Social Work Research on African Americans and Suicidal Behavior: A Systematic 25-Year Review
Sean foe and Danielle M. Niedermeier Suicide among African Americans is a neglected topic. Social workers practice in both clinical and nonchnical settings, and as the largest occupational group of mental health professionals, they have a unique opportunity to reach this underserved group. However, little is known about social work's empirical knowledge base for recognition and treatment of suicidal behavior among African Americans.The authors performed a systematic critical review of published articles by social workers on African American suicide and suicidal behavior, to ascertain the state of social worker's contribution to and knowledge of suicide risk factors and effective treatments. They conducted Web-based (for example. Social Work Abstracts, PsycINFO, PubMed,JSTOR) and manual searches of suicide research conducted by social work investigators and pubhshed in peer-reviewed journals from 1980 to 2005. References cited in the articles were used to identify candidate articles. According to the search results, social workers contributed only 11 empirical research articles focusing on African American suicide or nonfatal suicidal behavior. Risk factors for suicide are reviewed, and the implications for clinical social work practice and research are addressed.
KEY WORDS: African Americans; clinical knowledge; ethnic minority populations; suicide

S

uicide is one of the leading causes of death worldwide; in 2002 alone, approximately 877,000 deaths worldwide were due to suicide (World Health Organization, 2003) .The recent Institute of Medicine report. Reducing Suicide: A National /mperaiiVe (Goldsmith,Pellmar,Kleinman, Si Bunney, 2002), draws attention to the importance of training professionals capable of developing suicide prevention and treatment services. Because approximately 30,000 Americans die from suicide annually, there is increased national attention explicitly focused on the goal of reducing suicide, including suicide among members of racial and ethnic groups. Although African Americans have lower rates of suicide completion than do white Americans, epidemiological research has documented dramatic changes in the rates of suicidal behavior among this population (Centers for Disease Control and Prevention [CDC], 1998). Most disturbing about the trend in suicide among African Americans is that the burden of self-destructive behavior disproportionately affects young male African Americans ages 15 to 24 (CDC, 1998).

There is a common perception that African Americans, particularly adolescents and young adults, do not engage in suicidal behavior at levels comparable to that of white Americans, but recent research disproves this assumption when looking across the life span. Young male African Americans complete suicide at rates comparable to those of white male Americans (joe & Kaplan,2001),the rates of firearm suicide have increased more precipitously for this subpopulation Qoe & Kaplan, 2002), and male African Americans are more likely to report engaging in nonfatal suicidal behavior, that is, attempted suicide ([oe & Marcus, 2003). According to the CDC (2004), the prevalence rates of attempted suicides in 2003 were higher among older African American (8.4 percent) and Latino (10.6 percent) high school students than were the rates for their white (6.9 percent) peers. These statistics reflect a dramatic increase in the rates of suicidality among male African Americans. As a result of these and other changes, the Institute of Medicine and the U.S. surgeon general have called for increased research on the suicide risk factors for African Americans and

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other ethnic minority populations and for empirically tested treatments (Goldsmith et al., 2002; U.S. Public Health Service, 1999). Social workers are the largest occupational group of mental health professionals (Manderscheid et al, 2004), providing 70 percent of mental health services in the United States (Zlotnik & Solt, 2006), and are well positioned to intervene with suicidal African Americans. However, hecause of conventional wisdom that African Americans do not commit suicide (Early, 1992), social work clinicians may he unaware of the patterns of suicide or of the risk and protective factors among African Americans. This lack of awareness could cause misinterpretation of self-destructive hehaviors among this population. Social work clinicians have a significant role to play in the national strategy to prevent suicide, hut litde is known ahout social work's empirical knowledge base for practice in this area or the extent to which social work researchers have focused on this topic. It is important to review the state of social work knowledge regarding suicide risk factors and effective treatment approaches for African Americans hecause the largest increase in the professional mental health workforce has heen among social workers. During the period 1992 to 1998, there was a 309 percent increase in the numher of social workers serving mental health institutions, in contrast to a 119 percent increase among psychiatrists and a 204 percent increase among psychologists (Manderscheid et al., 2004). Most chnical professionals rely on their own profession's literature as their primary, hut not only, source of practice knowledge, so it is important to ascertain to what extent social work researchers have contrihuted to the knowledge hase. Moreover, although research on suicide from other disciplines ahounds, incorporating social work's unique concepts and perspectives (for example, person-in-environment across levels, client-centeredness, and so forth) can help huild a scientifically developed clinical knowledge hase more applicable for use hy social work practitioners working with suicidal African Americans. In an effort to gain a hetter understanding of the state of social work research and knowledge relating to African American suicidal hehaviors availahle to social work clinicians, we performed a systematic literature review of articles puhlished hy social work investigators in peer-reviewed journals from 1980 to

