A systematic review of school-based suicide prevention programs

Changes in State Laws on Suicide Prevention Training for School Staff, 2002-2022

OBJECTIVES

Youth suicide is an urgent public health problem. Gatekeeper training aims to prevent suicide by training people to identify warning signs and make referrals to appropriate services. Many states in the United States have enacted gatekeeper training laws (GTLs) to train school staff in suicide prevention. The objectives of this study were to describe the development of a dataset on GTLs and use the dataset to summarize trends in uptake of GTLs from 2002 through 2022 as well as differences in characteristics (eg, frequency and duration of training) of GTLs.

METHODS

We used publicly available legal databases from all 50 states and the District of Columbia to conduct a policy surveillance assessment of GTLs. We cross-checked data with the American Foundation for Suicide Prevention's 2022 Suicide Prevention in Schools (K-12) issue brief and used Westlaw Edge to conduct a sensitivity analysis. We included the following data in the full dataset: type of laws (encouraged, mandatory, or conditional mandatory), date passed, effective date, frequency of training, and length of training.

RESULTS

In 2022, 49 states and the District of Columbia had GTLs, 31 of which were mandatory laws. In 2002, only 6 states had such laws, and none were mandatory.

CONCLUSION

The growing proliferation of laws on suicide prevention training for school staff warrants evaluation of the laws' effectiveness. Our policy surveillance data may be used to better understand the role of these laws in a school-based approach to youth suicide prevention.

Development of an implementation plan for a school-based multimodal approach for depression and suicide prevention in adolescents

Strong Teens and Resilient Minds (STORM) is a multimodal, school-based approach for depression and suicide prevention in adolescents that is currently implemented in a region in the Netherlands. The STORM approach will be implemented in new regions in the coming years. This study used the implementation mapping protocol to report on the development of the STORM implementation plan. First, a needs assessment was conducted through semi-structured interviews with stakeholders and brainstorming sessions with regional programme leaders in the two regions that started implementing STORM in 2023. This led to the identification of six main barriers to implementation: high level of demands for schools, insufficient understanding of the programme content, insufficient network collaboration, no perceived relative advantage of STORM by stakeholders, lack of attention to sustainability, and high work pressure. Second, performance and change objectives were formulated based on these barriers. For example, a performance objective for potential providers was that they felt supported by STORM. Third, implementation strategies were selected from theory and translated into practical applications through brainstorming sessions with programme leaders. The following strategies were included in the implementation plan: collaborate with similar initiatives within the region, free up time for STORM tasks, tailor strategies, identify and prepare STORM champions, and promote network weaving. Last, a plan to evaluate the implementation of STORM and the application of the STORM implementation plan was formulated. Planned evaluation research will provide more insight into the usefulness and impact of the STORM implementation plan.

Educational agents and institutions called into action in suicide prevention, intervention, and postvention

Introduction

Suicide is the second leading cause of death in the 15 to 29 age group worldwide, and is a severe public health problem. Adolescent and young adult individuals attend educational institutions which can play an essential role in detecting and preventing suicide. For this reason, the purpose of this research is to identify what educational institutions and agents are called into action in suicide prevention, intervention, and postvention.

Methods

The method of systematic review of the literature based on the PRISMA protocol was used. The review protocol was registered in PROSPERO (PROSPERO 2020 CRD42020189127). The systematic review yielded 66 articles published between 1990 and February 2023.

Results

The results show that a wide variety of educational stakeholders are required to intervene for suicide prevention, interventions and postvention between primary education and college. The study describes the different programs that have been provided, the countries in which they have been implemented and the agents who have been targeted. It also identifies gaps in the research on suicide in the educational field.

Discussion

Overall, educational suicide initiatives report positive effects on participants' understanding, attitudes, and beliefs regarding suicide and suicide prevention, although some studies have expressed some caution.

School-based Mental Health Supports During COVID-19: School Professional Perspectives

Objective

The present study explored the ways school professionals adapted school-based mental health supports and services for remote delivery during the COVID-19 pandemic.

Method

We surveyed 81 school professionals (e.g., counselors, psychologists, social workers) and conducted in-depth interviews with a subsample of professionals (n=14) to explore their perceptions and experiences of supporting youth with mental health concerns and suicide-related risk during the fall and winter of the 2020-2021 school year.

Results

Commonly endorsed school-based mental health interventions (e.g., counseling services, checking in), ways of communicating (phone, email), and individuals delivering supports and services to students with suicide-related risk (e.g., counselors, teachers) were identified based on school professional survey responses. Qualitative findings point to facilitators (e.g., specific platforms for connecting with students and families) and barriers (e.g., limited communication) to successful service delivery during COVID-19.

Conclusion

Findings highlight the creative ways school support professionals adapted to provide school-based mental health supports. Implications for remote school-based mental health services during and following the pandemic are discussed.

Preventing Youth Suicide: A Review of School-Based Practices and How Social-Emotional Learning Fits Into Comprehensive Efforts

Schools in the United States increasingly incorporate social-emotional learning (SEL) as a part of comprehensive youth suicide prevention programs in schools. We reviewed the literature to investigate the inclusion of SEL in youth suicide prevention efforts. We identified several known risk factors to youth suicide, namely, hopelessness, anxiety, substance use, and child sexual abuse, then cross-walked that review to SEL competencies shown to mitigate each of those known risk factors. We found all SEL competencies, to some extent, across all the evidence-based, school-based youth suicide prevention programs we identified. Further, we found that all five SEL competencies are shown directly to address and mitigate the major, known risk factors for youth suicide. These findings suggest that SEL can play a productive role in upstream youth suicide prevention. State-level policy makers and school administrators should consider the inclusion of evidence-based SEL in efforts to address youth suicide prevention.

A Systematic Review of School-Based Suicide Prevention Interventions for Adolescents, and Intervention and Contextual Factors in Prevention

Suicide is the fourth leading cause of death among adolescents, globally. Though post-primary, school-based suicide prevention (PSSP) has the potential to be a key strategy for preventing adolescent suicidal thoughts and behaviours (STBs), there are persisting challenges to translating PSSP research to practice. Intervention and contextual factors relevant to PSSP are likely key to both PSSP effectiveness and implementation. As such, this systematic review aimed to summarise the effectiveness of PSSP for adolescent STBs and highlight important intervention and contextual factors with respect to PSSP. PsycINFO, Medline, Education Source, ERIC, Web of Science, and the Cochrane Central Register of Controlled Trials were searched to identify randomised and non-randomised studies evaluating the effectiveness of interventions located in post-primary, school-based settings targeting adolescent STBs. PSSP effectiveness and intervention and contextual factors were synthesised narratively. Twenty-eight studies were retained, containing nearly 47,000 participants. Twelve out of twenty-nine trials comparing intervention and independent control comparators reported statistically significant reductions in STBs postintervention, and 5/7 trials comparing preintervention and postintervention scores demonstrated significant reductions in STBs over time. Reporting and analysis of intervention and contextual factors were lacking across studies, but PSSP effectiveness and intervention acceptability varied across type of school. Although school personnel commonly delivered PSSP interventions, their input and perspectives on PSSP interventions were lacking. Notably, adolescents had little involvement in designing, inputting on, delivering and sharing their perspectives on PSSP interventions. Twenty out of twenty-eight studies were rated as moderate/high risk of bias, with non-randomised trials demonstrating greater risks of bias and trial effectiveness, in comparison to cluster randomised trials. Future research should prioritise complete reporting and analysis of intervention and contextual factors with respect to PSSP, involving key stakeholders (including adolescents and school personnel) in PSSP, and investigating key stakeholders' perspectives on PSSP. Given the inverse associations between both study quality and study design with PSSP effectiveness, particular consideration to study quality and design in PSSP research is needed. Future practice should consider PSSP interventions with universal components and PSSP which supports and involves key stakeholders in engaging with PSSP.

Vaping and Sleep as Predictors of Adolescent Suicidality

PURPOSE

To investigate sleep quantity as a moderator of vaping and self-reported suicidality among adolescents.

DESIGN

Cross-sectional. Setting: United States high schools.

SAMPLE

10,520 high-school students with complete data on the primary outcome of suicide attempt in the past year (76.9% response rate).

MEASURES

2019 Youth Risk Behaviors Survey.

ANALYSIS

Logistic regression to examine main effects and potential moderation.

