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INTERACTIVE SCREENING PROGRAM MANUAL 2011-2012

This Manual was created by the American Foundation for Suicide Prevention. Copyright © 2011 by the American Foundation for Suicide Prevention

For additional information, contact:

The American Foundation for Suicide Prevention120 Wall Street, 29th FloorNew York, New York 10005

Phone: 888-333-2377

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Table of Contents

Acknowledgements 4

Introduction 5

Section 1. The Interactive Screening Program (ISP) 6

Purpose of ISP 6

How ISP Works 6

Data Reports 8

Website and Data Security 9

Required Resources 9

Legal Considerations 11

ISP Evaluation Results 12

Section 2. Is the ISP Right for My Campus? 13

Can the ISP Fill a Gap in our Suicide Prevention Strategies? 13

Do We Have the Clinical Resources to Staff the ISP? 13

Can We See How the ISP Online Screening Process Works? 14

What Happens Next? 14

Section 3. Preparing to Implement the Interactive Screening Program 15

Assign or Secure Needed Clinical Personnel 15

Plan Desired Program Evaluation Activities 15

Identify Available Mental Health Services for Student Referrals 15

Customize the ISP Website 16

Develop the Student Invitation Process 16

Tailor the Demographic Items on the Stress & Depression Questionnaire 18

Section 4. Suggestions for Site-Based ISP Evaluation 19

Conclusion 20

Appendices 21

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Acknowledgements

The American Foundation for Suicide Prevention (AFSP) wishes to acknowledge the generous support for the initial development and testing of the Interactive Screening Program (ISP) from the Kristin Rita Strouse Foundation, the Johnny Foundation, Eli Lilly and Co., Janssen Pharmaceuticals Inc., Solvay Pharmaceuticals Inc., and Wyeth Pharmaceuticals. We also gratefully acknowledge the support of the Rainier Foundation for implementation of the program in the state of Washington, and the ongoing support of the Johnny Foundation for the ISP in several colleges and universities in Georgia.

We wish to especially note the generosity and support of the ISP by the AFSP Chapters across the country. Through their fundraising efforts, especially the Out of the Darkness Community Walks, the AFSP Chapters have played an essential role in expanding the number of colleges and universities that are able to offer this unique program on their campuses.

We also acknowledge our partnership with Entech, Inc., which has provided not only the expertise to develop the ISP technology, but also the creative vision that has guided its continued enhancement. Finally, we are deeply grateful for the partnerships we have developed with the colleges and universities where the ISP has been implemented. Their commitment to providing effective outreach to students in need has inspired our efforts, and this Manual is based in large part on what we have learned together.

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Introduction

In 2001, the American Foundation for Suicide Prevention (AFSP) began the development of an anonymous, Internet-based method of outreach to college students with serious depression or other suicide risk factors who were not currently receiving treatment. This effort was rooted in the recognition that, despite the availability of counseling centers and other mental health facilities on most U.S. college and university campuses, an estimated 80% of students who die by suicide each year had not used these services.1 Our hunch was that this was not just because at-risk students were unaware that campus services were available, but also because something in their life experiences, ways of thinking or fears and concerns prevented them from asking for help. What was needed, we felt, was a simple, convenient and safe way for troubled students to connect with an experienced, caring mental health counselor, who could help them more clearly identify the problems they were experiencing and work through their barriers to help-seeking.

In the spring of 2002, AFSP launched what was initially called the College Screening Project at Emory University in Atlanta, Georgia. Soon after, the University of North Carolina at Chapel Hill joined the pilot project. Between 2002 and 2005, a comprehensive evaluation of the screening initiative was conducted with undergraduates on these two campuses that led to several enhancements of program methods and technology. In 2006, we expanded the initiative to graduate students at the Massachusetts Institute of Technology, and in 2007, to medical students at the University of Pittsburgh. During the 2008-09 year, we welcomed four other universities to the program: The University of Maine at Orono, the University of California at San Diego, and two schools in Washington State: the University of Puget Sound and Heritage University.

In early 2009, we changed the name to the Interactive Screening Program (ISP), and launched a broader dissemination effort that resulted in 10 new schools deciding to implement the program in the 2009-10. In that same year, following review by outside experts appointed by the Suicide Prevention Resource Center (SPRC), the ISP was designated a Best Practice for Suicide Prevention and listed in the SPRC-AFSP Best Practices Registry.

By June 2011, a total of 30 colleges and universities had adopted the ISP, and we set the goal of having the program in 50 schools by the end of the 2011-12 academic year. As we were completing the 2011-12 edition of the Interactive Screening Manual, we learned that the 10 campuses of the University of California system will be implementing the ISP during 2011-12 as part of a major statewide student mental health initiative. We look forward to welcoming these campuses, as well as additional schools, to the program during the coming months.

This Manual is designed for colleges and universities that wish to learn more about how the Interactive Screening Program can augment their campus’s student mental health services. It describes how the program works, what it can achieve, what it costs and the key implementation procedures. After reviewing the Manual, interested schools are urged to submit a Request for Further Information Form, which can be completed on the AFSP website (www.afsp.org). Our staff will then contact you to talk in depth about bringing the ISP to your campus.

Thank you for your interest in the ISP. We hope to hear from you shortly.

Ann P. Haas, Ph.D., Senior Program Specialist Maggie Mortali, Education ManagerAmerican Foundation for Suicide Prevention American Foundation for Suicide Prevention 120 Wall Street, 29th Floor 120 Wall Street, 29th FloorNew York, NY 10005 New York, NY [email protected] [email protected] (207) 236-2475 (212) 363-3500, ext. 2034

1 Gallagher, R.P. (2008). National Survey of Counseling Center Directors. Alexandria, VA: International Association of Counseling Services.

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mailto:[email protected]


http://www.afsp.org/


1. The Interactive Screening Program (ISP)

Purpose of ISPThe purpose of the Interactive Screening Program (ISP) is to identify, engage and refer to treatment students with serious depression or other conditions that put them at risk of suicide.

How ISP WorksAlthough there are variations that a college or university may choose in implementing the ISP, this section presents an overview of how the program works on most campuses (specific options are discussed in a later section of the Manual).

Each school decides which students to target through the program, and these students receive an email invitation to make use of a unique campus service aimed at helping students assess whether depression or other mental health problems may be interfering with their academic or personal functioning. (See Appendix A for the copy of the invitational email). Only those students who have reached the age of 18 are invited to participate, and the invitations are usually staggered throughout the academic year to avoid overburdening clinical personnel and resources.

The invitational emails are sent from a designated university official and directed to students via their campus-registered email addresses. The email contains a link to a secure website which further explains the program, provides students an opportunity to sign up with a self-assigned User ID and password and complete an online Stress & Depression Questionnaire. The questionnaire incorporates the PHQ-9, a 9-item standardized depression screening scale that has been validated in two large multi-site studies,2,3

and found to be strongly predictive of major depressive disorder. In addition to the depression items, the Stress & Depression Questionnaire contains questions about suicidal ideation and attempts, problems related to depression such as anger and anxiety, alcohol and drug abuse, and eating disorder symptoms. The questionnaire contains 35 questions and normally takes less than 10 minutes to complete. (See Appendix B for screen shots of the questionnaire as it appears online and Appendix C for a Word document copy).

At the end of the questionnaire, students are asked to provide an email address so that they can be notified when a counselor has prepared a personalized response and posted it to their attention on the program website. Students are assured that their email address will be encrypted into the computer system to protect their identity, and will not be made available to anyone, including the counselor who will be responding to them.

Immediately after the student submits the questionnaire, it is computer analyzed and, based on specific answers, the student is classified into one of four tiers; 1a, 1b, 2, or 3, with 1a suggesting highest risk and 3 lowest risk. (See Appendix D for the tier designation criteria). The computer system then generates an email to the counselor, which indicates the student’s tier level and provides a link to the student’s record on the secure website.

Program guidelines call for all Tier 1 students to be answered within 24 hours, Tier 2 students within 36 hours and Tier 3 students within 48 hours. Within the appropriate time frame, the counselor reviews the student’s questionnaire and writes a response, using a template specific to the student’s tier. (See Appendix E for counselor response templates). Each response begins with a brief self-introduction which includes the counselor’s name, position at the college or university, office location and phone number. Although much of the response is standardized on the template, key problems indicated in the student’s questionnaire are addressed on an individual basis. All tier 1 and tier 2 students are urged to contact the counselor to arrange an in-person meeting. All students, regardless of tier designation, are offered the

2 Spitzer, R.L., Kroenke, K., Williams, J.B.L., and the Patient Health Questionnaire Study Group. (1999). Validity and utility of a self-report version of PRIME-MD: The PHQ Primary Care Study. JAMA, 282, 1737-1744.