2005. Specifically, we performed a critical review of puhlished articles to assess the state of social work knowledge production to inform clinical practice with suicidal African Americans. The puhlished literature was divided into research- or non-researchrelated articles and those puhlished in social work journals or non-social work journals.This approach was taken hecause it is important to assess the unique sources of information availahle in social \vorkjournals and the quality of the evidence availahle for use in clinical decisions hy social workers. METHOD Journal Review A comprehensive and generally representative corpus of social work research puhlished from 1980 to 2005 in arguahly the most prominent social work journals (seeTahle 1) and in three journals specializing in suicide studies were reviewed electronically and in print for articles that included information on African American suicide or nonfatal suicidal hehavior authored hy social work researchers (faculty or clinicians), determined hy their affiliation with a school or department of social work or hy whether they had a social work degree (for example, MSW, PhD, DSW) .When an author's social work affiliation was not descrihed, we used a Weh search to determine the affiliation. Articles authored hy non-social work researchers in social work journals were also included in this review.We reviewed journals specializing in suicide studies to increase the prohahility of identifying social work researchers puhlishing on the topic. For the purposes of this study, suicide was defined as self-inflicted fatal injury with the intent to kiU oneself (O'CarroU et al, 1996), and suiciderelated behavior was deñned as suicidal ideation or nonfatal self-inflicted injury with the intent to kill oneself.Journals were reviewed using the computer datahases Social Work Ahstracts, Social Service Abstracts, Proquest (searched only the Journal of Marital and Family Therapy),]STOK, and PuhMed. Phrases used to search these datahases were hroad (for example, suicide, suicidal hehavior, attempted suicide, self-harm,suicide ideation and thought). In addition, authors identified as social work researchers from the manual and electronic article search were then searched hy author name in the datahases PuhMed, PsycINFO, and JSTOR to determine whether they had puhlished additional articles that included information on suicide or nonfatal suicidal hehavior in non—social work journals.

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Table 1: Journals Selected for Review of Research on African American Suicide, 1980-2005
Affilia American Journal of Orthopsychiatry Archives of Suicide Research The British journal of Social Work Child Abuse & Neglect Child and Adolescent Social Work Child Welfare Children and Youth Services Review Clinical Social Work Journal European Joumal of Social Work Families in Society Health & Social Work Journal of Ethnic & Cultural Diversity in Social Work Journal of Gay & Lesbian Social Services Journal ofHomosexuality Journal of Marital & Family Therapy Joumal of Social Work Education Joumal of Sociology & Social Welfare Joumal of Technology in Human Services Omega Psychoanalytic Social Work Research on Social Work Practice Social Service Review Social Work Social Work in Health Care Social Work Research Suicide and Life-Threatening Behaviof
•Indicates missing data; Suicide and Life-Threatening Behavm 1986. Volume 16(1-4) and 1981, Voiume ^^{}SlA): Archives of Suicide Research, 1996 (all issues).

determination when there was radng disagreements among the research assistants. Research articles were idendfied as studies in which data analysis was involved and were further categorized as follows: • Epidemiological (analyze trends of a populadon) • Risk factor (idendfy characteristics that increase the probabihty of a suicidal act) • Measurement (examine the factor structure and psychometric properties of instruments assessing suicidal thoughts and behaviors) • Case studies (present a particular case and analyze it to idendfy its implicadons for the larger population of suicidal clients) • Intervention/treatment (evaluate an intervention for results). Non-research-related árdeles were identified as articles in which no data analysis was involved, and include the following categories: • Theory (study the applicadon of a pardcular model) • Literature review (synthesis of the studies that have been done) • Book review (synthesis of what is presented in a book and qualitadve rating of the book) and • Letters/commentary (editorials written in response to an article published in the journal). Articles were placed into categories on the basis of the definidons stated earlier. FINDINGS Scientific Contribution The broad electronic and manual search resulted in 181 suicide-related árdeles. When examined, 45 of the árdeles (24.9 percent) were found to include informadon on African Americans (Table 2).A litde over 75 percent (34) of the 45 árdeles were research studies, more than half of which studied suicidal risk factors. The remaining 11 árdeles were literature reviews focusing mosdy on adolescent mental health. In fact, adolescents (49 percent, 20/41, X" = 10.7, p < .001) were most often studied in the suiciderelated articles that included information on African Americans (Table 3). From 1980 to 2005 only 11