RESULTS

Students with under seven sleep hours on school nights (OR = 2.6; 95% CI = 2.1-3.3) and who vaped in the past month (OR = 3.0; 95% CI = 2.1-3.9) had higher odds of attempting suicide in the last year. Sleep quantity moderated the relationship between vaping and suicidal thoughts in the past year (P = .01) but did not moderate the relationship between vaping and a suicide plan (P = .15) or suicide attempts (P = .06). Specifically, vaping had a smaller effect on suicidal thoughts among students who slept under seven hours on school nights (OR = 1.8) compared to the descriptively larger effect among participants with more sleep (OR = 2.5).

CONCLUSIONS

Students who vape or report low sleep quantity would be ideal participants in suicide prevention interventions as they may be at higher risk for suicidality. Organizations implementing sleep or vaping interventions should incorporate information regarding the higher odds of suicide among students with low sleep quantity or vaping habits.

Worry-related sleep problems and suicidal thoughts and behaviors among adolescents in 88 low-, middle-, and high-income countries: an examination of individual- and country-level factors

A strong association between sleep problems and suicidal thoughts and behaviors (STBs) has been demonstrated in high-income countries. The sleep-STB relationship, however, is minimally understood among youth in low and middle-incomes countries. There also is a limited understanding of how individual- (i.e., age, sex) and country-level (i.e., economic inequality, economic quality) factors may moderate the magnitude of the sleep-STB association among youth. Data were analyzed from the cross-national Global School-based Health Survey 2003-2017, which assessed a range of health behaviors among school-enrolled adolescents aged 11-18 years from 88 low-, lower-middle, upper-middle, and high-income countries. Multilevel models were used to examine the influence of individual- and country-level factors on the association between past-year worry-related sleep problems and past-year suicide ideation, suicide plans, and suicide attempts. Worry-related sleep problems were significantly associated with suicide ideation, plans, and attempts. Adolescent sex, country economic quality (income group designation), and country economic inequality moderated the sleep-STB association, but age did not. The sleep-STB relationship was stronger for males and across macroeconomic indices, the relationship was generally strongest among upper-middle income countries (economic quality) and countries with a big income gap (economic inequality). When examining how individual-level factors differentially affected the sleep-STB relationship within economic quality (income group designation), the effects were driven by older adolescents in high-income countries for suicide ideation and suicide plans. Study findings suggest an important role for global macroeconomic factors, for males, and older adolescents in high-income countries in the sleep-STB relationship. Future directions include expanding worldwide coverage of countries, assessing a wider range of sleep problems, and longitudinal work to understand potential mechanisms in the sleep-STB relationship.

The developmental origins of suicide mortality: a systematic review of longitudinal studies

Suicide prevention efforts generally target acute precipitants of suicide, though accumulating evidence suggests that vulnerability to suicide is partly established early in life before acute precipitants can be identified. The aim of this systematic review was to synthesize evidence on early life vulnerability to suicide beginning in the prenatal period and extending through age 12. We searched PubMed, Embase, PsycNet, Web of Science, Scopus, Social Services Abstracts, and Sociological Abstracts for prospective studies published through January 2021 that investigated early life risk factors for suicide mortality. The search yielded 13,237 studies; 54 of these studies met our inclusion criteria. Evidence consistently supported the link between sociodemographic (e.g., young maternal age at birth, low parental education, and higher birth order), obstetric (e.g., low birth weight), parental (e.g., exposure to parental death by external causes), and child developmental factors (e.g., exposure to emotional adversity) and higher risk of suicide death. Among studies that also examined suicide attempt, there was a similar profile of risk factors. We discuss a range of potential pathways implicated in these associations and suggest that additional research be conducted to better understand how early life factors could interact with acute precipitants and increase vulnerability to suicide.

Loneliness and self-harm in adolescents during the first national COVID-19 lockdown: results from a survey of 10,000 secondary school pupils in England

Adolescents' loneliness and self-harm have received considerable attention during the COVID-19 pandemic with concerns that the socioecological changes taking place would contribute to an escalation of both loneliness and self-harm. However, empirical evidence is scant. We estimated the prevalence of loneliness and self-harm in adolescent school pupils and investigated the association of loneliness and change in loneliness during the UK's first lockdown with self-harm during lockdown in a cross-sectional school survey (OxWell) involving 10,460 12-18-year-olds from south England. Loneliness was measured with four items. Self-harm was ascertained through a detailed questionnaire. The prevalence of loneliness and self-harm were estimated applying post-stratification weights to account for differences between the study sample and the target population. The associations between indicators of loneliness and self-harm were examined using mixed effect models. 1,896 of 10,460 adolescents (18.1%) reported feeling lonely 'often' (weighted proportion 16.8%). 3,802/10,460 (36.4%; weighted proportion 35%) felt more lonely since lockdown. Self-harm during lockdown was reported by 787/10,460 adolescents (7.5%; weighted proportion 6.7%). Controlling for confounders, adolescents who reported feeling lonely 'often' [adjusted odds ratio (aOR) 2.8, 95% CI 2.1-3.9, p < 0.0001] or 'sometimes' (aOR 2.2, 95% CI 1.5-3.2, p < 0.0001) were more likely to self-harm during lockdown relative to adolescents who reported 'never' or 'hardly ever' feeling lonely. Exacerbation in loneliness during lockdown was associated with an increase in the odds of self-harm during lockdown. Loneliness, heightened loneliness and self-harm were common during lockdown and closely linked. It is important to support schools in address loneliness and self-harm as part of efforts to improve well-being as the long tail of the pandemic continues to impact on child and adolescent mental health. Understanding how loneliness and self-harm may co-vary could be important for future self-harm reduction strategies in young persons.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12144-022-03651-5.

Systematic review of suicide prevention studies with data on youth and young adults living in low-income and middle-income countries

OBJECTIVES

This review aimed to provide a summary of peer-reviewed, published literature on suicide preventive interventions with data on youth and young adults in low-income and middle-income countries (LMIC).

DESIGN

A systematic review was conducted using electronic databases of PubMed/MEDLINE, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Education Resources Information Center and The Campbell Collaboration databases for English-language articles published between 1 January 1990 and 15 February 2022.

ELIGIBILITY CRITERIA

Interventions of interest could include behavioural, community, clinical/medical or policy studies, or any combination of these, so long as the studies had at least one outcome of interest and at least one control group or control period. Outcomes included suicide ideation, suicide attempt and suicide. Interventions must have been conducted in an LMIC. Studies with individuals ages 0-25 in the sample were included. Articles describing data on individuals over age 25 could be included if individuals ages 0-25 were part of the sample.

RESULTS

A total of 44 eligible studies were identified, representing a broad range of universal, selective and indicated interventions. Most studies assessed interventions designed to address lethal means or mental health. Most studies were conducted in lower-middle-income or upper-middle-income countries, with the largest proportion in Asia. Assessment of outcomes across studies was heterogeneous and there were few large-scale investigations tailored specifically for youth.

CONCLUSIONS

Most of the published, peer-reviewed suicide intervention research from LMIC is concentrated in a few countries. While geographical coverage to date has been limited, strategies and samples in included studies were diverse, representing populations in clinical, educational and community settings. While current findings hold promise, this review identified a need for large-scale studies designed specifically for youth.

Efficacy of interventions for suicide and self-injury in children and adolescents: a meta-analysis

Despite increased numbers of children and adolescents seeking and receiving mental health treatment, rates of self-injurious thoughts and behaviors (SITBs) in youth are rising. In the hopes of aiding ongoing efforts to alleviate the burden of SITBs in this vulnerable population, the present study summarizes current knowledge on the efficacy of SITB interventions in children and adolescents. We conducted a meta-analysis of randomized controlled trials (RCTs) assessing treatment effects on SITBs in child and adolescent populations. A total of 112 articles comprising 558 effect sizes were included in analyses. Nearly all interventions produced nonsignificant reductions in SITBs. For binary SITB outcomes, a nonsignificant treatment effect was detected, with an RR of 1.06 (95% CIs [0.99, 1.14]). For continuous SITB outcomes, analyses also yielded a nonsignificant treatment effect (g = - 0.04 [- 0.12, 0.05]). These patterns were largely consistent across SITB outcomes, regardless of intervention type, treatment components, sample and study characteristics, and publication year. Our findings highlight opportunities for improving SITB intervention development and implementation in child and adolescent populations. The most efficacious interventions are likely to directly target the causes of SITBs; therefore, future research is needed to identify the causal processes underlying the onset and maintenance of SITBs in youth.