3 Spitzer, R.L., Williams, J.B.L., Kroenke, K., McMurray, J., Heartwell, S.F., et al. (2000). Validity and utility of the Patient Health Questionnaire in assessment of 3000 obstetric-gynecology patients: The PRIME-MD Patient Health Questionnaire Obstetric-Gynecology Study. American Journal of Obstetrics and Gynecology, 183, 759-69.

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option of using the website’s “Dialogue” feature to communicate online with the counselor while remaining anonymous. The counselor’s key aims in the response are to convey interest, support and availability, and to encourage engagement, whether in-person or through the anonymous online dialogues.

Once the counselor has posted the response on the website, the computer system accesses the student’s encrypted email address and sends a notification that the response is ready. This email provides a link back to the program website, where the student can log in and open the counselor’s response. Two additional emails are automatically sent to tier 1 and tier 2 students, 15 and then 30 days after the counselor’s response has been posted. The reminders urge these students to access the counselor’s response if they haven’t already done so, and to follow the recommendations for follow-up. (See Appendix F for the copy of the email reminders). The second and final reminder contains a link to a brief Update Questionnaire that students who have not yet had contact with the counselor are asked to complete. Items inquire about how the student has been doing in recent weeks, and elicit reasons for not contacting the counselor as well as the student’s perception of what would be most helpful at this time. (See Appendix G for the copy of the Update Questionnaire).

Figure 1: Schematic representation of the ISP process

Data Reports

On the website page where the counselor’s response is posted, a “Dialogue” button provides direct access to a page where the student can send a message to the counselor. Students may exchange messages with the counselor on an unlimited basis, although the counselor continues to urge students with significant problems to arrange an in-person meeting. The dialogues with the counselor play a critical role in the process of encouraging the student to seek help by facilitating the resolution of barriers to treatment. Barriers commonly identified in student dialogues include concerns about parental notification, confidentiality of treatment records or impact of treatment on future academic or career goals. In addition, the dialogues offer an opportunity for the student to begin to develop a trusting relationship with the counselor, which increases the likelihood that the student will ultimately accept the counselor’s invitation

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Target group receives an email invitation through the university email system

Student logs on to the website, registers, and completes the Stress & Depression

Questionnaire

Within 24 hours, the student receives an email notification (directed to the

address provided) that the counselor’s response is available on the program

website (includes link to site)

Students assessed at Tier 1a, 1b, 2

Counselor suggests an in-person meeting for further evaluation and/or online

dialogue

Interested students follow the link to the program website

Student logs-on to the website and views counselor’s response

Tier 1 & 2 students receive four email reminders to access counselor’s response on

program website, 15 and 30 days after it is posted. The final

email includes a link to an Update Questionnaire for

students who haven’t contacted the counselor.

Counselor offers online dialogue to discuss any questions or concerns

Students assessed at Tier 3


for a face-to-face meeting. In the event that a student agrees to meet with the counselor in person, all scheduling activities are encouraged to be done via phone or personal email so that no personally identifying information about the student is communicated (and stored) via the ISP website. (In the event that any such information is inadvertently communicated, it is deleted following regular review by AFSP).

During the in-person meeting, the student is further evaluated and treatment options are discussed. These may include counseling or other treatment services on or off campus, depending upon available resources and student needs. Students who may need medication are referred to a psychiatrist or another appropriate clinician for evaluation. The program counselor coordinates all clinical referrals, and as needed, meets with the student for additional sessions to make the transition to longer-term treatment.

Students may also be referred to a peer support program or other non-clinical programs or services offered by the college or university. Such referrals may strengthen students’ support networks and sense of connectedness within the college/university community.

Data ReportsAll student and counselor-generated data transmitted over the ISP website are stored and organized in an administrative section that can be accessed by the counselors and other program personnel at each college or university. As shown in Figure 2 on the following page, the main administrative webpage displays and provides links to a variety of data reports. Reports can be generated for the full program period or for specific dates such as a given semester or academic year.

The most comprehensive is the Full Data report, which records individual answers to the Stress & Depression Questionnaire, listed by a computer-assigned ID number and the student-selected User ID. The Full Data report provides the dates and times the student submitted the questionnaire, the counselor posted the response to the student, and the student returned to the website and accessed the counselor’s response. The webpage displays these data in Excel format, which can be uploaded into a matching SPSS template for more detailed statistical analysis. Also included are answers to the Update Questionnaire for those tier 1 and tier 2 students who submit this form after not contacting the counselor within the 30-dayperiod after the counselor’s response is posted.

Other reports are designed to assist counselors and other program personnel in monitoring website communications to assure that all student questionnaires and dialogue messages are responded to in a timely fashion. All students whose questionnaires have not yet been reviewed and responded to by the counselor are listed in the Outstanding Responses report. Similarly, the students dialogues that have not yet been reviewed and responded to by a counselor are listed under the Outstanding Dialogue report. Both the Recently Completed Responses and the Recent Dialogues can be viewed by the counselor for the past 3 to 14 days. Collectively, these reports facilitate on-going administrative oversight of program activities, and are useful for year-end reporting of program accomplishments, as is discussed further in Section 4 of this Manual.

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Figure 2: Administrative reports

Website and Data Security

Each college and university that uses the Interactive Screening Program has its own secure website that is backed by a Secure Sockets Layer (SSL) digital certificate. The SSL is an established industry standard cryptographic protocol that provides security and data integrity for communications over Transmission Control Protocol/Internet Protocol (TCP/IP) networks such as the Internet. By encrypting all data during the process of transmission, SSL prevents eavesdropping, tampering and message forgery, thus providing authentication and confidentiality to the website application.

When any changes are made to the website, file transfers are made through a Virtual Private Network (VPN). The VPN enhances the security of communications that take place over public networks by incorporating procedures that emulate those used in a private network, such as requiring User ID and password for access. This restricts the ability to access and alter database files to those individuals who are specifically authorized. The ISP website also has sophisticated access controls which allow users to access only those parts of the website they are permitted to see.

To further enhance security and confidentiality of the data transmitted over the website; the user's self-assigned password and the email address provided at the end of the Stress & Depression Questionnaire are encrypted in the system. Case-sensitive passwords, which are required to be between 8 and 12 characters and contain both letters and numbers, are stored in a separate database on the server.

Required ResourcesThe ISP is a relatively low cost method of identifying at-risk students and encouraging them to get treatment. Participating colleges/universities pay an annual program fee, and also provide the clinical personnel who perform the online and in-person services offered by the ISP. In addition, the college/university must be able to offer appropriate clinical services to students who are identified as needing them. The resources listed in Table 1 (p. 9) and described below are needed for successful program implementation.

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Program FeesThe annual program fee of $5,000 in the initial year and $2,500 in subsequent years covers the following costs:

Initial Website Development (year 1) AFSP works with the college/university to customize the ISP website for each college/university.

Website Fees (all years) Included in the annual fee are costs related to registration and renewals of the website domain and security certificates, as well as hosting the website on an independent secure server.

Training of Local Program Staff (year 1 and as needed)AFSP trains the college/university staff in all website procedures. Although the primary training occurs in the initial year of implementation, AFSP will periodically update local staff on any new program features or provide training for new staff.

Technical Support (all years) AFSP staff provides technical support and assistance throughout the duration of the program.

Program Personnel The college/university covers the cost of the clinical personnel required to provide program services. These include:

ISP Counselor/s ISP counselor/s assess student questionnaires and write responses, communicate with students online, conduct in-person evaluations, make referrals and assist in transitioning students into treatment, as needed. ISP counselors may be psychiatrists, Master’s or Ph.D.-level clinical psychologists, clinical social workers or any other licensed mental health professional. Program experience suggests that one fulltime-equivalent counselor is required for every 10,000-12,000 students invited to participate in the program in a single academic year. A few campuses have a dedicated ISP counselor, but most utilize multiple counselors who contribute a limited number of hours each month to the ISP. The workload of the ISP counselors can usually be arranged so that weekend or evening monitoring of the website is kept to a minimum. Given the importance of prompt responses to students’ questionnaires and dialogues, however, daily checking of email notifications is recommended to ensure that urgent student communications are responded to in a timely manner. If a single counselor is used, a back-up counselor is also recommended to cover for the ISP counselor in the case of illness or vacation periods.