Rating Criteria The literature was reviewed systematically to affirm that articles included African American suicide or nonfatal suicidal behavior and to determine the age group of the population covered (for example adolescents).Although elderly people are a subgroup of the adult population, they were categorized separately, to acknowledge their significantly increased suicidal risk and to ensure no ovedap in analysis. Articles were also categorized as research or nonresearch, as social work or non-social work journals, and by the knowledge generated (for example, risk factor) by four graduate students trained by the lead author on the rating system, and each was given different árdeles to rate to develop their ability to rate appropriately. The lead author made the fmal

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Table 2: Social Work Knowledge Production, by Journal Type, 1980-2005

Social work journal Total

14(31.1) 34 (75.6)

Non—social work journal 20 (44.4),

7(1,5.6) 4 (8.9) 11(24.4)

21(46.7) 24(53.3) 45(100)

ofthe 34 research studies disaggregated their results by race or had a clear focus on African American suicidality. Of these 11 studies, six were risk factor studies and five were epidemiological; none studied the eíFectiveness of interventions. The analysis reveals that social work researchers were less likely to publish research that included information on African American suicidality in social work journals (31 percent) then they were to publish these studies in non-social work journals (44 percent); however, the differences were not statistically significant (x^= 1.68,;? = 0.19). Furthermore, social work researchers were strikingly more likely to publish non-research articles in social work journals (Table 2). Over the 25 years studied, social work researchers modestly increased their contribution to the study of African American suicide and nonfatal suicidal behavior (see Table 4). Overall, social workers' contribution has been marginal.The next sections critically review and summarize the practice-relevant knowledge gleaned from the social work studies on suicide that focused on or included African Americans in their samples. Adolescents Epidemiological studies of adolescents revealed changes in the suicide rate of African Americans. National trend analysis revealed a narrowing gap in the rate of suicide between 15- to 24-year-old African American and white male Americans, due to the disproportionate increase in the rate of suicide among male African Americans in this group (Joe & Kaplan, 2002).Trends also showed a marked increase in attempted suicide among African American male adolescents (Joe & Marcus, 2003) and a disproportionate increase in suicidal firearm usage among this group (Joe & Kaplan, 2002) .These studies used death certificates to examine suicidal trends that may not accurately reflect the actual rate of suicide because of underreporting errors (Phillips & Ruth, 1993).

A number of factors were identified that increase adolescents' risk of suicide or nonfatal suicidal behaviors. Adolescents with a history of abuse (Evans, Albers, Macari, & Mason, 1996; Perkins & Jones, 2004;Tubman, Langer, & Calderón, 2001 ;Weinman, Smith, Geva, & Buzi, 1998), or male adolescents who are delinquent and not in a gang, are at an increased risk of suicide (Evans et al., 1996). Furthermore, abused adolescents who report receiving support from an adult other than a parent were more likely to have considered or attempted suicide (Perkins & Jones, 2004). One study that included African American adolescents found suicidal ideation to be more likely among students of color than among white students (Albers & Evans, 1994); another study of adolescents found being African American to be a protective factor against suicide (Chandy, Blum, & Resnick, 1996). Future research is needed to test the reliability of these findings because ofthe small number of African Americans in these studies. In addition, research is needed to determine whether the risk factors found in these studies persist when examined with African Americans only. Adults Research also identified suicidal risk factors specific to African American adults. Adults living with AIDS (Mancoske,Wadsworth, Dugas, & Hasney, 1995) or those with a history of abuse (Benda, 2003; Osgood & Manetta, 2000-2001) were at an increased risk of suicide. Furthermore, poor caretaking in childhood increases the risk of self-harm behavior in adulthood (Sansone, Gaither, & Barclay, 2002). High divorce rates were also found to increase suicidal risk, whereas high population density has been

Table 3: Social Work's Contribution to Research on African American Suicide, 1980-2005

Adolescents Adults Elderly People Total Percentage

15

4
1 20
44.4

21' 46.7

Note; Represents the number of studies conducted by social workers from 1980 to 2005, of each age group, on the study of African American suicide. 'Totals include one general population study from social work journals and three from non-social work journals.