Scoping review of 30 years of suicide prevention in university students around the world: efficacy, effectiveness, and cost-effectiveness

A scoping review of systematic reviews was carried out to identify evidence of efficacy, effectiveness, and cost-effectiveness of universal and selective suicide prevention programs among university students worldwide. Five databases were reviewed using terms in English, Spanish, and Portuguese. The following were the inclusion criteria: systematic review or meta-analysis or meta-synthesis, suicide prevention in college students, evaluation of the efficacy, effectiveness and/or cost-effectiveness of interventions, and peer-reviewed studies. The quality of reviews was assessed. The field of study features three decades of publication in high-income countries. The strategy used, the components of the program, and the target audience to which they are delivered interfere with efficacy. In the psychoeducation strategy, the experiential and didactic components are more efficacious in the knowledge about suicide. And the motivational enhancement component promotes greater self-efficacy in suicide prevention. Programs that take a multimodal approach are effective in increasing short-term attitudes related to suicide and reducing rates of completed suicide. The gatekeeper strategy delivered to peer counselors is the most effective one in the outcomes, including short-term and long-term knowledge about suicide and its prevention and self-efficacy in suicide prevention. A greater number of evaluated studies of gatekeeper interventions were identified, indicating a trend in this research field. No review addressed the effects on subgroups that were classified based on sex, racial or sexual minorities, and special (indigenous) populations. Only one study addressed cost-effectiveness, pointing out that the psychoeducation and gatekeeper strategies have relevant net benefit rates, but the gatekeeper strategy has a higher cost–benefit ratio compared to the psychoeducation strategy. The findings indicate that psychoeducation and gatekeeper interventions tend to be more efficacious when they combine education and skills training to intervene in suicidal behavior. The components of the intervention and the target audience to which it is delivered influence efficacy. Multimodal interventions evaluate completed suicide outcomes, but require greater implementation efforts, in terms of human and financial resources and more time for the evaluation.

Utilization and Acceptability of Formal and Informal Support for Adolescents Following Self-Harm Before and During the First COVID-19 Lockdown: Results From a Large-Scale English Schools Survey

Background

Little is known about the perceived acceptability and usefulness of supports that adolescents have accessed following self-harm, especially since the onset of the COVID-19 pandemic.

Aims

To examine the utilization and acceptability of formal, informal, and online support accessed by adolescents following self-harm before and during the pandemic.

Method

Cross-sectional survey (OxWell) of 10,560 secondary school students aged 12-18 years in the south of England. Information on self-harm, support(s) accessed after self-harm, and satisfaction with support received were obtained via a structured, self-report questionnaire. No tests for significance were conducted.

Results

1,457 (12.5%) students reported having ever self-harmed and 789 (6.7%) reported self-harming during the first national lockdown. Informal sources of support were accessed by the greatest proportion of respondents (friends: 35.9%; parents: 25.0%). Formal sources of support were accessed by considerably fewer respondents (Child and Adolescent Mental Health Services: 12.1%; psychologist/ psychiatrist: 10.2%; general practitioner: 7.4%). Online support was accessed by 8.6% of respondents, and 38.3% reported accessing no support at all. Informal sources of support were rated as most helpful, followed by formal sources, and online support. Of the respondents who sought no support, 11.3% reported this as being helpful.

Conclusions

More than a third of secondary school students in this sample did not seek any help following self-harm. The majority of those not seeking help did not find this to be a helpful way of coping. Further work needs to determine effective ways of overcoming barriers to help-seeking among adolescents who self-harm and improving perceived helpfulness of the supports accessed.

Adolescent suicide attempts in the United States: When suicide ideation and suicide capability interact

INTRODUCTION

Guided by the interpersonal theory of suicide, this study examined whether the relationship between level of suicide ideation and attempted suicide varies as a function of suicide capability.

METHODS

Cross-sectional data were obtained from the 2017 and 2019 Youth Risk Behavior Survey in which 28,442 respondents were sampled. Confirmatory factor analysis was conducted to create a latent suicide capability variable. Structural equation modeling was used to test the moderating effects of suicide capability on the relationship between level of suicide ideation and attempted suicide, adjusting for sociodemographic characteristics, sadness/hopelessness, and the sampling design.

RESULTS

Compared to adolescent with no reported ideation, those reporting single and dual ideation experienced increased odds of attempted suicide. The relationship between level of suicide ideation and attempted suicide significantly varied as a function of capability. While adolescents with dual suicide ideation experienced higher rates of attempted suicide at increasing levels of capability, faster rates of change of attempted suicide at increasing levels of capability were observed among those with single and no reported ideation.

CONCLUSION

Capability may heighten the risk of suicide attempts among youth, suggesting that treatment efforts could be directed at reducing exposure to painful and provocative experiences associated with suicide behaviors.

Quo vadis? Problems of prevention of suicidal behavior in adolescents (narrative review)

Among the existing problems related to the health and quality of life of Russian youth, the topic of suicidal behavior is the most biased, but at the same time the least solvable in a practical sense. This is due to the fact that suicide is an integrative phenomenon, and the suicidal act itself is interpreted in essence as the tip of the iceberg. Especially clearly manifested in adolescence is the fact that suicidal readiness is associated not so much with the level of severity of mental pathology and personality dysfunction, but with the general social context of total trouble. In this regard, suicide prevention cannot be based only on the timely identification of persons at risk for mental pathology. The purpose of this article is to provide a meaningful overview of modern integrated prevention programs that have shown to be effective in reducing the level of suicidal behavior among young people, compared with isolated approaches. The article discusses the problems associated with the implementation and evaluation of the effectiveness of such preventive programs, and also suggests approaches that allow them to be adapted in the public health system and, in particular, in the clinical practice of psychiatrists.

Mental Health Difficulties Related to Suicidal Behavior in Adolescents: The Moderating Role of Self-Esteem

OBJECTIVE

The objective was to analyze the moderating effect of self-esteem on the relationship between mental health difficulties and suicidal behavior in adolescence.

METHOD

The sample was composed of 1,790 Spanish adolescents (M = 15.70 years; SD = 1.26; 53.7% girls) through a stratified random sampling by cluster at classroom level. The participants completed questionnaires about emotional symptoms, behavioral problems, peer relationship difficulties, hyperactivity, suicidal behavior, and self-esteem.

RESULTS

The results evidenced gender differences, showing that girls tend to have more emotional symptoms (t = -15.27; p ≤ .001; d = -0.71), more difficulties in peer relationship (t=-2.49; p = .013; d = -0.12) and less self-esteem (t = 12.15; p ≤ .001; d = 0.57), as well as more suicidal behaviors (t = -5.36; p ≤ .001; d = -0.25) than boys. It is also noted that emotional and behavioral difficulties influence suicidal behavior (R² = 0.35; ΔF = 197.42; p ≤ .001). In addition, self-esteem appeared to act as a protective factor, buffering the relationship between emotional and behavioral problems and suicidal behavior (R² = 0.39; F = 376.92; p ≤ .001).

CONCLUSIONS

Adolescents who present mental health difficulties might commit suicidal behavior if they have an unfavorable attitude toward themselves. However, the risk of committing suicidal behavior decreases if their attitude toward themselves is favorable. Thus, the development of self-esteem may be included in intervention programs for the prevention of suicidal behavior.HIGHLIGHTSGirls present more suicidal behaviors and less self-esteem than boys.Mental health difficulties influence the appearance of suicidal behavior.Self-esteem moderates the relationship between emotional problems and suicidal behavior.

Saving Lives: A Systematic Review on the Efficacy of Theory-Informed Suicide Prevention Programs

Suicide is a global epidemic. This review assessed the scope and effectiveness of suicide prevention programs. Systematic literature searches were conducted using PsycINFO, ERIC and MEDLINE to retrieve articles published between January 2007 and March 2017 and fulfilled inclusion criteria (studies evaluating the efficacy of theory/model-informed suicide prevention programs in increasing participant knowledge or skills when presented with a peer at risk of suicide). The review is informed by PRISMA guidelines. Of 1398 studies identified, 25 were reviewed and most: targeted professionals; were 1-4-day workshops; were underpinned by 21 different theories; taught less detail to the community than professionals; and improved target outcomes. Current programs, although effective, are limited by their inaccessibility, narrow content for the community and substantial variability in theory base. Future suicide prevention programs will benefit from being informed by a more specific theory, delivered through technology, targeting more of the community and improving methodological rigour.