Administrative MonitorAn administrative monitor is highly recommended to regularly ensure timely and appropriate responses by the counselor/s and periodically report program accomplishments to the counselor/s and appropriate administrative officials. Although the computer system notifies the ISP counselor/s by email when a response has not been posted within the time periods specified for the student’s tier, regular review of the Administrative Reports by the monitor provides additional confidence that no student’s questionnaire or dialogue note has been missed.

On-call Psychiatrist A psychiatrist should be available on or off-campus to conduct medication evaluations of students referred by the ISP counselor/s.

Program Evaluator (optional)A designated program evaluator is recommended if the college/university wishes to systematically assess program outcomes (as discussed in Section 4 of the Manual).

Counselor OverheadISP counselors will generally require a private office to review student questionnaires, write and send responses and conduct in-person meetings with students. Each counselor will also need a computer with Internet access. A designated email account is recommended for ISP communications, which is shared by all participating counselors.

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Treatment ServicesMental health services must be available to students referred through the ISP program. These may be on or off campus, and costs may be borne by the college/university, student insurance, self-pay, or any combination of these options.

Table 1: Summary of Required Resources

Item Covered byProgram Fee

Covered by College/

University

Covered byStudent/

InsuranceWebsite Development and Fees Training of Local Program Staff Technical Support Program Personnel Counselor Overhead Treatment Services

In areas of the country where there is an AFSP Chapter or where an Out of the Darkness Community Walk has been held, funding may be available to initially cover the annual program fees for colleges/universities who wish to adopt the ISP during 2011-12 (see Appendix M for Chapter information). For more information about Out of the Darkness Community Walk locations, please visit the Walk website (www.outofthedarkness.org).

Legal ConsiderationsUnderstandably, colleges and universities may be concerned about the implications of the ISP for the institution’s legal liability in the event that a student whose questionnaire suggests serious distress does not respond to the counselor’s invitation for additional communication or in-person contact, and goes on to engage in suicidal behavior. Guided by legal professionals with specific experience in working with issues related to college suicide, AFSP has designed the ISP to ensure the fullest possible measure of safety and protection for the colleges/universities who utilize the program as well as for the students themselves.

Specifically, program procedures include:

1. Emphasizing in the introduction of the ISP to students that the program is NOT a crisis intervention service and that there will be a time delay between their submission of the Stress & Depression Questionnaire and the counselor’s response.

2. Underscoring from the outset that students’ anonymity is maintained throughout their use of the online services. It is made clear to students that their email addresses are encrypted into the computer system and will not be provided to counselors, or otherwise used by program staff.

3. Clearly indicating that beyond the counselor’s written response to every student who submits a questionnaire, no program services will be provided unless the student requests them.

4. Indicating that the ISP website and the services offered are intended only for students (or other target groups) within the particular college or university, and requiring confirmation of status before access to the screening questionnaire is provided.

These procedures comply with recommendations made by a panel of legal experts assembled by the Jed Foundation (see Student Mental Health and the Law: A Resource for Institutions of Higher Education at http://www.jedfoundation.org). We strongly recommend this resource to all colleges and universities that are considering using the ISP.

Over the last decade, as it has been increasingly recognized that many at-risk students do not avail themselves of available mental health services, colleges and universities have been taking more proactive approaches to identifying and offering help to those in need. Because such programs do not create the need, but rather reflect the institution’s awareness of it – as well as its willingness to take extra steps to meet it – liability in the event of a campus suicide is generally considered to be mitigated rather

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http://www.outofthedarkness.org/


than increased. These issues are further discussed in a recent article available for download on the AFSP website (www.afsp.org).4

ISP Evaluation ResultsA three-year evaluation of the pilot implementation of the Interactive Screening Program at two universities (one public, one private) provided evidence of program effectiveness in identifying at-risk students and referring them for treatment. Two published papers (available for download from www.afsp.org) present these results. 5,65,6

In one paper, student responses to the questionnaire data and follow-up data on in-person evaluations and referrals to treatment were examined.6 Data were examined by student level of risk: tier 1, high risk; tier 2, moderate risk; and tier 3, low risk. (The tier system has since been modified by dividing tier 1 into two categories: tier 1a and tier 1b.) Key descriptive data are summarized in Table 2 on the following page.

Other salient results of this study include the following:

A total of 132 students entered treatment following the evaluation; this represents 11% of the 1,162 students who responded to the questionnaire.

Counselor evaluations indicated that at least 75% of those who entered treatment would likely not have sought professional help without the outreach effort.

Students were three times more likely to come for an in-person meeting with the ISP counselor after engaging in at least one online dialogue.

Primary diagnoses among the 132 students who entered treatment were major depressive disorder (40%), adjustment disorder (31%), anxiety disorders (14%), and substance use disorder (13%).

Of the 57 students for whom treatment data were available, 46% had evidence of a positive therapeutic outcome, 32% prematurely terminated treatment, and 23% were referred to a provider outside the program.

The availability of the ISP counselor to provide short-term treatment was an important aspect of the outreach effort because many students seemed to feel a sense of connection to the counselor; in some cases immediate referral might have been counter-productive. Students were three times more likely to come for an in-person meeting with the ISP counselor after engaging in at least one online dialogue.

Table 2: Tier designation and short-term outcomes for questionnaire respondents

Category Number PercentNumber of students who completed questionnaire 1,162Risk level of those who completed questionnaire Tier I (high risk) Tier 2 (moderate risk) Tier 3 (low risk)

572409181

49%35%16%

Students who returned to website for counselor’s response 1,033 89%Students who engaged in online dialogue with counselor 279 24%Students who met with counselor for in-person evaluation

4 4 Haas, A.P. (2010). Detecting and engaging at-risk students. Washington and Lee Journal of Civil Rights and Social Justice, 17(1), 79-91.

5 Garlow, S.J., Rosenberg, J., Moore J.D., Haas, A.P., Koestner, B., Hendin, H., & Nemeroff, C.B. (2008). Depression, desperation, and suicidal ideation in college students: Results from the American Foundation for Suicide Prevention College Screening Project at Emory University. Depression & Anxiety, 25(6), 482-488.

5,6

6 6 Haas, A. P., Koestner, B., Rosenberg, J., Moore, D., Garlow, S. J., Sedway, J., Nicholas, L., Hendin, H., Mann, J. J., Nemeroff, C. B. (2008). An interactive web-based method of outreach to college students at risk for suicide. Journal of American College Health, 57(1), 15-22.

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Tier 1 Tier 2

11872

21%18%

2. Is the ISP Right for My Campus?

This section of the Manual is designed to assist college and university decision-makers in considering whether to adopt the Interactive Screening Program.

Can ISP Fill a Gap in our Suicide Prevention Strategy?Perhaps the most important issue to weigh in considering the ISP is its fit within the institution’s overall strategy for supporting well-being and preventing suicidal behavior among students. On most campuses, no single approach or program is sufficient to address the problem of campus suicide. Rather, the complexity of the problem suggests the need for a comprehensive strategy that includes awareness and educational activities that highlight and encourage reduction of suicide risk factors, early identification of at-risk students, counseling services for students at varying levels of risk, and clear policies and procedures for handling student risk behaviors, supporting at-risk students and restricting access to lethal means and methods. Considering whether to adopt the ISP provides college and university officials an opportunity to critically assess the full range of suicide prevention activities and programs currently in place on their campus.

The ISP targets, in particular, a segment of students who likely pose the highest risk for suicide: those with depression, substance abuse or other mental disorders who are not currently receiving treatment services. Campus officials should consider whether these students are currently being reached through any existing program or service. If not, the ISP may fill an important gap within the college or university’s suicide prevention strategy.

Do We Have the Clinical Resources to Staff the ISP?An essential requirement of the ISP is the availability of one or more counselor/s with the appropriate training and experience to work with students who may have serious mental disorders. Most campuses will naturally look to identify personnel within the student counseling center. This may be an ideal location for the ISP, given the pivotal role of the counseling center in providing mental health services to students and its ready access to referral resources. On many campuses, however, counseling center staff is burdened with increasing numbers of students seeking mental health services without any special outreach or invitation. Under these circumstances, administrators and staff may be appropriately cautious about the prospect of proactively encouraging yet more troubled students to come for services, even while recognizing that some of those with the greatest need are not coming forward on their own.