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Table 4: Trends in Social Work Research on African American Suicide, 1980-2005

1980-1984 1985-1989 1990-1994 1995-1999 2000-2005
Note: Total n = 45.

0 2 3 11 18

1 3 0 2

0 2 0 1 0

1

5
3 13 23

5

found to decrease suicidal risk (Cutright & Fernquist, 2004). Specifically among homeless Vietnam veterans, diagnosis of a psychiatric disorder, severe substance abuse problems, problems with friends, a history of abuse, being homeless for longer, or using substances for longer increased the likelihood of a suicide attempt (Benda, 2003). Risk factors for suicidal thoughts among homeless veterans who abuse substances were strikingly similar to risk factors among the homeless Vietnam veterans; however, marital status, attachment to caregivers, and employment pattern also affected homeless veterans' risk of suicidal thoughts (Rodell, Benda, & Rodell, 2003). Research also revealed risk and protective factors specific to African American women. African American women lacking a social support system are at increased risk of suicidal behaviors, whereas having an intact marriage appears to be a protective factor against suicide (Manetta, 1999). In addition, there was an inverse relationship between single motherhood and suicide rates among African American women, which may be partially due to a strong support system (Fernquist, 2004). Among clinically depressed African American women, an inverse relationship between self-esteem and suicide risk, locus of control and suicide risk, and a positive correlation between age and self-esteem was found (Palmer, Rysiew, & Koob, 2003).There is also a comorbidity between depression, aggression, and suicidal ideation, and as the magnitude of depression increased, the strength in the relationship between problems with selfesteem and severity of suicidal ideation also increased (Nugent & Williams, 2001). Among African American men, poverty was found to reduce suicide risk (Fernquist, 2004), whereas African American men who attained higher levels of education were at an increased risk

of suicide (Fernquist, 2004). A weakened social integration due to frustrations that their education is not paying off as it should may account for the positive association between suicide risk and education (Fernquist, 2001). In summary, further studies are needed to determine whether the risk factors identified hold true across races and what role race plays in suicidal risk. Furthermore, Manetta's (1999) and Palmer et al.'s (2003) studies included suicidal African American women; however, both studies used relatively small sample sizes (less than 200). Additional studies should be conducted using larger sample sizes to test the reliability of these results. Elderly People The rate of suicide death among elderly African American men was substantially lower than the rate among white men; however, the pattern in the rate of suicide for African Americans and white Americans was similar, indicating a possible connection in suicidal risk factors among races that is in need of further exploration (Kaplan, Adamek, & Johnson, 1994). Firearms have become the choice suicide method among African American and white older women (Adamek & Kaplan, 1996b). The recent increase in suicidal firearm usage among elderly African Americans and white Americans increased the likelihood that both groups will succeed in their suicide attempt, which is of further concern for a population that is already at an increased risk of suicide and nonfatal suicidal behaviors (Adamek & Kaplan, 1996a, 1996b; Kaplan et al., 1994). However, these studies used national data from death certificates, which may not accurately reflect the actual rate of suicide because of underreporting (Kaplan et al., 1994). Interventions Studies of interventions that disaggregate results by race or that focus on African Americans are essential for providing effective treatment to suicidal African Americans. Over the 25 years studied, social work researchers did not conduct such studies. However, we did find two studies on treatment interventions for suicidal clients that included African Americans in the sample. The first intervention was intended to reduce suicidal and self-destructive behaviors among adolescents with a history such behaviors. The program attempted to achieve these goals by providing direct services through outreach to these