Under the Surface: The Role of Covert Cues in Peer Suicide Risk Referrals

Suicidal thoughts and behaviors are highly prevalent among adolescents, and peers are often the first, and sometimes only, people to know about youth suicidality. Since many adolescents do not directly disclose suicidal thoughts, school-based suicide prevention programs aim to train youth to recognize warning signs of suicide in their peers that serve as "cues" to refer at-risk peers to an appropriate adult. However, peer-presented cues vary widely in presentation, and adolescents are more likely to recognize overt (i.e., obvious or explicit) as opposed to covert (i.e., hidden or implied) cues. The type of cue exhibited may, in turn, affect whether adolescents make a referral to an adult. The current study examined whether training suicide prevention influences referral intentions for overt and covert suicide cues. Participants included 244 high school students (54% female; M _age = 16.21) in the Southeastern United States who received suicide prevention training (SOS; Signs of Suicide) as part of their health curriculum. Prior to training, students endorsed higher referral intentions for peers exhibiting overt compared to covert cues. Training was associated with increased intentions to refer peers across cue type, but referral intentions for covert cues improved significantly from pre to post-training while those for overt cues remained high and stable. Findings suggest that suicide prevention training might differentially improve students' ability to detect and respond appropriately to less obvious indicators of suicide risk. These findings may inform the adaptation and development of future, more nuanced school-based suicide prevention programming.

Early Age of Cannabis Initiation and Its Association With Suicidal Behaviors

Background:

Suicide rates in the U.S. have continued to rise over the last 2 decades. The increased availability and broader legalization of cannabis is a public health concern, particularly among adolescents. The objective of this study was to examine the association between the age of cannabis initiation and lifetime suicidal ideations and attempts in a sample of adults aged 18 or older.

Methods:

Data are from the Collaborative Psychiatric Epidemiology Surveys (CPES), 2001 to 2003 (N = 15 238). The primary objective of the CPES was to collect data about the prevalence of mental disorders, impairments associated with these disorders, and their treatment patterns from representative samples of majority and minority adult populations in the U.S. Logistic regression analyses were conducted to test the association between cannabis initiation age (early ⩽14 years old; later >14 years old) and outcomes of lifetime suicide ideation and attempts. Cigarette use, cannabis use, gender, income, race, education, and age were controlled for the analyses.

Results:

Overall, 12.5% of participants reported suicide ideation, while 4.2% reported attempt. Early cannabis use was associated with a higher risk of suicide ideation (AOR = 3.32, 95% CI [2.75, 3.80]) than later cannabis use (AOR = 2.15, 95% CI [1.92, 2.39]). Early cannabis use was associated with a higher risk of suicide attempt (AOR = 4.38, 95% CI [3.48, 5.52]) than later cannabis use (AOR = 2.56, 95% CI [2.14, 3.06]). Wald chi-squared tests revealed significant differences between the early and late initiation for both ideation (χ2 = 26.99; P < .001) and attempts (χ2 = 26.02; P < .001).

Conclusions:

Significant associations were found between early initiation of cannabis and suicide behaviors. As suicide rates continue to rise, it is recommended that clinicians, treatment providers, and other professionals consider the use of cannabis at an early age as a risk for subsequent suicide behaviors.

Preparing for the Impact of COVID-19 on the Mental Health of Youth

The COVID-19 pandemic is continuing to have long-term and global effects that the vaccine may not ease. Children and adolescents endured unprecedented periods of loneliness, social isolation, financial stressors, in-home conflicts, changes in living circumstances, and variable access to healthcare, resulting in increased mental health sequelae. Timely recognition of students’ anxiety, depression, and disruptive behaviors will allow appropriate interventions to de-escalate these feelings and prevent suicidal ideations and attempts. As youth return to school, their mental health needs will not subside. School nurses and the multidisciplinary team have a vital role in impacting this population’s already surging increase of mental and behavioral health disorders.

Effects of polygenic risk for suicide attempt and risky behavior on brain structure in young people with familial risk of bipolar disorder

Bipolar disorder (BD) is associated with a 20-30-fold increased suicide risk compared to the general population. First-degree relatives of BD patients show inflated rates of psychopathology including suicidal behaviors. As reliable biomarkers of suicide attempts (SA) are lacking, we examined associations between suicide-related polygenic risk scores (PRSs)-a quantitative index of genomic risk-and variability in brain structures implicated in SA. Participants (n = 206; aged 12-30 years) were unrelated individuals of European ancestry and comprised three groups: 41 BD cases, 96 BD relatives ("high risk"), and 69 controls. Genotyping employed PsychArray, followed by imputation. Three PRSs were computed using genome-wide association data for SA in BD (SA-in-BD), SA in major depressive disorder (SA-in-MDD) (Mullins et al., 2019, The American Journal of Psychiatry, 176(8), 651-660), and risky behavior (Karlsson Linnér et al., 2019, Nature Genetics, 51(2), 245-257). Structural magnetic resonance imaging processing employed FreeSurfer v5.3.0. General linear models were constructed using 32 regions-of-interest identified from suicide neuroimaging literature, with false-discovery-rate correction. SA-in-MDD and SA-in-BD PRSs negatively predicted parahippocampal thickness, with the latter association modified by group membership. SA-in-BD and Risky Behavior PRSs inversely predicted rostral and caudal anterior cingulate structure, respectively, with the latter effect driven by the "high risk" group. SA-in-MDD and SA-in-BD PRSs positively predicted cuneus structure, irrespective of group. This study demonstrated associations between PRSs for suicide-related phenotypes and structural variability in brain regions implicated in SA. Future exploration of extended PRSs, in conjunction with a range of biological, phenotypic, environmental, and experiential data in high risk populations, may inform predictive models for suicidal behaviors.

Association of Online Risk Factors With Subsequent Youth Suicide-Related Behaviors in the US

IMPORTANCE

The association between online activities and youth suicide is an important issue for parents, clinicians, and policy makers. However, most information exploring potential associations is drawn from survey data and mainly focuses on risk related to overall screen time.

OBJECTIVE

To evaluate the association between a variety of online risk factors and youth suicide-related behavior using real-world online activity data.

DESIGN, SETTING, AND PARTICIPANTS

A matched case-control study was conducted from July 27, 2019, to May 26, 2020, with the sample drawn from more than 2600 US schools participating in an online safety monitoring program via the Bark online safety tool. For 227 youths having a severe suicide/self-harm alert requiring notification of school administrators, cases were matched 1:5 to 1135 controls on location, the amount of follow-up time, and general volume of online activity.

EXPOSURES

Eight potential online risk factors (cyberbullying, violence, drug-related, hate speech, profanity, sexual content, depression, and low-severity self-harm) through assessment of text, image, and video data.

MAIN OUTCOMES AND MEASURES

Severe suicide/self-harm alert requiring notification of school administrators; severe suicide alerts are statements by youths indicating imminent or recent suicide attempts and/or self-harm.

RESULTS

The 1362 participants had a mean (SD) age of 13.3 (2.41) years; 699 (51.3%) were male. All 8 online risk factors studied exhibited differences between case and control populations and were significantly associated with subsequent severe suicide/self-harm alerts when examining total direct and indirect pathways. These associations ranged from an adjusted odds ratio (aOR) of 1.17 (95% CI, 1.09-1.26) for drug-related content to an aOR of 1.82 (95% CI, 1.63-2.03) for depression-related content. When considering the total number of different types of online risk factors among the 8 measured, there was an exponentially larger risk of severe suicide/self-harm alerts; youths with 5 or more of the 8 risk factors present in their online activity had a more than 70-fold increased odds of subsequently having a severe suicide/self-harm alert (aOR, 78.64; 95% CI, 34.39-179.84).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that many discrete types of risk factors are identifiable from online data and associated with subsequent youth suicide-related behavior. Although each risk factor carries a specific association with suicide-related behavior, the greatest risk is evident for youths demonstrating multiple types of online risk factors.

Suicide prevention in childhood and adolescence: a narrative review of current knowledge on risk and protective factors and effectiveness of interventions

INTRODUCTION

Suicide is a global mental health problem for people of all ages. While rates of suicide in children and adolescents are reported as lower than those in older populations worldwide, they represent the third leading cause of death in 15-19-year-olds. The rates are higher among boys than girls worldwide, though the death rates for girls exceed those for boys in Bangladesh, China, India, and Nepal. There has been a general decrease in adolescent suicide rates over recent decades. However, increases are reported in South East Asia as well as South America over the same time period.

METHODS

A narrative review method has been used to summarize current knowledge about risk and protective factors for suicide among children and adolescents and to discuss evidence-based strategy for suicide prevention in this age group.