Many campuses struggling with this dilemma but also wanting to provide the unique services of the ISP have found it helpful to utilize multiple counselors for the program, with each counselor devoting a limited number of hours to this effort. Some current sites involve as many as eight different counselors in the ISP, and find this system to be not only effective from an administrative viewpoint, but also well-received by the counselors. Many counselors increasingly recognize the potential of online communications with students and welcome the opportunity to receive training in the ISP technology. Some campuses have obtained support for ISP personnel through federal, state or local grants. Although outside funding of personnel has obvious advantages to institutions, care must be taken to ensure that from the outset, a plan is in place for funding ISP personnel after the grant period is over.

Consideration of the ISP has prompted other campuses to reexamine their counseling center’s current allocation of clinical resources; assigning a higher priority to outreach services targeting high-risk students and devising less costly ways to serve students having less serious problems and needs. Where this can be done, the campus will likely find the ISP to be an efficient and cost-effective method for identifying, engaging and encouraging into treatment currently untreated at-risk students.

It should also be noted that the ISP may be housed in another unit of the college or university, such as the student health service, the psychiatry department of the medical school or a graduate department of

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psychology or social work. Departments affiliated with clinics that train clinical professionals may be particularly suitable. Some Interactive Screening Programs have been very successful with a single counselor, linked to a suitable academic department, who is able to refer students for treatment across the spectrum of available services, including the counseling center, training clinics and faculty practice plans. Some campuses have found that locating the ISP in a setting other than the counseling center makes some students feel less “identifiable” in seeking services, and may offer greater flexibility related to student registration and intake procedures. The ISP is also being used in schools that offer no counseling services and contract with community clinics or agencies for the services of an ISP counselor.

In short, there are many different ways that the ISP can be staffed. The important point is that the college or university must be able to provide or obtain at least one counselor who will communicate with students online, conduct in-person evaluations and make appropriate referrals to available treatment services on or off-campus. Interested college and university personnel are encouraged to talk with AFSP about options for how appropriate clinical personnel can be identified and supported.

Can We See How the ISP Online Screening Process Works?ISP websites that are under development or being updated are placed on a non-secure “test site.” These websites can be used by prospective colleges/universities to view the Welcome page and to access and review the Stress & Depression Questionnaire. The general URL for the test sites is http://site1.isptestsites.com/welcome.cfm. There are currently over 30 test sites available for review; the different sites can be accessed by substituting other numbers into the URL (site1-site30).

By following the instructions on the Welcome page, a visitor can sign up with a User ID and password and then view and complete the Stress & Depression Questionnaire, just as an actual student would do. Answers that are provided to the questionnaire items are not included in the college or university’s actual database. Visitors to the test sites will not receive a counselor’s response.

What Happens Next?Colleges/universities with a serious interest in the ISP should undertake the following next steps:

1. Complete the online Expression of Interest Form that can be found (and submitted on the AFSP website (www.afsp.org).

2. Participate in a conference call with AFSP staff to discuss the specifics of the ISP implementation. As part of this call, the school can request a review of one of the live ISP websites to see how the counselor retrieves and responds to student questionnaires and engages in the online dialogues with students. This demonstration will also show how ISP campus personnel can utilize the various administrative reports for monitoring and evaluation purposes.

3. Submit a written Memorandum of Understanding (MOU) to AFSP, signed by an appropriate institutional official. This document spells out what AFSP and the institution will each contribute to the program (see Appendix H for the copy of the MOU). Once this is signed, the college/university will receive the ISP Start-Up Packet and can begin preparing for the ISP implementation, a process that is described in detail in the following section.

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http://site1.isptestsites.com/welcome.cfm


3. Preparing to Implement the Interactive Screening ProgramThis section of the Manual outlines the steps that need to be undertaken in preparing for a college or university’s initial implementation of the Interactive Screening Program. In discussing each major step, we identify the key “choice points” or decisions that will need to be made. Although the steps are presented sequentially, typically the process is not strictly linear. Several steps may be in process simultaneously and in some cases, it may be necessary to address a particular matter earlier, or later, in the process.

1. Assign or Secure Needed Clinical PersonnelIn making sure that adequate personnel are available to the program, the following choice points should be considered.

Choice Point #1: Match clinical resources to anticipated student demandOne fulltime counselor is generally adequate for every 10,000-12,000 students invited to participate in the program in a single academic year. It should also be noted that the counselor’s time spent on the ISP will vary across the program period, with demands the greatest during the 24-48 hours after invitational emails are sent to students. (See Figure 3 under Choice Point #13).

Choice Point #2: Decide who will serve as ISP counselor/s Some programs prefer to have one designated ISP counselor, but on other campuses, a number of clinicians rotate program responsibilities so that each person is able to maintain other responsibilities. AFSP can arrange consultations with schools using one or the other of these models so that the pros and cons of each can be discussed.

Choice Point #3: Identify appropriate back-up personnel for sick or vacationing counselors, and for monitoring online communications with studentsIdeally, the counselor’s response should be posted to the student’s User ID within 24 hours of questionnaire completion, and all student dialogue notes should be answered as promptly as possible. It is therefore critical that coverage is provided for ISP counselors who are temporarily unable to respond to student questionnaires and dialogues. Someone should also be assigned the task of reviewing appropriate administrative reports to ensure that all students submitting questionnaires are responded to in a timely fashion.

2. Plan Desired Program Evaluation Activities The topic of program evaluation is discussed in more detail in the following section of this Manual. If a systematic evaluation of the ISP outcomes is to be undertaken, the following choice points should be considered.

Choice Point #4: Assign program evaluation activities to an appropriate person One or more persons on campus who have the appropriate skills and interests should be assigned responsibility for overseeing and carrying out program evaluation tasks.

Choice Point #5: Consult with campus Institutional Review Board (IRB) All campuses should consult with the appropriate IRB before beginning the program, but this is particularly important if the college/university plans to assess intermediate or long-term outcomes (see pp. 17-18). This will generally mean that an application for IRB approval be submitted, which includes an Informed Consent Form that students will sign to allow the counselor to submit de-identified information about the in-person evaluation and treatment to be submitted to the program evaluator.

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3. Identify Available Mental Health Services for Student ReferralsMental health professionals, or group practices which are available to see students, need to be identified prior to inviting student participation in the ISP. In compiling a complete list of treatment providers to whom program counselors can refer students in need of treatment, the following choice point should be considered.

Choice Point #6: Identify appropriate outside treatment providers The ISP provides a unique opportunity to engage students who are resistant to seeking help through normal channels. Because some students may be particularly resistant to receiving treatment services on campus, consideration should be given to identifying low-cost treatment alternatives.

4. Develop the ISP WebsiteEach ISP website is specifically designed for the individual college or university. Tailoring the website involves the following steps:

Choice Point #7: Select a domain nameEach college/university has its own ISP website with a unique domain name (URL). The domain name begins with the college/university name and some rubric that conveys in a general way the purpose of the ISP; for example https:// www.metrouniversitywellness.org or https:// www.metrocares.org . Note that the ISP website is completely separate from the college or university’s own website and is developed and maintained by a private company contracted by AFSP.

Choice Point #8: Provide logo and banner for the Welcome pageThe website Welcome page is headed by a banner bearing the name and logo of the college/university (in appropriate colors and fonts). This must be provided in a size that does not exceed a width of 260 pixels and a height of 75 pixels. (See Appendix B for an example of a Welcome page).

A standard text for the Welcome page introduces the ISP and provides enough information about how it works to allow students to make an informed decision about whether to complete the screening questionnaire. This includes (1) an explanation of the program and its purpose, (2) a description of the screening process, (3) an assurance of anonymity, (4) an assurance of the voluntary nature of the program and (5) the name and contact information for someone who can answer students’ questions prior to completing the questionnaire. Because the questionnaire is completed anonymously, signed informed consent is not necessary. The Welcome page also encourages the student’s participation, and explains the sign-up procedures.

Choice Point #9. Decide content of Welcome page sidebar. A sidebar on the Welcome page is divided up into 3 sections. The first is titled Counseling Services and provides campus-specific information about the counseling center and other mental health resources for students, on and off campus. The second section is titled Emergency Contacts and includes appropriate resources and contact information for students to use in the event of a mental health crisis or emergency. In the third section, the college/university can list Additional Resources, including links to other helpful websites or print materials related to mental health and well-being. (See Appendix I for Sidebar template).