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adolescents and by educating peer leaders and professionals working with them on suicidal behavior and adolescent depression (Deykin, Hsieh, Joshi, & McNamarra, 1986).The results did not show a reduction in suicidal or self-destructive behaviors; however, the intervention appeared to be effective in increasing referrals for suicidal ideation.The second intervention Hnked at-risk elderly participants to a clinical social worker over the telephone and emphasized accessing community mental health services (Morrow-Howell, Becker-Kemppainen, & Judy, 1998). The intervention was found to be moderately effective in improving social contact, treating depressive symptoms, and reducing unmet needs of the elderly participants. However, neither study disaggregated results by race, which is striking considering that 41 percent of Morrow-Howeü et al.'s (1998) and 32.6 percent of Deykin et al.'s (1986) samples were composed of African Americans. As noted, treatment studies that include African American adults were not found, clearly indicating that social work researchers' contribution to the development of evidence-based treatments for suicidal African Americans is severely limited.
DISCUSSION

suicidal behaviors, to gain understanding of the unique aspects of suicide among African Americans and to implement effective treatment measures for this underserved population. Strengths and Limitations Although this systematic review was comprehensive, we acknowledge the possibility that some journals containing articles contributing to social work's study of African American suicide may have been excluded from review. Furthermore, this study examined social work's contribution to research on African American suicide over 25 years, within which period the racial or ethnic term for this population has changed multiple times. Because of this change in terms, some articles may have been missed during the searches. Furthermore, we cannot determine the extent to which the findings of the studies that did not disaggregate their results by race can be applied to suicidality among African Americans. However, these limitations do not outweigh the many strengths of this study, namely, searching over a 25-year period, reviewing 24 journals both electronically and in print and searching numerous computer databases. Finally, probing for additional articles by searching for those by the social work researchers found in the electronic and print searches further supports the credibility of the findings of this study. Implications for Clinical Practice and Future Research The descriptive statistics and review of research on African American suicide presented here clearly refute conventional beliefs about negligible rates of suicide among this population. In their practice, social work clinicians must understand the demographic patterns and the trends in suicide, namely that younger African Americans are completing suicide at higher rates; therefore, early preventive interventions with older adolescents and young adults, particularly male adolescents and young adults, must become an integral part of more coordinated suicide prevention efforts. Social work research has contributed to our understanding that male African Americans are at highest risk of suicide and must be screened for suicidal behavior when thought to evidence known risk factors (for example, depression, higher education, history of abuse, substance abuse). The results also highlight important psychological, social, and cultural risk factors, while emphasizing

Despite social w^orkers being the largest group of providers of mental health services, our 25-year study found that social work's contribution to research in the area of African American suicide and nonfatal suicidal behavior is woefully inadequate. Suicide is a major health concern, and social work clinicians engage with potentially suicidal African American clients daily. However, we found no rigorously designed study testing the ability or inability of social work interventions to reduce suicide specifically in African American populations. Although interventions used by social workers may be effective, the interventions lack empirical examination and backing, raising major ethical concerns regarding their efficacy and potential harm to clients. Also, social work research on the risk or protective factors that are specific to African American adolescents or the elderly population is nonexistent. Furthermore, none of the studies examined engaged in data collection and data analysis of individuals to create clinical assessment and screening tools, or analyzed a specific case to draw a deeper understanding of its implications for African American suicidal clients. Social work needs to encourage more researchers to study African American suicide and nonfatal

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the need for an integrated understanding of their influences.These factors are global and are not specific to African Americans (Goldsmith et al., 2002). Clinicians should also seek to reduce hopelessness, psychiatric disorders, childhood trauma, or psychical violence, which increase the suicide risk of both male and female African Americans. It is clear that social workers, many of whom are mental health professionals, should be skilled in discussing suicide risk with African American clients, providing interventions for those at imminent risk of the expression of suicidal behavior, and referring them for expert assessment and treatment. This implies that graduate social work education should provide training that includes practice experiences in managing suicidal adolescents, led by faculty who have treated or assessed suicidal adolescents. Social workers also need to be knowledgeable of the various risk factors and treatments designed to reduce assessed risk. More specific recommendations for social work practice and education are limited by the lack of scientifically tested preventive or treatment interventions for suicidal African American youths. Future investigations are needed to determine whether the increase in suicidal behavior among African American youths is attributable to changes in their attitudes toward suicidal behavior, willingness to report such behavior, or increased social isolation and prevalence of mental disorders. In addition, research is needed to examine the relationship between suicide attempts and suicide completion among African American youths and to identify the situational or contextual triggers and mental health risk factors that may be unique to this group. Information gained from such studies can further national efforts to develop suicide prevention policies and interventions for this high-risk group. Methodologically, future studies need to be based on larger African American samples, particularly those big enough for examining within-group variability in suicide risk or that are at least representative of the population. When studies include African Americans in the sample, it is important that the results are disaggregated by race to provide for a clear interpretation of the findings. Given the scant attention to suicide among African American youths in the social work research literature and social workers' potential effect on this neglected problem, we hope that this article will stimulate . social workers to undertake such research.

