation Science"},{"key":"ref_106","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1027\/0227-5910\/a000478","article-title":"Mental health professionals\u2019 suicide risk assessment and management practices: The impact of fear of suicide-related outcomes and comfort working with suicidal individuals","volume":"39","author":"Roush","year":"2018","journal-title":"Crisis: The Journal of Crisis Intervention and Suicide Prevention"},{"key":"ref_107","doi-asserted-by":"crossref","first-page":"1723","DOI":"10.1377\/hlthaff.2013.0133","article-title":"Access and cost barriers to mental health care, by insurance status, 1999\u20132010","volume":"32","author":"Rowan","year":"2013","journal-title":"Health Affairs"},{"key":"ref_108","doi-asserted-by":"crossref","first-page":"265","DOI":"10.1080\/13811110701403916","article-title":"Low resilience in suicide attempters","volume":"11","author":"Roy","year":"2007","journal-title":"Archives of Suicide Research"},{"key":"ref_109","doi-asserted-by":"crossref","first-page":"214","DOI":"10.1521\/jscp.2020.39.3.214","article-title":"Unit cohesion and social support as protective factors against suicide risk and depression among National Guard Service members","volume":"39","author":"Rugo","year":"2020","journal-title":"Journal of Social and Clinical Psychology"},{"key":"ref_110","doi-asserted-by":"crossref","unstructured":"Sakashita, T., and Oyama, H. (2019). Developing a hypothetical model for suicide progression in older adults with universal, selective, and indicated prevention strategies. Frontiers in Psychiatry, 10.","DOI":"10.3389\/fpsyt.2019.00161"},{"key":"ref_111","doi-asserted-by":"crossref","first-page":"1249","DOI":"10.1001\/archpsyc.62.11.1249","article-title":"Anxiety disorders and risk for suicidal ideation and suicide attempts: A population-based longitudinal study of adults","volume":"62","author":"Sareen","year":"2005","journal-title":"Archives of General Psychiatry"},{"key":"ref_112","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1016\/j.socscimed.2019.01.023","article-title":"Benefits and risks of suicide disclosure","volume":"223","author":"Sheehan","year":"2019","journal-title":"Social Science & Medicine"},{"key":"ref_113","doi-asserted-by":"crossref","first-page":"169","DOI":"10.1111\/acps.13059","article-title":"Resilience as a focus of suicide research and prevention","volume":"140","author":"Sher","year":"2019","journal-title":"Acta Psychiatrica Scandinavica"},{"key":"ref_114","doi-asserted-by":"crossref","first-page":"1240","DOI":"10.1176\/appi.ps.201500271","article-title":"Suicide-related knowledge and confidence among behavioral health care staff in seven states","volume":"67","author":"Silva","year":"2016","journal-title":"Psychiatric Services"},{"key":"ref_115","doi-asserted-by":"crossref","first-page":"149","DOI":"10.1093\/hsw\/hlz016","article-title":"Barriers to mental health care for transgender and gender-nonconforming adults: A systematic literature review","volume":"44","author":"Snow","year":"2019","journal-title":"Health & Social Work"},{"key":"ref_116","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1017\/S1121189X00002621","article-title":"Stigma and discrimination limit access to mental health care","volume":"17","author":"Thornicroft","year":"2008","journal-title":"Epidemiology and Psychiatric Sciences"},{"key":"ref_117","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1192\/bjp.bp.116.188078","article-title":"Undertreatment of people with major depressive disorderin 21 countries","volume":"210","author":"Thornicroft","year":"2017","journal-title":"The British Journal of Psychiatry"},{"key":"ref_118","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1038\/s41572-019-0121-0","article-title":"Suicide and suicide risk","volume":"5","author":"Turecki","year":"2019","journal-title":"Nature Reviews Disease Primers"},{"key":"ref_119","first-page":"271","article-title":"Improving access to psychological therapies: A national initiative to ensure the delivery of high quality evidence-based therapies","volume":"29","author":"Turpin","year":"2008","journal-title":"Papeles del Psic\u00f3logo"},{"key":"ref_120","unstructured":"U.S. Department of Defense (2025, December 28). Annual suicide report, Available online: https:\/\/www.dspo.mil\/Portals\/113\/Documents\/CY20%20Suicide%20Report\/CY%202020%20Annual%20Suicide%20Report.pdf?ver=0OwlvDd-PJuA-igow5fBFA%3D%3D."},{"key":"ref_121","unstructured":"U.S. Preventive Services Task Force (2023). Final recommendation statement: Screening for depression and suicide risk in adults, USPSTF. Available online: https:\/\/www.uspreventiveservicestaskforce.org\/uspstf\/recommendation\/screening-depression-suicide-risk-adults."},{"key":"ref_122","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1016\/j.mhp.2013.10.001","article-title":"Effectiveness of a six-session stress reduction program for groups","volume":"1","author":"Vansteenwegen","year":"2013","journal-title":"Mental Health & Prevention"},{"key":"ref_123","doi-asserted-by":"crossref","first-page":"2385","DOI":"10.1016\/S0140-6736(21)00684-X","article-title":"The Lancet women and cardiovascular disease commission: Reducing the global burden by 2030","volume":"397","author":"Vogel","year":"2021","journal-title":"Lancet"},{"key":"ref_124","unstructured":"West Health (2025, December 28). 112 million Americans struggle to afford healthcare [Fact sheet], Available online: https:\/\/www.westhealth.org\/press-release\/112-million-americans-struggle-to-afford-healthcare\/#:~:text=WASHINGTON%2C%20D.C.