5. Develop the Student Invitation ProcessIn most cases, students gain access to the ISP website through an email invitation from a college/university official. In planning the invitation process, several choice points need to be addressed.

Choice Point #10: Select the “source” for the email invitation Each school determines the appropriate official/s in whose name/s the email invitation will be sent. This might be the Director of the Counseling Center or Student Health, the Dean of

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http://www.metrocares.org/

http://www.metrouniversitywellness.org/

0%

10%

20%

30%

40%

50%

60%

70%

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 >10

Days after Email Invitation Sent

Percent of Total R

espondents to Em

ail


Students or another person who is in a good position to make a compelling case for student participation in the ISP. Choice Point #11: Determine the email contentThe first direct student contact with the ISP is through this email. Therefore, the content of that email is critical (see Appendix A for the copy of the introductory email to students). The invitation provides a clear statement of the program’s purpose and a brief overview of what is involved. It also encourages students to participate, and includes a link to the ISP website.

Choice Point #12: Decide who will be invited to participate, and in what orderEach college/university must decide who the program will target. Because parental consent is generally required for minor students, invitations should be sent only to students aged 18 and over. At smaller schools, the entire student body may be included at some point during the academic year; on larger campuses, selected undergraduate classes or other student groups might be selected, such as graduate students, medical or other professional students, transfer students, student veterans or student athletes.

The decision of how many students to target is largely dependent on the clinical resources available to the program. Rather than sending the invitations all at one time, they should be staggered across the year so that the program counselor/s will not be overburdened. Initially, it is advisable to start small and work up as the counselor/s become more adept at the online communications. AFSP staff will work with each new college or university to develop an initial plan for the number of students to be invited at a given time.

The graph in Figure 3 below provides guidance in anticipating student response to the email invitation to participate in the ISP. As can be seen, the large majority of student questionnaires are submitted within the first two days of receiving the email invitation, with almost 60% submitted within the first 24 hours.

Choice Point #13: Decide how the flow of emails will be controlledEmails can be sent on pre-arranged dates, or they can be sent dependent upon the volume of responses to earlier email invitations. Even if a schedule has been decided in advance, the ISP counselor should always confirm the program’s readiness to send the next batch of emails. Determining the mechanism for how the ISP counselor arranges the flow of emails generally requires close collaboration with the school’s information technology (IT) department or other relevant unit.

Figure 3: Distribution of student response following email invitation

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Choice Point #14: Decide whether access to the website will be advertised through any other methodsOn some campuses, a link to the ISP website is given on the webpage of the counseling center or in another appropriate place on the institution’s own website. Another method that some schools are testing involves the use of “referral cards” with the ISP website address, which faculty, residence hall advisers or other staff can give to students who might benefit from the ISP services. If a campus decides to use one or more of these alternatives, we recommend that this be discussed in advance with AFSP so that these alternative access links can be differentiated from that given to students in the invitational emails, thus allowing traffic coming from different sources to be tracked.

6. Tailor the Demographic Items on the Stress & Depression QuestionnaireAlthough the questionnaire items are generally standard across all program sites, individual schools may tailor the items on student demographics as appropriate for the group or groups they will be targeting.

Choice Point #15. Identify a limited number of demographic itemsWe recommend that items be included on the student’s class, gender and age. Various formats for the answers to the question on class are available, depending on the student group/s that will be targeted (undergraduate students, graduate students, medical students, etc). Other items that might be considered are resident/commuter status, transfer status or veteran status. Consistent with the anonymous nature of the Stress & Depression Questionnaire, it is recommended that the number of demographic items be kept to a minimum. It should be remembered that the questionnaire is designed to be a springboard for more in-depth communications between the counselor and the student. The counselor’s response to the student and the subsequent dialogue exchanges provide opportunities for the counselor to seek additional relevant information.

After the college/university returns the MOU to AFSP, a start-up packet will be sent to the designated ISP counselor/s. This packet is designed to guide new colleges/universities in preparing to launch the ISP (see Appendix J for the checklist of start-up activities).

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4. Suggestions for Site-based ISP Evaluation Some campuses may wish to conduct a systematic evaluation of their ISP outcomes, in order to assess program effectiveness and improve delivery of program services. Following the evaluation design used in the pilot study, three levels of program outcomes are particularly appropriate to be studied, as shown in Table 3.

Table 3: ISP Short, Intermediate, and Long-term OutcomesISP Program Outcomes

Short-term Intermediate Long-term

# of students completing questionnaires

# of students accessing the counselor’s response

# of students engaging in online dialogues w. counselor

# of students meeting in person w. counselor

# of students referred to mental health treatment

# of students entering treatment nature and duration of treatmenttreatment outcomes

Evaluation questions related to each level of program outcomes include the following:

Short-term

How many students are logging on to the website and completing the Stress & Depression Questionnaire?

How many of these students are assessed at tiers 1a, 1b, 2, and 3? How many students returned to the website to access the counselor’s response? How many students engaged in online dialogues with the ISP counselor?

Intermediate-term How many students met in-person with the ISP counselor? How many students were referred to mental health treatment?

Long-term How many at-risk students received treatment as a result of program referral? What was the nature and duration of treatment for these students? What outcomes were achieved as a result of treatment?

Short-term outcomes can be determined using information captured by the program website and recorded in the various reports available on the Administrative web page. Forms have been developed for collecting data on intermediate and long-term outcomes. These data can be entered into the SPSS file

19


that each school is able to create from the Full Data report stored in the Administrative section of the website. Technical assistance on evaluation issues is available from AFSP.

It is important to note that, prior to program start-up each college or university should check with its Institutional Review Board, or comparable group responsible for reviewing and approving the collection of data from human subjects. Schools vary somewhat regarding policies and requirements in this area. Because the ISP is essentially a student service rather than a research endeavor, many IRBs will not require a formal review. If an evaluation is planned that includes collecting any information after students are personally identified (i.e., following the initial in-person meeting with a program counselor), the IRB will generally require that students sign an informed consent form, specifically agreeing to the counselor’s providing de-identified data to the program evaluator (see Appendix K for the copy of the informed consent form). AFSP staff is available for guidance and technical assistance regarding IRB review.

ConclusionThank you for your interest in the Interactive Screening Program.

We hope that this Manual has provided a helpful overview of the ISP process. Please keep in mind that AFSP will function as a partner with the college or university in preparing for the initial implementation of the ISP, as well as throughout the duration of the program. During the pre-implementation phase, regular telephone conferences with personnel at the college or university will be scheduled to ensure that the process proceeds smoothly and that all questions and concerns are able to be fully discussed.

Appendices

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A: Introductory Email to Students

B: Screen Shots of ISP Website Interfaces

C: Stress & Depression Questionnaire

D: Tier Designation Criteria

E: ISP Counselor Responses

F: Email Reminders

G: Update Questionnaire for Tier 1 & 2 Non-Responders

H: Memorandum of Understanding

I: Welcome Page Sidebar Information

J: ISP Start-Up Activities

K: Informed Consent Form

L: Current ISP Campuses

M: Current AFSP Chapter Locations

A: Introductory Email to Students

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To: [Student’s Email Address]

From: [Counselor Name and Title] (i.e. Steve Wilson, Director of Counseling Services)

Subject: [Confidential Stress and Depression Screening]

We are writing to let you know about a unique online service offered to [College/University] [Target Group] (i.e. University of North Carolina Graduate students) from the [Program/Counseling Center Name] (i.e. UNC Wellness Center). Our goal is to enhance student wellness by helping students identify – and do something about – stress, anxiety, depression and other problems that can interfere with academic, social and personal functioning.

Clicking the link at the bottom of this message will take you to a secure website where you have the option of completing a brief online questionnaire, which you’ll submit using a self-assigned User ID. This will be the only way your responses are identified, and thus, the process is entirely confidential.

An experienced [College/University] counselor will then review your questionnaire and will send a personal response to you over the secure website, which will include any recommendations for follow-up. You will then have an opportunity to exchange online messages with the counselor through the anonymous dialogue feature using only your User ID, or to set up a face-to-face meeting to talk to the counselor in more detail.