The failure to advance research on African American suicide may leave many social work clinicians inadequately prepared to respond to the needs and experiences of depressed and suicidal African Americans.
Future research on African American suicide risk and management should seek to make contributions in a manner consistent with the framework offered by Rosen, Proctor, and Staudt (1999) for the three types of knowledge generated (descriptive, explanatory, and control) from research. Descriptive studies provide social work clinicians with information to assess and classify clients and problems, including their central tendencies or distribution, which can be used to make decisions about which services are needed and by whom. Explanatory reports are defined as studies examining the relationships among two or more variables, such that researchers understand factors influencing their variability and consequences. They are hypothesis-driven examinations of differences between groups, and they may consider multiple variables simultaneously (that is, risk factor studies). Finally, control studies examine the effects of services delivered or those testing the efFicacy or effectiveness of interventions. This survey of the empirical social work literature on African American suicide reveals a need for explanatory and control knowledge. Advancement in such research should be a multidisciplinary effort, but the professional social worker is well positioned to advance evidence given that large numbers of African Americans are disproportionately represented in the caseloads of many social work practitioners (Berger, McDaniel, & Paxson, 2005; Lindsey et al., 2006; Schräm, 2005; Winston, 2006).
CONCLUSION

Suicide among African Americans is a neglected public health concern that should be addressed by social work researchers and in the education of social work clinicians.To our knowledge, this study is the only comprehensive examination of social work's contribution to the empirical knowledge base for the recognition and treatment of suicidal behavior among African Americans. As a profession, social work is dependent on evidence-based practice.The failure to advance research on African American suicide may leave many social work

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Joe, S., & Kaplan, M. S. (2002). Firearm-related suicide among young African-American males. Psychiatric Services, 53, 332-334. Joe, S., & Marcus, S. C. (2003).Trends by race and gender in suicide attempts among U.S. adolescents, ^99'i-200\. Psychiatric Services, 54, 454. Kaplan, M. S., Adamek, M. E., & Johnson, S. (1994).Trends in firearm suicide among older American males: 1979-1988. Cerontologist, 34, 59-65. Lindsey, M. A., Korr,W. S., Broitman, M., Bone, L., Green, A., & Leaf P. J. (2006). Help-seeking behaviors and depression among African American adolescent boys. Social Work, 51, A9-S%. REFERENCES Mancoske, R. J.,Wadsworth, C. M., Dugas, D. S., & Hasney, Adamek, M. E., & Kaplan, M. S. (1996a). Firearm suicide J. A. (1995). Suicide risk among people living with among older men. Psychiatric Services, 47, 304—306. AIDS. Social Work, 40, 783-787. Adamek, M. E., & Kaplan, M. S. (1996b).The growing use Manderscheid, R.W.,Atay,J. E., Male,A., Blacklow,B., of firearms by suicidal older women, 1979—1992:A Forest, C , Ingram, L., Maedke,J., Sussman,J., & research note. Suicide and Life-Threatening Behavior, 26, Ndikumwami,A. (2004). Highlights of organized 71-78. mental health services in 2000 and major national Albers, E., & Evans,W. (1994). Suicide ideation among a and state trends. In R.W. Manderscheid & M.J. stratified sample of rural and urban adolescents. Child Henderson (Eds.),MeH(ii/ health. United States, 2002 & Adolescent Social Work Journal, 11, 379-389. (DHHS Pubhcation No. SMA- 3938, pp. 243-279). Rockville, MD: Center for Mental Health Services, Benda, B. B. (2003). Discriminators of suicide thoughts Substance Abuse and Mental Health Services and attempts among homeless veterans who abuse Administration. substances. Suicide and Life-Tlneatenin