RESULTS

Identified suicide risk and protective factors for children and adolescents largely overlap with those for adults. Nevertheless, developmental characteristics may strengthen the impact of some factors, such as decision-making style, coping strategies, family and peer relationships, and victimization. The implementation of evidence-based suicide preventive strategies is needed. Restricting access to lethal means, school-based awareness and skill training programs, and interventions delivered in clinical and community settings have been proven effective. The effectiveness of gatekeeper training and screening programs in reducing suicidal ideation and behavior is unproven but widely examined in selected settings.

DISCUSSION

Since most studies have been conducted in western countries, future research should assess the effectiveness of these promising strategies in different cultural contexts. The use of more rigorous study designs, the use of both short- and long-term follow-up evaluations, the larger inclusion of individuals belonging to vulnerable groups, the evaluation of online intervention, and the analysis of programs' cost-effectiveness are also required.

Online interventions to prevent mental health problems implemented in school settings: the perspectives from key stakeholders in Austria and Spain

BACKGROUND

Schools are key settings for delivering mental illness prevention in adolescents. Data on stakeholders' attitudes and factors relevant for the implementation of Internet-based prevention programmes are scarce.

METHODS

Stakeholders in the school setting from Austria and Spain were consulted. Potential facilitators (e.g. teachers and school psychologists) completed an online questionnaire (N=50), policy makers (e.g. representatives of the ministry of education and health professional associations) participated in semi-structured interviews (N=9) and pupils (N=29, 14-19 years) participated in focus groups. Thematic analysis was used to identify experiences with, attitudes and needs towards Internet-based prevention programmes, underserved groups, as well as barriers and facilitators for reach, adoption, implementation and maintenance.

RESULTS

Experiences with Internet-based prevention programmes were low across all stakeholder groups. Better reach of the target groups was seen as main advantage whereas lack of personal contact, privacy concerns, risk for misuse and potential stigmatization when implemented during school hours were regarded as disadvantages. Relevant needs towards Internet-based programmes involved attributes of the development process, general requirements for safety and performance, presentation of content, media/tools and contact options of online programmes. Positive attitudes of school staff, low effort for schools and compatibility to schools' curriculum were seen as key factors for successful adoption and implementation. A sound implementation of the programme in the school routine and continued improvement could facilitate maintenance of online prevention initiatives in schools.

CONCLUSIONS

Attitudes towards Internet-based mental illness prevention programmes in school settings are positive across all stakeholder groups. However, especially safety concerns have to be considered.

Systematic review and narrative synthesis of suicide prevention in high-schools and universities: a research agenda for evidence-based practice

Background

Youth suicide prevention in high-schools and universities is a public health priority. Our aim was to propose a research agenda to advance evidence-based suicide prevention in high-schools and universities by synthesizing and critically reviewing the research focus and methodologies used in existing intervention studies.

Methods

Fourteen databases were systematically searched to identify studies which evaluate suicide prevention interventions delivered on high-school or university campuses, with before and after measures. Data from included studies (n = 43) were extracted to identify what, where, how and for whom interventions have been tested. Narrative synthesis was used to critically evaluate research focus and methodology. Study quality was assessed.

Results

Research has focused primarily on selective interventions, with less attention on indicated and universal interventions. Most evidence comes from North America and high-income countries. The target of interventions has been: non-fatal suicidal behaviour; confidence and ability of staff/students to intervene in a suicidal crisis; suicide-related knowledge and attitudes; and suicide-related stigma. No studies included suicide deaths as an outcome, evaluated eco-systemic interventions, explored how context influences implementation, used multisite study designs, or focused explicitly on LGBTQ+ youth. Two studies evaluated digital interventions. Quality of the majority of studies was compromised by lack of methodological rigour, small samples, and moderate/high risk of bias. Interventions often assume the existence of an external well-functioning referral pathway, which may not be true in low-resource settings.

Conclusion

To advance evidence-based suicide prevention in educational settings we need to: conduct more high-quality clinical and pragmatic trials; promote research in low- and middle-income countries; test targeted interventions for vulnerable populations (like LGBTQ+ youth), evaluate interventions where death by suicide is the primary outcome; include translational studies and use implementation science to promote intervention uptake; evaluate the potential use of digital and eco-systemic interventions; and conduct multisite studies in diverse cultural settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11124-w.

Dos and Don'ts in Designing School-Based Awareness Programs for Suicide Prevention

Abstract.Background: Despite the promising evidence for the effectiveness of school-based awareness programs in decreasing the rates of suicidal thoughts and suicide attempts in young people, no guidelines on the targets and methods of safe and effective awareness programs exist. Aims: This study intends to distill recommendations for school-based suicide awareness and prevention programs from experts. Method: A three-stage Delphi survey was administered to an expert panel between November 2018 and March 2019. A total of 214 items obtained from open-ended questions and the literature were rated in two rounds. Consensus and stability were used as assessment criteria. Results: The panel consisted of 19 participants in the first and 13 in the third stage. Recommended targets included the reduction of suicide attempts, the enhancement of help-seeking and peer support, as well as the promotion of mental health literacy and life skills. Program evaluation, facilitating access to healthcare, and long-term action plans across multiple levels were among the best strategies for the prevention of adverse effects. Limitations: The study is based on opinions of a rather small number of experts. Conclusion: The promotion of help-seeking and peer support as well as facilitating access to mental health-care utilities appear pivotal for the success of school-based awareness programs.

Impact of a School-Based, Multi-Tiered Emotional and Behavioral Health Crisis Intervention on School Safety and Discipline

Schools across the United States are struggling with how to formulate comprehensive and effective programs to address the mental health needs of students and to promote school safety. This study, funded as part of the National Institute of Justice Comprehensive School Safety Initiative, employed a randomized controlled study design to evaluate the impact of a multi-component package of crisis prevention and response interventions on school safety and discipline outcomes, including suspensions, office discipline referrals, bullying reports, juvenile justice referrals, threat assessments, and follow-up procedures. Forty schools participated, all in a culturally diverse Mid-Atlantic, US school system spanning urban, suburban, and rural areas. The Emotional and Behavioral Health-Crisis Response and Prevention (EBH-CRP) intervention is a comprehensive training, organizational, and support protocol for school and community stakeholders aimed at increasing competence in preventing and responding to student EBH crises using multiple evidence-informed strategies that address emotional and behavioral health concerns across the continuum of supports. Results indicate that the EBH-CRP intervention had a significant positive effect on suspensions, office discipline referrals, and juvenile justice referrals for secondary schools. In addition, the intervention had positive effects on the number of bullying reports overall, with a particularly strong impact on primary schools. The intervention also had positive effects in maintaining more use of threat assessment and follow-up procedures. Although the intervention had a significant positive effect on secondary school-level suspensions, there was no impact on racial/ethnic disproportionality rates for this outcome. Implications for school safety prevention are discussed.

Youth Experiencing Homelessness with Suicidal Ideation: Understanding Risk Associated with Peer and Family Social Networks

Suicide is the leading cause of death among youth experiencing homelessness, and these youth report high rates of suicide attempts. Research suggests that the interpersonal factors of perceived burdensomeness and thwarted belongingness are proximal causes of suicide, but little is known about factors associated with these risks. The current study examined the relationship of social network characteristics, perceived social network support, and interpersonal risks for suicide among a sample of 150 youth experiencing homelessness who reported severe suicide ideation. Findings indicate that characteristics of the social network, including engagement in crime and alcohol use, interrupted the potentially protective effects of high perceived social network support for interpersonal risk factors of suicide. Findings imply that increasing perceived social network support as a protection against suicide will not be uniformly successful, and consideration of the social network characteristics is necessary. Future work needs to continue to uncover the complexity of modifiable intervention targets to prevent future suicide attempts among this high-risk group.

Non-communicable diseases among adolescents: current status, determinants, interventions and policies

BACKGROUND

Addressing non-communicable disease (NCDs) is a global priority in the Sustainable Development Goals, especially for adolescents. However, existing literature on NCD burden, risk factors and determinants, and effective interventions and policies for targeting these diseases in adolescents, is limited. This study develops an evidence-based conceptual framework, and highlights pathways between risk factors and interventions to NCD development during adolescence (ages 10-19 years) and continuing into adulthood. Additionally, the epidemiologic profile of key NCD risk factors and outcomes among adolescents and preventative NCD policies/laws/legislations are examined, and a multivariable analysis is conducted to explore the determinants of NCDs among adolescents and adults.