Completing the online questionnaire and making use of this service is completely voluntary. Your access to student health and counseling services will not be affected in any way if you choose not to make use of this service. (Also, if you’ve completed the questionnaire in a past semester, it’s fine to do it again if you think it would be useful).

We urge all students to take advantage of this safe and easy way to find out if stress, anxiety or depression may be affecting you. The good news is that treatments for these challenges are highly effective and are available right here on the [College/University] campus, or off-campus, if you prefer.

If you have any questions about this service, please contact [Primary ISP Contact] at [Phone #].

We hope all of you will take a few minutes right away to go to the secure website, log in and complete the Stress & Depression Questionnaire:

[Link to secure website] (i.e. www.uncwellness.org)

B: Screen Shots of ISP Website Interfaces

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The ISP website has unique website interfaces for students, counselors, and administrators.

Student Welcome PageWhen a student follows the link from the email invitation, this is the webpage they’ll see.

Student Confirmation Page

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Stress & Depression Questionnaire (first page)

24


This is the first of 10 web pages of the Stress & Depression Questionnaire as seen by students.

ISP Counselor’s View of Student Responses25


Counselors can review student answers to specific questions from the Stress & Depression Questionnaire.

ISP Counselor’s View of Dialogue Webpage

26


Counselors and students can communicate through the dialogue feature of the ISP.

Administrative Webpage

27


A variety of different reports can be generated from the stored information that the administration webpage provides. Reports can be generated for different time periods and in different formats (e.g., Excel).

C:

Stress & Depression Questionnaire

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The Stress & Depression Questionnaire takes about 10 minutes to complete. The web version differs in format from that below, but the questions and the page numbers remain the same.

Page 1 of 10

During the last 4 weeks, how often have you been bothered by any of the following?

Not at all

Some of the time A lot of the

time

Most or all of the

timeFeeling nervous or worrying a lotBecoming easily annoyed or irritableFeeling your life is too stressful

Having arguments or fights

Feeling intensely lonely

Feeling intensely angry

Feeling hopeless

Feeling desperate

Feeling out of control

Page 2 of 10

During the last 4 weeks have you experienced any of the following?

Not at all

Some of the time

A lot of the time

Most or all of the time

Drinking alcohol (including beer or wine) more than usual

Feeling like you were drinking too much

Feeling that your work or school attendance or performance was being affected by your drinkingUsing drugs other than alcohol (marijuana, cocaine, etc.) or taking prescription medications without medical

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supervision?

Page 3 of 10

During the last 4 weeks have you experienced any of the following in relation to eating?

Not at all

Some of the time

A lot of the time


Feeling that you can’t control what or how much you eat

Feeling overly concerned about staying thin or losing weightMaking yourself vomit after eating

Page 4 of 10

Thinking now about the last 2 weeks, how often have you been bothered by any of the following problems?

Not at all

Some of the time

A lot of the time


Feeling tired or having little energy

Having trouble falling or staying asleep, or sleeping too much

Having a poor appetite or overeating

Having trouble concentrating on things, such as reading the newspaper or watching televisionFeeling bad about yourself – or that you are a failure or have let yourself or your family downMoving or speaking so slowly that other people could have noticed?Or the opposite – being so restless that you have been moving around a lot more than usualFeeling a lack of interest or pleasure in doing things

Feeling down or depressed

Having thoughts that you would be better off dead or thoughts of physically harming yourself

Page 5 of 10

During the last 2 weeks, how often have you… Not at all

Some of the time

A lot of the time


Had thoughts about taking your own life?

Planned ways of taking your own life?Done things to hurt yourself?

Page 6 of 10No Yes

Have you ever made a suicide attempt?

Page 7 of 10

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Not at all difficult

Somewhat difficult

Very difficult

Extremely difficult

If you checked off any problems on this Questionnaire, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Page 8 of 10

Are you currently…No Yes

Taking medications for anxiety?

Taking any medication for depression?

Taking any medication for stress?

Taking any medication for sleep?

Taking any medication for pain?

Getting counseling or therapy?

Page 9 of 10

Please tell us a few things about yourself. (Note: This page may be modified by each college/university. Modifications can be made on the demographic form in the ISP Start-Up Packet).

Are you

Class

Your age:

Proceed to the next page to submit your questionnaire.

Page 10 of 10

After you submit your Questionnaire, a counselor will review it and will write a personal response to you that you can access on the website. If you provide your email address, we will send you and email with a link back to the website when the counselor’s response is ready.

To protect your identity, your email address will be encrypted in the computer system and will not be revealed to anyone including the counselor.

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Female Male

Freshman Sophomore Junior Senior


Please type your e-mail address in the box below.

Email address:

Re-enter email:

Comments. Please take a minute to let us know about anything that has been particularly stressful for you lately – death of a loved one, relationship break-up, academic stressors, family or money problems,

difficulty with your living situation – or anything else that might be contributing to how you are feeling.

Thank you for answering this Questionnaire. To submit, please click below.

Submit

D: Tier Designation Criteria

Based on their answers to specific questions in the Stress & Depression Questionnaire, students are placed in one of four tiers, as follows. (Page numbers correspond to the layout of the questionnaire as it appears on the ISP website and in Appendix C).

Criteria for Tier 1a

1. An answer of “some of the time,” “a lot of the time“ or “most or all of the time” to any of the items on page 5: had thoughts about taking your own life, planned ways of taking your own life, or done things to hurt yourself.

2. An answer of “a lot of the time” or “most or all of the time” to the last of the 9 depression items on page 4: having thoughts that you would be better off dead or thoughts of physically harming yourself.

2. A total score of 15 or more on the 9 depression items on page 4 AND an answer of “yes” to the question on page 6: “Have you ever made a suicide attempt?”

3. A total score of 15 or more on the 9 depression items on page 4 AND an answer of “most or all of the time” to any of the following items on page 1: feeling intensely anxious, feeling intensely angry, feeling hopeless, feeling desperate or feeling out of control.

Criteria for Tier 1b

1. A total score of 15 or more on the 9 depression items on page 4.

2. An answer of “some of the time” to the last of the 9 depression items on page 4, “Having thoughts that you would be better off dead or thoughts of physically harming yourself.”

3. A total score of 10-14 on the 9 depression items on page 4 AND an answer of “yes” to the question on page 6: “Have you ever made a suicide attempt?”

4. An answer of “most or all of the time” to any of the following items on page 1: feeling nervous or worrying a lot, becoming easily annoyed or irritable, feeling your life is too stressful, having arguments or fights, or feeling intensely lonely.

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5. An answer of “a lot of the time” or “most or all of the time” to any of the following items on page 1: feeling intensely anxious, feeling intensely angry, feeling hopeless, feeling desperate or feeling out of control.

6. An answer of “very difficult” or “extremely difficult” to the question on page 7: “If you checked off any problems on this questionnaire, how difficult have these problems made it for you to do your work, take care of things, or get along with other people?”

Criteria for Tier 2

1. A total score of 10-14 on the 9 depression items on page 4.

2. An answer of “some of the time” to any of the following items on page 1: feeling intensely anxious, feeling intensely angry, feeling hopeless, feeling desperate or feeling out of control.

3. An answer of “a lot of the time” or “some of the time” to any of the following items on page 1: feeling nervous or worrying a lot, becoming easily annoyed or irritable, feeling your life is too stressful, having arguments or fights, or feeling intensely lonely.

4. An answer of “some of the time,” “a lot of the time“ or “most or all of the time” to any of the four items on page 2 related to drinking or drug use: drinking alcohol (including beer or wine) more than usual, feeling like you were drinking too much, feeling that your work or school attendance or performance was affected by your drinking, or using drugs other than alcohol (marijuana, cocaine, etc.) or taking prescription medications without medical supervision.

5. An answer of “some of the time,” “a lot of the time“ or “most or all of the time” to any of the three items on page 3 related to eating problems: feeling that you can’t control what or how much you eat, feeling overly concerned about staying thin or losing weight, or making yourself vomit after eating.

6. An answer of “somewhat difficult” to the question on page 7: “If you checked off any problems on this questionnaire, how difficult have these problems made it for you to do your work, take care of things, or get along with other people?”

Criteria for Tier 3

Those who do not meet any the tier 1 or tier 2 criteria will fall into this tier.

