Lethal Means and Adolescent Suicidal Risk: An Expansion of the PEACE Protocol R. Elizabeth Capps, Kurt D. Michael, and J. P. Jameson Appalachian State University Suicide is one of the leading causes of death among adolescents. With rates of suicide among rural youth nearly double those of urban youth, suicide among adolescents in rural areas is a major public health concern. School mental health programs, which provide mental health services to students in the context of the school, address many barriers to accessing mental health treatment in rural areas and may include efforts to address suicide prevention. Of critical importance in suicide prevention strategies for schools are methods for restricting access to lethal means and methods for facilitating student referral for risk assessment and management. In addition, there is a need to develop effective suicide crisis response protocols appropriate for the school setting. The Prevention of Escalating Adolescent Crisis Events (PEACE) protocol was devel- oped and revised to create a thorough risk assessment process for mental health clinicians working in tandem with school personnel in educational contexts. The PEACE protocol was utilized for 78 crisis events that involved 58 students during the 2016 –2017 school year. During 2016 –2017, the PEACE protocol was revised to collect more detailed information on how students were referred for assessment and to directly track how crisis response and safety plans addressed access to lethal means. These results and the clinical implications of utilizing this protocol and the assessment findings to address school-based suicide prevention efforts are discussed. Keywords: adolescent, lethal means, rural, suicide In the United States between 1999 and 2014, age-adjusted rates of suicide have increased from 10.5 to 13.0 per 100,000 individuals (Cur- tin, Warner, & Hedegaard, 2016). Among those between ages 10 and 24, suicide is the second leading cause of death (Heron, 2016), and rates of suicide among female teens between the ages of 10 and 14 have increased 200% from 0.5 to 1.5 per 100,000 individuals between 1999 and 2014 (Curtin et al., 2016). Suicide rates are higher in rural regions (Fontanella et al., 2015; Singh, Azuine, Siahpush, & Kogan, 2013), and the data over time indicate a widening disparity (Singh & Siahpush, 2014), especially for males (Singh & Siahpush, 2002). From 1996 to 2010, rates of suicide comparing rural to urban youth followed a similar trend whereby rates of sui- cide among rural teens was nearly double those of their urban counterparts (Fontanella et al., 2015). As evidenced by these trends, suicide is a persistent, if not worsening, major public health problem, particularly in rural communi- ties and among our youth. Although some studies have not found sig- nificant differences in the rates of suicidal ide- ation among rural and urban adolescents (Al- bers & Evans, 1994; Murphy, 2014), some study results suggest differences exist in the rates of death by suicide among rural and urban adolescents. In a recent time-series comprehen- sive study of individuals between 10 and 24 years old, Fontanella et al. (2015) reported greater rates of suicide among rural youth com- pared with their urban counterparts. Thus, even though evidence suggests no differences in rates of suicidal ideation between rural and urban R. Elizabeth Capps, Kurt D. Michael, and J.P. Jameson, Department of Psychology, Appalachian State University. Correspondence concerning this article should be ad- dressed to R. Elizabeth Capps, 222 Joyce Lawrence Lane, ASU Box 32109, Boone, NC 28608. E-mail: cappsre@ appstate.edu This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Journal of Rural Mental Health © 2019 American Psychological Association 2019, Vol. 43, No. 1, 3–16 1935-942X/19/$12.00 http://dx.doi.org/10.1037/rmh0000108 3