METHODS

We reviewed literature to develop an adolescent-specific conceptual framework for NCDs. Global data repositories were searched from Jan-July 2018 for data on NCD-related risk factors, outcomes, and policy data for 194 countries from 1990 to 2016. Disability-Adjusted Life Years were used to assess disease burden. A hierarchical modeling approach and ordinary least squares regression was used to explore the basic and underlying causes of NCD burden.

RESULTS

Mental health disorders are the most common NCDs found in adolescents. Adverse behaviours and lifestyle factors, specifically smoking, alcohol and drug use, poor diet and metabolic syndrome, are key risk factors for NCD development in adolescence. Across countries, laws and policies for preventing NCD-related risk factors exist, however those targeting contraceptive use, drug harm reduction, mental health and nutrition are generally limited. Many effective interventions for NCD prevention exist but must be implemented at scale through multisectoral action utilizing diverse delivery mechanisms. Multivariable analyses showed that structural/macro, community and household factors have significant associations with NCD burden among adolescents and adults.

CONCLUSIONS

Multi-sectoral efforts are needed to target NCD risk factors among adolescents to mitigate disease burden and adverse outcomes in adulthood. Findings could guide policy and programming to reduce NCD burden in the sustainable development era.

Influence of coping strategies on the efficacy of YAM (Youth Aware of Mental Health): a universal school-based suicide preventive program

The school-based mental health promotion and suicide prevention universal program Youth Aware of Mental Health (YAM) significantly reduces incident suicide attempts and severe suicidal ideation. This paper aims at elucidating psychological mechanisms underlying YAM's efficacy. Our hypothesis is that YAM operates through interactions with coping strategies (CS) on the reduction of suicidal ideation (SI). In the Saving and Empowering Young Lives in Europe (SEYLE) study, five coping strategies were assessed at baseline (T0) and 12-month follow-up (T12): "learning", "help-seeking", "arts", "sports" and "fight". We analyzed interactions between the YAM intervention, coping strategies and SI in the YAM group (N = 1693) and the minimal intervention group (N = 1909), after excluding prevalent cases with SI and previous suicide attempts from our total sample (N = 5654). General Linear Mixed Model regressions were performed. The present study confirms that coping strategies play an influential role on suicidal ideation. Our results showed that YAM acts whatever the prevailing coping strategies used. It is particularly efficient for pupils insufficiently using adaptive coping strategies such as LEARN and HELP-SEEKING or using maladaptive coping strategies, such as ARTS and FIGHT. The socialization induced by the YAM intervention seems to be a strong component of its efficiency.

Depressed Mood Prior to Death

Abstract. Background: Suicide is a leading cause of death among youth in the United States. Multiple factors have been shown to increase risk for suicidal behavior, including depressed mood. Aims: The purpose of this study was to examine individual characteristics and precipitating circumstances of suicide in youth decedents with and without depressed mood at the time of death. Method: Data from the National Violent Death Reporting System (NVDRS) were analyzed for 17 US states from 2003 to 2012. Participants included suicide decedents aged 10–19 years ( N = 4,053). Analyses compared youth suicide decedents with depressed mood at time of death with those without depressed mood using logistic regression. Sex-specific differences in youth with depressed mood were also explored. Results: Youth suicide decedents with depressed mood were more likely than those without depressed mood to exhibit clinical characteristics and precipitating circumstances associated with suicide. Comparison of males and females with depressed mood found unique sex-specific differences. Limitations: Data were limited to 17 states, analyses did not include a control group, and data were collected through postmortem reporting. Conclusion: Findings support a significant association between depressed mood and factors associated with suicidal behavior in youth and offer potential areas to focus prevention strategies.

Duties When an Anonymous Student Health Survey Finds a Hot Spot of Suicidality

Public health agencies regularly survey randomly selected anonymous students to track drug use, sexual activities, and other risk behaviors. Students are unidentifiable, but a recent project that included school-level analysis discovered a school with alarmingly prevalent student suicidality. Given confidentiality protocols typical of surveillance, the surveyors were uncertain whether and how to intervene. We searched literature for duties to warn at-risk groups discovered during public health surveillance, but we found no directly applicable guidance or cases. Reasoning by analogy, we conclude that surveyors should contact the school's leaders to call attention to its outlier status, but public warning is unwarranted. However, such an ad hoc decision to issue a warning, even if only to school leaders, raises significant practical, legal and ethical issues. National public health and education associations should produce guidance that clarifies ethical and legal duties owed to schools and students involved in population health-risk surveillance.

Adaptation of evidence-based suicide prevention strategies during and after the COVID-19 pandemic

Suicide is preventable. Nevertheless, each year 800,000 people die of suicide in the world. While there is evidence indicating that suicide rates de-crease during times of crises, they are expected to increase once the immediate crisis has passed. The COVID-19 pandemic affects risk and pro-tective factors for suicide at each level of the socio-ecological model. Economic downturn, augmented barriers to accessing health care, increased access to suicidal means, inappropriate media reporting at the societal level; deprioritization of mental health and preventive activities at the community level; interpersonal conflicts, neglect and violence at the relationship level; unemployment, poverty, loneliness and hopelessness at the individual level: all these variables contribute to an increase of depression, anxiety, post-traumatic stress disorder, harmful use of alcohol, substance abuse, and ultimately suicide risk. Suicide should be prevented by strengthening universal strategies directed to the entire population, including mitigation of unemployment, poverty and inequalities; prioritization of access to mental health care; responsible media reporting, with information about available support; prevention of increased alcohol intake; and restriction of access to lethal means of suicide. Selective interventions should continue to target known vulnerable groups who are socio-economically disadvantaged, but also new ones such as first responders and health care staff, and the bereaved by COVID-19 who have been deprived of the final contact with loved ones and funerals. Indicated preventive strategies targeting individuals who display suicidal behaviour should focus on available pharmacological and psychological treatments of mental disorders, ensuring proper follow-up and chain of care by increased use of telemedicine and other digital means. The scientific community, health care professionals, politicians and decision-makers will find in this paper a systematic description of the effects of the pandemic on suicide risk at the society, community, family and individual levels, and an overview of how evidence-based suicide preventive interventions should be adapted. Research is needed to investigate which adaptations are effective and in which con-texts.

Effects of perceived stress and resilience on suicidal behaviors in early adolescents

Suicidal behaviors are significant public health issues. The aim of the current study is to examine the effects of perceived stress and resilience on suicidal ideation (SI), plan (SP), and attempt (SA) among early adolescents. A longitudinal study was conducted with data collected from 1035 junior high-school students at baseline and 1-year follow-up. Participants were assessed for suicidal behaviors, resilience, and perceived stress. Logistic regression was performed to analyze for the associations between independent variables and suicidal behaviors. 210 (20.3%) of the participants reported to have SI, 59 (5.7%) had SP, and 49 (4.7%) had SA at baseline. Perceived stress was a strong risk factor (p < 0.001) for SI (OR 1.16-1.18), SP (OR 1.20-1.21), and SA (OR 1.12-1.16) while accounting for different dimensions of resilience. Students with persistent high stress during the 1-year follow-up period had significantly increased risk of SI (OR 7.14-9.64), SP (OR 3.92-6.37), and SA (OR 3.76-3.84) than the persistent low-stress group (p < 0.01). Increased perceived stress scale (PSS) (OR 2.89-3.15) and decreased PSS (OR 2.47) also had a higher risk for SI than persistent low PSS group. Moreover, students with high perceived stress who reported to have higher hope and optimism were less likely to show SI (OR 0.90, p = 0.001) and SP (OR 0.87, p = 0.002) at baseline, and the problem-solving and cognitive maturity mature dimension of resilience showed a significant protective effect on SP longitudinally (OR 0.25, p = 0.003). Perceived stress substantially increased the risk for suicidal behaviors, and moderates the protective effect of resilience on suicide. Considering both risk and protective factors of suicidal behaviors is essential in designing future suicide prevention and intervention programs.

Suicide Prevention Videos Developed by and for Adolescents

Background: One strategy to prevent youth suicide is awareness-raising video campaigns. To date, little is known about how best to include adolescents in the production process, and how they experience their involvement. Aims: This study used a participatory qualitative research approach to explore the experiences of adolescents producing suicide prevention videos targeting other adolescents in a school setting. Method: The project was conducted in Vienna, Austria, from 09/2018 to 01/2019. Eighteen high school students aged 15-19 produced suicide prevention videos. Focus group discussions with 17 of these students captured qualitative information on their experiences related to the process. Focus group content was analyzed following the documentary method. Results: Students produced seven suicide prevention videos in groups of two to three individuals. The production process was found to be positive, and numerous benefits and learning effects were noted. Limitations: No conclusions can be made about video effects on adolescents not involved in the process. Conclusion: Including adolescents in the process of developing suicide prevention videos has multiple benefits. The process researched here can inform similar campaigns with adolescents.