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E: ISP Counselor Responses

Counselor Response Template for Tier 1a

[Counselor Name, Designation] (Steve Wilson, Director of Counseling Services)[Clinic Name] (UNC Wellness Center)[University Name] (University of North Carolina)[Counselor Address] (James A. Taylor Building, First Floor)Tel: [Counselor Direct Line] (1-919-669-8122)

My name is [Counselor Name] (i.e. Steve Wilson) and I’m a counselor at the [College/University Counseling Center] (i.e. UNC Wellness Center). I have reviewed your responses to the Stress & Depression Questionnaire and am particularly concerned that you have recently [been having thoughts of …..]. You also say in the questionnaire that you often feel…..and that these feelings are making your life {very/extremely} difficult. I am also concerned that you……

I believe I can help you find relief, and I hope that you will contact me to set up a time we can get together within the next day or two.

If you would rather talk to me without coming in or identifying yourself, we can continue to exchange messages on this website. You can respond to me by clicking on the “Dialogue” button below, and I promise I will I will respond to your message over the website as quickly as I can. You can generally expect to hear back from me within 24

34


hours, although over the weekend or during holiday periods, it may take me a little longer to get back to you. If you provided an email address in the questionnaire you submitted, you will receive an email message when I have responded to your Dialogue note. If you contact me through this website, please make sure you keep a record of your User ID and password so you can log back on to get my response.

If you prefer, we can also talk by phone; just give me a call at the number listed above. You will not need to identify yourself by name unless you want to.

If you are in crisis, please call me. If you are unable to reach me, please refer to the Welcome page of this website for other numbers to call.

Please do let me hear from you. I think I can be of help and would like to see you as soon as possible.

Counselor Response Template for Tier 1b

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My name is [Counselor Name] (i.e. Steve Wilson) and I’m a counselor at the [College/University Counseling Center] (i.e. UNC Wellness Center). I have reviewed your responses to the Stress & Depression Questionnaire and would like to meet with you to talk about the issues that are troubling you. You say in the questionnaire that you often feel….and that these feelings are making your life {very/extremely} difficult. I am also concerned that you……

I believe I can help you find relief, and I hope that you will contact me to set up a time we can get together within the next day or two.

If you would rather talk to me without coming in or identifying yourself, we can continue to exchange messages on this website. You can respond to me by clicking on the “Dialogue” button below, and I promise I will I will respond to your message over the website as quickly as I can. You can generally expect to hear back from me within 24 hours, although over the weekend or during holiday periods, it may take me a little longer to get back to you. If you provided an email address in the questionnaire you submitted, you will receive an email message when I have responded to your Dialogue note. If you contact me through this website, please make sure you keep a record of your User ID and password so you can log back on to get my response.


I believe it is important for us to stay in touch. I think I can be of help and hope to hear from you.

Counselor Response Template for Tier 2

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My name is [Counselor Name] (i.e. Steve Wilson) and I’m a counselor at the [College/University Counseling Center] (i.e. UNC Wellness Center). I have reviewed your responses to the Stress & Depression Questionnaire and would like to meet with you to talk about the issues that are troubling you. You say in the questionnaire that you are feeling ...and that these feelings are causing some difficulty in your life. I am also concerned that you……

I believe I can help you find relief, and I hope that you will contact me to set up a time we can get together.



I sincerely hope to hear from you soon. I think I can be of help.

Counselor Response Template for Tier 3

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My name is [Counselor Name] (i.e. Steve Wilson) and I’m a counselor at the [College/University Counseling Center] (i.e. UNC Wellness Center). I have reviewed your responses to the Stress & Depression Questionnaire, and don’t see any indication of problems at this time. If you feel I may have missed something that is troubling you, I would, of course, be happy to talk with you. Just contact me and we can set up a time to get together.


If you do not wish to use these services at this time, please keep a record of my name and contact information in case you wish to talk about something that is bothering you at a future time. I would be happy to hear from you.

F: Email Reminders

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Email reminders are sent to tier 1 and tier 2 students 15 and 30 days after the Counselor’s Response has been posted on the website. The text of each email is provided below.

First Reminder (sent 15 days after the Counselor’s Response is posted on the website)

A couple weeks ago you completed an online questionnaire. I hope that you've gone back to the secure website, [Site Link] (i.e. www.uncwellness.org), to receive your personalized response. This reminder is being sent from an automated system, so if you've already contacted me, please disregard this email.

If you've not yet read my response, please do so as soon as you can - and please follow up with the recommendations. You can access the response by clicking on [Response Site Link] (i.e. www.uncwellness.org/response) and logging in with your User ID and password, at which point you will be taken directly to my response. If the link doesn't work, please copy the URL and paste it into your browser's address field.

If you're having trouble getting my response, please call [Counselor Phone #] and ask for me. You will be asked to provide your User ID, which is the name you assigned yourself at the time you completed the screening questionnaire. No other identification is required.

If you'd rather communicate with me online, please click on [Dialogue Site Link] (i.e. www.uncwellness.org/dialogue), log in with your User ID and password, and you will be taken directly to the dialogue. If the link doesn't work, please copy the URL and paste it into your browser's address field. Again, your only identification will be your User ID. I will respond to you promptly over that website.

These services are free of charge and totally confidential. I hope you'll take advantage of them.

Second Reminder (sent 30 days after the Counselor’s Response is posted on the website)39


I am writing to remind you again to read my response to the online questionnaire you completed a month or so ago, and to follow up with the recommendations. This reminder is being sent from an automated system, so if you've already contacted me, please disregard this email.

If you've not yet accessed my response: Click on this link [Response Site Link], log in with your User ID and password, and you will be taken directly to my response. If the link doesn't work, please copy the URL and paste it into your browser's address field.

If you've already accessed my response but haven't been in touch with me, I'd really like to hear how you're doing. Could you please take a few minutes to let me know? Just click on this link [Link to Student Update Questionnaire], log in with your User ID and password, and you'll see a few questions that you can answer online. This should take no more than 5 minutes, and you may skip any questions you do not wish to answer. I will get back to you in a dialogue note.

If you don't wish to respond right now, I hope you'll save this information. I will be happy to hear from you at any time. The services offered through this program are free of charge and totally confidential. I hope you'll take advantage of them.

G: Update Questionnaire for Tier 1 & 2 Non-Responders

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1. Since submitting the Stress and Depression Questionnaire a couple of months ago, how have you been feeling?

2. Since then, have you received any kind of treatment for the problems you indicated you were

having?

3. If you have received treatment, please indicate what kind. Check off all that apply.

4. After we reviewed your responses to the Stress and Depression Screening Questionnaire, we recommended that you come in to talk with us about the issues that were troubling you. We’re interested in your reasons for not coming in. Please check all that apply.

5. What do you think would be most helpful to you at this time?

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Much worse

Somewhat worse

About the same

Somewhat better

Much better

Yes

No

Medication Other

Counseling or psychotherapy

I feel I can handle my problems on my own.

I would be more comfortable seeing someone off-campus

I'm concerned about confidentiality.

I don't want it to be on my record that I've gotten counseling

I started feeling better. My problems aren't serious enough to need counseling/therapy.

I don't think talking to someone would help me feel better.

I haven't heard good things about the services offered on campus.

I'm too busy. For most people, counseling is a waste of time.

I don't want to be coerced into getting treatment. I don't want to be forced to take medication.

I don't feel comfortable talking to someone I don't know. Other

I think my problems will be resolved when I'm under less stress.


H: Memorandum of Understanding

This Memorandum of Understanding (“Memorandum of Understanding”) pertains to the implementation and operation of the Interactive Screening Program (ISP) and related support services (the “Program”), developed by the American Foundation for Suicide Prevention (“AFSP”), to be based at the [College/University] (“University Short Name”), during the period of [Project Start Date] through [Project End Date] (“Project Period”).

AFSP hereby grants to [College/University] an unlimited, nonexclusive, royalty-free, worldwide right and license to use the website and all intellectual property in connection with the Website and the Program, including but not limited to the Stress & Depression Questionnaire (“Licensed Materials”).

AFSP represents and warrants that: (i) AFSP is either the sole and exclusive owner of the Licensed Materials and other related rights or holds sufficient license to such Licensed Materials to grant the rights and licenses in this Memorandum of Understanding without violating any rights of any third party; and (ii) the Licensed Materials, and [College/University]’s use of the Licensed Materials as permitted under this Memorandum of Understanding, does not and will not infringe on, misappropriate or violate any intellectual property rights, rights of publicity or privacy, moral rights or any other third party rights.