%20%E2%80%94%20Mar.,is%20not%20worth%20the%20cost."},{"key":"ref_125","doi-asserted-by":"crossref","first-page":"11","DOI":"10.53841\/bpscpf.1995.1.76.11","article-title":"An analysis of components in large group didactic therapy: \u201cStress Control\u201d","volume":"76","author":"White","year":"1995","journal-title":"Clinical Psychology Forum"},{"key":"ref_126","doi-asserted-by":"crossref","first-page":"43","DOI":"10.1002\/(SICI)1520-6394(1997)5:1<43::AID-DA9>3.0.CO;2-6","article-title":"\u201cStress control\u201d large group therapy: Implications for managed care systems","volume":"5","author":"White","year":"1997","journal-title":"Depression and Anxiety"},{"key":"ref_127","unstructured":"White, J. (2017). Stress control: A mind, body, life approach to boosting your well-being, Hachette UK."},{"key":"ref_128","unstructured":"White, J. Personal communication."},{"key":"ref_129","unstructured":"Bennett-Levy, J., Richards, D., Farrand, P., Christensen, H., Griffiths, K., Kavanagh, D., Klein, B., Lau, M. A., Proudfoot, J., Ritterband, L., White, J., and Williams, C. (2010a). The STEPS model: A high-volume, multi-level, multi-purpose approach to address common mental health problems. Oxford guide to low intensity CBT interventions, Oxford University Press."},{"key":"ref_130","unstructured":"Bennett-Levy, J., Richards, D., Farrand, P., Christensen, H., Griffiths, K., Kavanagh, D., Klein, B., Lau, M. A., Proudfoot, J., Ritterband, L., White, J., and Williams, C. (2010b). Large group didactic CBT classes for common mental health problems. Oxford guide to low intensity CBT interventions, Oxford University Press."},{"key":"ref_131","doi-asserted-by":"crossref","first-page":"42","DOI":"10.1108\/17465729200800007","article-title":"STEPS: Going beyond the tip of the iceberg. A multi-level, multipurpose approach to common mental health problems","volume":"7","author":"White","year":"2008","journal-title":"Journal of Public Mental Health"},{"key":"ref_132","doi-asserted-by":"crossref","first-page":"143","DOI":"10.1017\/S0141347300018267","article-title":"Stress control: A pilot study of large group therapy for generalized anxiety disorder","volume":"18","author":"White","year":"1990","journal-title":"Behavioural and Cognitive Psychotherapy"},{"key":"ref_133","doi-asserted-by":"crossref","first-page":"48","DOI":"10.53841\/bpscpf.2021.1.342.48","article-title":"Getting online quickly in the first COVID-19 lockdown: \u2018Stress Control at Home\u2019","volume":"1","author":"White","year":"2021","journal-title":"Clinical Psychology Forum"},{"key":"ref_134","doi-asserted-by":"crossref","first-page":"68","DOI":"10.1192\/bjp.bp.115.166124","article-title":"Mindfulness-based cognitive therapy v. group psychoeducation for people with generalised anxiety disorder: Randomised controlled trial","volume":"209","author":"Wong","year":"2016","journal-title":"The British Journal of Psychiatry"},{"key":"ref_135","unstructured":"World Health Organization [WHO] (2023). Suicide prevention [Fact sheet], Available online: https:\/\/www.who.int\/health-topics\/suicide#tab=tab_1."},{"key":"ref_136","doi-asserted-by":"crossref","first-page":"114737","DOI":"10.1016\/j.socscimed.2022.114737","article-title":"Wingman-connect program increases social integration for air force personnel at elevated suicide risk: Social network analysis of a cluster RCT","volume":"296","author":"Wyman","year":"2022","journal-title":"Social Science & Medicine"},{"key":"ref_137","doi-asserted-by":"crossref","first-page":"1065","DOI":"10.1111\/jcpp.13102","article-title":"Peer-adult network structure and suicide attempts in 38 high schools: Implications for network-informed suicide prevention","volume":"60","author":"Wyman","year":"2019","journal-title":"Journal of Child Psychology and Psychiatry, and Allied Disciplines"},{"key":"ref_138","doi-asserted-by":"crossref","first-page":"e2022532","DOI":"10.1001\/jamanetworkopen.2020.22532","article-title":"Effect of the wingman-connect upstream suicide prevention program for Air Force personnel in training: A cluster randomized clinical trial","volume":"3","author":"Wyman","year":"2020","journal-title":"JAMA Network Open"},{"key":"ref_139","doi-asserted-by":"crossref","first-page":"1746","DOI":"10.1111\/sltb.12568","article-title":"Efficacy of a problem-solving intervention for the indicated prevention of suicidal risk in young Brazilians: Randomized controlled trial","volume":"49","author":"Xavier","year":"2019","journal-title":"Suicide and Life-Threatening Behavior"},{"key":"ref_140","doi-asserted-by":"crossref","first-page":"172","DOI":"10.1016\/j.jad.2022.04.046","article-title":"Effectiveness of a resilience-targeted intervention based on \u201cI have, I am, I can\u201d strategy on nursing home older adults\u2019 suicidal ideation: A randomized controlled trial","volume":"308","author":"Zhang","year":"2022","journal-title":"Journal of Affective Disorders"}],"container-title":["Behavioral Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-328X\/16\/2\/243\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,9]],"date-time":"2026-02-09T10:07:14Z","timestamp":1770631634000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-328X\/16\/2\/243"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,9]]},"references-count":140,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,2]]}},"alternative-id":["bs16020243"],"URL":"https:\/\/doi.org\/10.3390\/bs16020243","relation":{},"ISSN":["2076-328X"],"issn-type":[{"value":"2076-328X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,9]]}}}