Associations of Substance Use Behaviors With Suicidal Ideation and Suicide Attempts Among US and Chinese Adolescents

Background: Adolescence has been described as a period of increased health risk-taking behaviors. Given the variety of cultural contexts, healthcare systems, and public health policies in different regions, the present study aimed to determine whether there are similar or different associations of substance use behaviors with suicidal ideation and suicide attempts among US and Chinese adolescents. Methods: This study included a total of 14,765 US adolescents from the 2017 National Youth Risk Behavior Surveillance System (YRBSS) and 24,345 Chinese adolescents from the 2017 School-based Chinese Adolescents Health Survey (SCAHS). Results: The proportions of suicidal ideation and suicide attempts were 17.4 and 5.7% among US adolescents, which were higher than those among Chinese adolescents (suicidal ideation: 13.7% and suicide attempts: 2.7%). Among Chinese adolescents, the most common substance use behavior was "alcohol use (55.4%)," followed by "cigarette use (11.6%)." Among US adolescents, the most popular substance was alcohol (ever used: 55.9%), followed by marijuana (ever used: 34.6%). Moreover, alcohol use was significantly related to suicidal ideation/suicide attempts only in Chinese adolescents [suicidal ideation: Adjusted odds ratio (AOR) = 1.88, 95% CI = 1.71~2.06; suicide attempts: AOR = 2.12, 95% CI = 1.71~2.63], and marijuana use was associated with suicidal ideation and suicide attempts only in the US adolescent group (suicidal ideation: AOR = 1.23, 95% CI = 1.06~1.44; suicide attempts: AOR = 1.51, 95% CI = 1.21~1.87). Moreover, although the associations of prescription pain medication use with suicide attempts were significant in both Chinese and US adolescent groups, the adjusted associations were stronger in Chinese adolescents than in US adolescents (Chinese adolescents: AOR = 3.97, 95% CI = 2.76~5.72; US adolescents: AOR = 1.76, 95% CI = 1.43~2.16; P < 0.05). Conclusions: The associations of alcohol use with suicidal ideation and suicide attempts were only significant in Chinese adolescents. Marijuana use was associated with suicidal ideation and suicide attempts only in the US adolescent group. Although the associations of prescription pain medication use with suicide attempts were significant in both Chinese and US adolescent groups, the adjusted associations were significantly stronger for Chinese adolescents. These findings might be related to the differences in cultural contexts, healthcare systems, and public health policies in the two different countries.

The Effect of Peer Leadership on Suicidal Ideation in Senior High School Teenagers

This study aimed to determine the effect of peer leadership training on suicidal ideation in senior high school teenagers. This study followed a quasi-experimental pretest-posttest design without a control group. We obtained 43 respondents using a purposive sampling technique. An intervention was provided in the form of peer leadership training sessions. Measurements were conducted twice-once pre- and once post-intervention-using the Beck Scale for Suicidal Ideation. The analysis used was the Wilcoxon t-test. Suicidal ideation decreased significantly (p value <0.05) after peer leadership training. Providing peer leadership training could reduce suicidal ideation in adolescents from severe categories into mild ones. Peer leadership training was an effective method for reducing suicidal ideation in adolescents and should be recommended by mental health nurses for adolescents at school.

Risk and protective factors for suicide among Guyanese youth: Youth and stakeholder perspectives

Guyana, a low-to-middle-income country (LMIC) in South America, leads the world in youth suicide. As an understanding of risk and protective factors is critical to the development of culturally informed suicide prevention efforts, research exploring these factors among youth in Guyana is needed. The current study expands on current research on adolescent suicide in Guyana and LMICs broadly by using qualitative focus groups and interviews to explore adult stakeholders' and youth's perspectives. Participants included 17 adult stakeholders and 40 adolescents in Guyana. Data were analysed using a grounded theory approach. Themes related to participants' perceptions of risk factors for suicide included demographic characteristics, pressure and expectations, adults' responses to youth, limited coping with stressful life events and exposure to suicide. Themes related to protective factors for suicide included positive social support and involvement in community activities. Findings have implications for the development and tailoring of suicide prevention efforts for Guyanese youth.

Qualitative case study investigating PAX-good behaviour game in first nations communities: insight into school personnel's perspectives in implementing a whole school approach to promote youth mental health

OBJECTIVES

PAX-Good Behaviour Game (PAX-GBG) is associated with improved mental health among youth. First Nations community members decided on a whole school approach to facilitate PAX-GBG implementation, by offering intervention training to all staff members in their schools. Our objective is to gain a greater understanding of how this approach was viewed by school personnel, in order to improve implementation in remote and northern First Nations communities.

DESIGN

We conducted a qualitative case study using semi-structured interviews.

SETTING

Interviews were conducted in First Nations schools located in northern Manitoba, Canada, in February 2018.

PARTICIPANTS

We used purposive sampling in selecting the 23 school staff from First Nations communities.

INTERVENTION

PAX-GBG is a mental health promotion intervention that teachers deliver in the classroom alongside normal instructional activities. It was implemented school-wide over 4 months from October 2017 to February 2018.

OUTCOME MEASURES

We inquired about the participants' perception of PAX-GBG and the whole school approach. We applied an iterative coding system, identified recurring ideas and classified the ideas into major categories.

RESULTS

Implementing the PAX-GBG whole school approach improved students' behaviour and created a positive school environment. Students were learning self-regulation, had quieter voices and demonstrated awareness of the PAX-GBG strategies. All teachers interviewed had used the programme. Support from school administrators and having all school personnel use the programme consistently were facilitators to successful implementation. Challenges included the timing of training, lack of clarity in how to implement and implementing among students in older grades and those with special needs.

CONCLUSIONS

The whole school approach to implementing PAX-GBG was viewed as an acceptable and feasible way to extend the reach of PAX-GBG in order to promote the mental health of First Nations youth. Recommendations included ensuring school leadership support, changes to the training and cultural and literacy adaptations.

Nonsuicidal Self-Injury and Suicidal Behaviors in Girls: The Case for Targeted Prevention in Preadolescence

Non-suicidal self-injury (NSSI) affects 15-20% of adolescents-disproportionately girls-and is a strong predictor of eventual suicide attempts and suicide. Many girls now initiate NSSI before age 10. These early-starters exhibit greater frequency of NSSI, use more diverse methods, and are hospitalized more often, yet there are no empirically supported prevention programs for preadolescents. Obstacles to prevention include ascertaining who is sufficiently vulnerable and specifying mechanistic intervention targets. Recent research indicates that (1) preadolescent girls with ADHD who are also maltreated are at alarming risk for NSSI and suicide attempts by adolescence, and (2) the conjoint effects of these vulnerabilities are sufficiently potent for targeted prevention. Research also indicates that existing interventions are effective in altering child- and family-level mechanisms of NSSI. These interventions alter neurobiological markers of vulnerability, which can be used as proximal efficacy signals of prevention response, without waiting for NSSI and suicide attempts to emerge.

Evidence available for patient-identified priorities in depression research: results of 11 rapid responses

OBJECTIVES

Patient priority setting projects (PPSPs) can reduce research agenda bias. A key element of PPSPs is a review of available literature to determine if the proposed research priorities have been addressed, identify research gaps, recognise opportunities for knowledge translation (KT) and avoid duplication of research efforts. We conducted rapid responses for 11 patient-identified priorities in depression to provide a map of the existing evidence.

DESIGN

Eleven rapid responses.

DATA SOURCES

Single electronic database (PubMed).

ELIGIBILITY CRITERIA

Each rapid response had unique eligibility criteria. For study designs, we used a stepwise inclusion process that started with systematic reviews (SRs) if available, then randomised controlled trials and observational studies as necessary.

RESULTS

For all but one of the rapid responses we identified existing SRs (median 7 SRs per rapid response, range 0-179). There were questions where extensive evidence exists (ie, hundreds of primary studies), yet uncertainties remain. For example, there is evidence supporting the effectiveness of many non-pharmacological interventions (including psychological interventions and exercise) to reduce depressive symptoms. However, targeted research is needed that addresses comparative effectiveness of promising interventions, specific populations of interest (eg, children, minority groups) and adverse effects.