To support the implementation of the Program during the Project Period, AFSP will:

In collaboration with its technical partners, ENTECH, Inc. and AccuFind Internet Services, Inc., develop and maintain a secure website, specifically designed for [College/University], which will give students online access to a Stress & Depression Questionnaire and to a personalized assessment of their responses by a Program Counselor. The website also will allow students to exchange anonymous online messages with the Program Counselor, and will record all data exchanged on the website for monitoring and reporting purposes.

Train the Project Counselor(s) and back-up staff in the use of the online technology, the monitoring and data analysis functions, and all other functions related to the Project.

Provide on-going technical assistance with all aspects of the Program.

[College/University] will provide services of one or more Program Counselor(s) whose functions will be as follows:

Write individualized assessments of students’ questionnaire responses Communicate with students through the online dialogues Conduct in-person evaluations of students who agree to seek help, and complete written

evaluation reports Provide initial counseling sessions to students, as necessary, to transition them to

appropriate on-campus or off-campus treatment providers Generate regular reports on project progress and accomplishments for submission to AFSP

and appropriate university officials

[College/University] also will provide the necessary back-up staff to perform the above functions in the absence of the regular Program Counselor(s) due to vacation or illness. The back-up staff also will regularly monitor the online communications between students and the Program Counselor to promote timely and quality responses.

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At the close of the Project Period, this collaboration between AFSP and [College/University] may be extended upon mutual agreement of the parties.

For AFSP: For [College/University]:

_______________________________ ______________________________Ann P. Haas, Ph.D. Name:Senior Program Specialist Title:_______________________________ ______________________________Date Date

I: Welcome Page Sidebar Information

Counseling Services[College/University Counseling Center][Street Address][Building Name, Rm/Fl #][Counseling Center Phone 3]

Counseling Center Service Hours[Semester][Days of the Week][Hours of Operation][Winter/Summer Break Hours]

Counseling Services Website Link

Emergency Contacts[On-campus][Campus Police #][Emergency Services #]

[Off-campus][Hospital/ER]National Suicide Prevention Lifeline1-800-273-TALK (8255)

Additional Resources(Non-emergency/non-counselingServices relevant to students mentalhealth)

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J: ISP Start-Up Activities

Decide on domain name – Examples: https://www.umainetouchstone.org https://www.assumptionwellness.org

Set up screening program email account at college/university for use by counselor(s).

Obtain college/university logo/banner in gif file (recommended size for the logo is approximately 260 pixels wide by 75 pixels high).

Decide on person (and contact info) to whom students will be directed for questions about the screening (Welcome page).

6. Edit ‘Questions’ section at the bottom of the Welcome page to include the contact information for the primary counselor for the ISP.

Decide what information to put in Welcome page sidebar; Counseling Services, Emergency Contacts, Additional Resources (e.g., counseling center info and website link, emergency info, etc).

Provide name/position and contact information for ISP counselor(s) for assessment templates.

Define student target group(s) and schedule for inviting them to participate in the screening.

Decide on demographic questions to be included at end of questionnaire.

Decide who will send out invitational email to students.

Work with IT people on campus to arrange procedures and schedule dates for invitational emails to be sent to targeted students.

Determine evaluation activities and whether IRB approval is needed. Typically IRB approval will be required if data will be systematically collected from students who come for in-person session(s). If needed, complete IRB application (AFSP can help with this).

Schedule initial 90-minute staff training session with AFSP.

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https://www.umainetouchstone.org/


Complete practice communications on live website, under review by AFSP.

Prepare student body, faculty/staff, parents, etc. for introduction of the ISP (student newspaper, general media, etc.)

K: Sample Informed Consent Form

INFORMED CONSENT FORM

Thank you for completing the on-line Stress & Depression Questionnaire, which dealt with psychological problems often experienced by college/university students. Your responses suggested that it might be helpful for you to speak to a counselor, and we are pleased with your decision to come in for an evaluation. At this time we are asking you to participate in a research study to evaluate the impact and effectiveness of this program in helping students cope with and resolve the problems they are experiencing. Your participation in this study is voluntary and you may withdraw consent and discontinue participation at any time without its affecting your use of any of student services offered by [College/University].

Specifically, we are asking you for your permission to allow your counselor to complete a questionnaire after this evaluation, which will request information about the kind of problems that you are experiencing and the counselor’s recommendations regarding treatment. This form will identify you only by the User ID that you assigned yourself at the time you filled out the Stress & Depression Questionnaire and will not request any information that could reveal your identity.

If you decide to pursue treatment, we are also requesting your permission to allow your treatment provider to periodically complete a brief questionnaire dealing with the status of your treatment. In this phase of the study, we are interested in looking at the range of problems that bring students into treatment, as well as students’ responses to treatment. The first questionnaire will be completed by your treatment provider after your first session, and will request a brief synopsis of the treatment plan. The questionnaire will be updated monthly as long as you are in treatment. Again, it should be emphasized that these questionnaires will identify you only by your self-assigned User ID. Your treatment provider will send all questionnaires to program staff for tabulation and analysis. Please understand that your regular clinical records will not be accessed or used in this program, and will be maintained according to the highest standards of confidentiality.

If you have any questions about the procedures to be used in this program, or about what you are being asked to do, please do not hesitate to call or schedule an appointment to see [Primary Contact Name and Title]. [His/Her] office is located in the [Building, Room/Floor #] and [he/she] can be reached at [Telephone #] or by e-mail at [Email Address].

Please read and sign the following if you agree to participate:

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I give permission for my counselor to complete a brief questionnaire after my initial evaluation. If I decide to pursue treatment, I also give permission for my treatment provider to complete periodic questionnaires dealing with my treatment, as part of the evaluation of the impact and effectiveness of the Stress & Depression Questionnaire. I understand that none of the information requested on these questionnaires will identify me in any way other than the User ID that I assigned myself at the time I completed the Stress & Depression Questionnaire.

I understand that I may contact the Chair of the University Institutional Review Board at [Telephone #] if I have concerns about the program or feel I have been treated unfairly.

_____________________________________________________________________________Participant Signature Date Witness Signature Date

L: Current ISP Campuses (June 2011)

Agnes Scott CollegeBeth Krakow, PhD: [email protected]

Assumption CollegeNeil Castronovo: [email protected]

The Commonwealth Medical CollegeJacquelyn Ghormoz, MSW, CSW: [email protected]

Cornell UniversityBarbara Jastran: [email protected]

Creighton UniversityHope Russell: [email protected]

Emory UniversityLauren Bell Moffit: [email protected]

Farmingdale CollegeShane Owens, PhD, ABPP: [email protected]

Georgia CollegeSteve Wilson: [email protected]

Heritage UniversityAngel Gamet: [email protected]

Jefferson Medical CollegeMatthew Wintersteen: [email protected]

Kennesaw State University

Amy Westergren-Amlicke: [email protected]

Massachusetts Institute of TechnologySimon Lejeune: [email protected]

North Dakota State UniversityAmber Bach-Gorman: [email protected]

Ohio State University College of MedicineKaren Hartner: [email protected]

Ohio State University School of Veterinary MedicineJennifer Brandt: [email protected]

Ohlone Community CollegeSally Bratton, RN, FNP, PA-C: [email protected]

Rhode Island CollegeTom Lavin, PhD: [email protected]

Rocky Mountain CollegeKatie Carpenter: [email protected]

The Sage CollegesTrena Harrington, LCSW, CASAC: [email protected] Washco, MS, LMHC: [email protected]

St. Cloud State University

John Eggers: [email protected]

University at AlbanyHeidi Wright: [email protected]

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University of California San Diego Medical SchoolBrittany Kirby: [email protected]

University of Colorado BoulderAmy Robertson: [email protected]

University of MaineKylie Cole: [email protected]

University of Massachusetts Medical SchoolCharlene Paradise: [email protected]

University of Pittsburgh Medical School

Lee Wolfson: [email protected]

University of Puget SoundDonn Marshall: [email protected]

University of the SciencesSarah Thompson, PhD: [email protected]

University of Southern MaineRobert Small, Psy. D: [email protected] McCormick, Post-Doctorate Intern: [email protected]

Xavier UniversityMichael Meier: [email protected]

M: AFSP Division Contact Information

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Western Division Acting Director, Mike Lamma: [email protected] Division Director, Janice Hurtado Aeppli: [email protected] Division Director, Kimberly Gleason: [email protected]

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