CONCLUSIONS

We identified an extensive body of evidence addressing patient priorities in depression and mapped the results and limitations of existing evidence, areas of uncertainty and general directions for future research. This work can serve as a solid foundation to guide future research in depression and KT activities. Integrated knowledge syntheses bring value to the PPSP process; however, the role of knowledge synthesis in PPSPs and methodological approaches are not well defined at present.

Improving Schools' Readiness for Involvement in Suicide Prevention: An Evaluation of the Creating Suicide Safety in Schools (CSSS) Workshop

Schools have an important role to play in combatting suicide, a significant public health problem that disproportionately affects adolescents and young adults. Schools can work to reduce youth suicidality by adopting policies that align with best practice recommendations pertaining to suicide prevention, intervention, and postvention. This study examined the impact of a one-day training, the Creating Suicide Safety in Schools (CSSS) workshop, on the readiness of school personnel to improve their schools’ suicide-related policies and procedures. Participants (N = 562) consisted predominantly of school-based mental health professionals working in communities of low or mixed socioeconomic status in New York State. Survey data were collected according to a one-group pre-test—post-test design with a 3-month follow-up. Workshop participants demonstrated improvements from pre-test to post-test in their attitudes about the importance of school-based suicide prevention, knowledge of best practices, perceptions of administrative support, and feelings of empowerment to work collaboratively to enhance their schools’ suicide safety. At follow-up, participants reported barriers to implementing changes, most commonly in the form of insufficient time and stigma surrounding the topic of suicide. The results of this study provide preliminary evidence for the effectiveness of the CSSS workshop as a promising method for improving schools’ suicide safety, yet additional research using randomized controlled trials needs to be conducted.

Evaluation of A Suicide Prevention Program in Switzerland: Protocol of A Cluster Non-Randomized Controlled Trial

Suicide is a major public health concern, which disproportionally affects young people. Therefore, effective prevention strategies are needed, but there is a dearth of controlled trials on this topic. Our study will evaluate the effectiveness of a suicide prevention program in Switzerland, where data are scarce. It will test whether the prevention program (1) increases knowledge of suicide and awareness of suicidal risks, (2) provides resources to seek/offer help, (3) increases communication skills related to suicide, (4) increases coping skills, (5) is acceptable, and (6) reduces suicidal ideation and psychological distress. The project will be a single-center cluster non-randomized controlled trial designed to compare an intervention group benefitting from the suicide prevention program with a control group. The potential benefits include a better understanding and evaluation of suicide prevention programs, which may lead to improved primary and secondary prevention practices.

Evidence Base Update of Psychosocial Treatments for Self-Injurious Thoughts and Behaviors in Youth

The current review provides an evidence base update of psychosocial treatments for self-injurious thoughts and behaviors (SITBs) in youth. A systematic search was conducted of 2 major scientific databases (PsycInfo and PubMed) and ClinicalTrials.gov for relevant randomized controlled trials (RCTs) published prior to June 2018. The search identified 26 RCTs examining interventions for SITBs in youth: 17 were included in the 2015 review and 9 trials were new to this update. The biggest change since the prior review was the evaluation of Dialectical Behavior Therapy for adolescents (DBT-A) as the first Level 1: Well-established intervention for reducing deliberate self-harm (composite of nonsuicidal and suicidal self-injury) and suicide ideation in youth and Level 2: Probably efficacious for reducing nonsuicidal self-injury and suicide attempts. Five other interventions were rated as Level 2: Probably efficacious for reducing SITBs in youth, with the new addition of Integrated Family Therapy. This evidence base update indicates that there are a few promising treatments for reducing SITBs in youth. Efficacious interventions typically include a significant family or parent training component as well as skills training (e.g., emotion regulation skills). Aside from DBT-A, few treatments have been examined in more than one RCT. Given that replication by independent research groups is needed to evaluate an intervention as Well-established, future research should focus on replicating the five promising interventions currently evaluated as Probably efficacious. In addition, an important future direction is to develop brief efficacious interventions that may be scalable to reach large numbers of youth.

Suicide Prevention Experiences, Knowledge, and Training among School-based Counselors and Nurses in King County, Washington - 2016

Objective

Few studies have assessed the suicide-specific perceptions and awareness of school-based nurses and counselors. This project assessed the self-reported training, beliefs, and professional experiences of school counselors and nurses towards suicide prevention, and identified areas for enhancing efforts to respond to student suicidality.

Methods

A self-report needs assessment survey was conducted with school-based nurses and counselors in King County, Washington. Group comparisons and descriptive statistics were calculated to characterize providers' perceptions and experiences.

Results

Most training experiences reported by counselors and nurses corresponded with greater perceptions of comfort in applying suicide prevention knowledge and skills. Fewer respondents endorsed means safety and safety planning as regularly implemented interventions for at-risk students compared to other interventions.

Conclusion

Means safety and safety planning appeared to be areas for enhancing existing suicide prevention efforts.

Religious education can contribute to adolescent mental health in school settings

Background

Mental disorders contribute substantial burden to the society due to their widespread occurrence and debilitating effects. A quarter of the world’s population are children and adolescents, a significant number of whom experience mental disorders as early as the age of 14. Some interventions have been found to effectively reduce the risk factors and reinforce protective or preventive factors. However, there is still a need to put emphasis on mental health promotion strategies such as religious education. This paper aims to discuss the importance of religious education in promoting mental health.

Discussion

Religious education can be instrumental to improving adolescent mental health. Specifically, it can: (1) help develop healthier reaction to stimuli through the internalization of religious morality; (2) reinforce religious coping mechanisms which reduce the impact of stresses, enhance coping skills, and promote a less risky lifestyle; (3) increase awareness regarding religious beliefs and practices and their influence on the individual, the family, and the community; and finally, (4) promote connectedness which can enhance self-esteem and well-being. However, negative health outcomes such as discrimination and social isolation can also develop, especially among religious or gender minority groups.

Conclusion

It is important to reflect on the crucial role of religious education on adolescent mental health. School-based mental health education and promotion strategies can maximize the benefits of religious education by putting emphasis on effective implementation of religious education to positively influence adolescent mental health.

Suicidal ideation, suicidal behaviors, and attitudes towards suicide of adolescents enrolled in the Alternative Learning System in Manila, Philippines-a mixed methods study

BACKGROUND

Globally, suicide is a significant cause of death among adolescents. Previous studies conducted in high-income countries suggest that students in alternative schools are more likely to engage in suicidal behaviors than those in formal schools. This study aimed to document suicidal ideation and behaviors among adolescent learners enrolled in the Alternative Learning System (ALS) in Manila, Philippines.

METHODS

A mixed methods study was conducted in 24 ALS centers in the city of Manila. ALS centers were stratified according to congressional district and selected using probability proportionate sampling. A cross-sectional survey to determine attitudes towards suicide and prevalence of suicidal ideation and behaviors was administered to 171 learners aged 13 to 17 years old. In-depth interviews with 18 teachers and 12 learners were conducted to explore the school psychosocial environment's role on learners' suicidal ideation and behaviors. Exploratory factor analysis was used to extract attitude factors. Fisher's exact test and Student's t-test were used to identify differences in sociodemographic characteristics and attitudes towards suicide between learners with or without suicidal ideation or behaviors. Qualitative data were analyzed using thematic analysis.

RESULTS

Non-specific active thoughts were the most common type of lifetime suicidal ideation (40.9%) while passive ideation was the most common in the past month (13.5%). Aborted suicide attempt was the most frequent behavior in both lifetime (16.4%) and in the past month (4.7%). Non-fatal suicide attempt in the past month was 2.3%, reaching 12.9% for the entire lifetime. Age, sex, education, and attitudes towards suicide were significantly associated with suicidal ideation or behavior. Thematic analysis showed five themes: (1) fostering belongingness, (2) securing learners' safety, (3) teaching philosophy, (4) teacher and learner beliefs towards suicidal behavior, and (5) availability of school-offered and community-based services.

CONCLUSION

Suicidal ideation and behaviors are prevalent among adolescent ALS learners. This study also showed a significant difference in attitudes towards suicide and sociodemographic characteristics between learners with and without suicidal ideation behaviors. It also suggests that the school psychosocial environment, through social norms and learner-teacher interactions, can potentially prevent progression of suicidal ideation to behavior, influence help-seeking, and promote mental health among learners.