Suicide Prevention Programs in the Schools: A Review and Public Health Perspective

Clinical utility of depression measures and symptoms: Implications for suicide risk assessment in high risk, resource limited youth populations

OBJECTIVE

Suicide risk for youth in resource- limited settings has been largely underrepresented in the literature and requires targeted examination of practical ways to address this growing public health concern. The present study focuses on the clinical utility of depression risk assessment tools addressing how and for whom suicide prevention intervention is most beneficial within a low-middle-income-country, high suicide risk youth sample.

METHODS

Youth who reported a previous suicide attempt versus those who did not were criterion to test the validity of depression and hopelessness symptom assessment tools. We used item analyses to identify depressive symptom endorsements that most informed youth suicide risk, which will better equip rural practitioners for targeted intervention and monitoring of youth with an already high risk for suicide.

RESULTS

Findings demonstrated that practitioners may target symptoms of social anhedonia, depressed mood, concentration disturbance, feelings of worthlessness, sleep disturbance, and fatigue for suicide prevention-intervention efforts among high-risk youth.

CONCLUSIONS

Study implications are for clinicians' use of the BDI-II and CES-D for depression symptom identification and suicide risk monitoring in settings with limited mental health infrastructure.

Perspective on the Prevention of Suicide among School Learners by School Management

BACKGROUND

Adolescents in South Africa have higher suicide rates than older people. A suicide or unexpected death of a fellow student can result in increased copycat behavior. Previous studies have placed emphasis on the significance of school involvement in the prevention of suicide. The study sought to explore the perspective on the prevention of suicide among school learners by school management. A qualitative phenomenological design was applied. The study used purposive sampling to select six high schools. In-depth interviews were conducted with six focus group discussions comprising fifty school management. A semi-structured interview guide guided the interviews. Data were analyzed using a general inductive approach. Findings revealed that school management should be supported through workshops to increase their skills in handling stressful situations at school. Support for learners through audio-visuals, professional counseling, and awareness campaigns also emerged. Parents-school partnership was said to be effective in preventing suicide among learners as both parties will be free to discuss the problems faced by the learner. In conclusion, empowering school management in the prevention of suicide is critical for Limpopo learners. Awareness campaigns conducted by suicide survivors where they can share their testimonies is necessary. School-based professional counseling services should be established to benefit all learners, particularly those experiencing financial challenges. Pamphlets in local languages should be developed for students to convey information about suicide.

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.

Awareness isn't saving lives: An experimental exploration of suicide risk reduction methods for emerging adults

OBJECTIVE

Suicide prevention campaigns commonly employ brief informational materials aimed at emerging adults. Are such programs helpful, and do design characteristics yield differences in user outcomes? Literature is reviewed from the interpersonal theory of suicide, escape theory, and terror management theory, to inform our experimental design.

METHOD

Participants (n = 977 MTurk emerging adults) reported demographics and suicide histories and were randomized to one of nine experimental cells with varying video and journaling conditions to approximate suicide prevention materials. Participants were surveyed on perceptions of the materials' risk reduction effectiveness, indicated their suicidality risk factors (e.g., hopelessness, depressiveness, purposelessness, and non-belongingness), and conducted an implicit association test of suicidality.

RESULTS

Suicide risk factors did not differ between experimental and control conditions, but certain conditions were rated as more effective (i.e., essay conditions prompting reflection, and the video condition featuring a personal/affective narrative). While there was no actual comparative reduction of risk, there was a perception that certain designs were more helpful.

CONCLUSION

Real-world suicide prevention campaigns often feel justified despite lacking impact. Effective suicide risk reduction requires greater time investment and deeper personal connection than brief campaigns can offer, as well as systemic changes from a public health policy perspective.

Research Review: The effect of school-based suicide prevention on suicidal ideation and suicide attempts and the role of intervention and contextual factors among adolescents: a meta-analysis and meta-regression

BACKGROUND

Globally, suicide is the fourth highest cause of adolescent mortality (Suicide: https://www.who.int/news-room/fact-sheets/detail/suicide). The effects of post-primary school-based suicide prevention (PSSP) on adolescent suicidal thoughts and behaviours (STBs) have not been comprehensively synthesised. We aim to estimate the population effect for PSSP interventions on adolescent STBs and explore how intervention effects vary based on intervention and contextual moderators.

METHODS

Searches of PsycINFO, Medline, Education Source, ERIC, Web of Science, and the Cochrane Central Register of Controlled Trials identified cluster randomised trials examining the effectiveness of PSSP on adolescent STBs. The Cochrane Risk of Bias tool assessed bias. Crude and adjusted back-transformed odds ratios (ORs) were calculated. Multilevel random-effects models accounted for dependencies of effects. Univariate meta-regression explored variability of intervention and contextual moderators on pooled effects.

RESULTS

There were 19 and 12 effects for suicidal ideation (SI) and suicide attempts (SA). Compared with controls, interventions were associated with 13% (OR = 0.87, 95%CI [0.78, 0.96]) and 34% (OR = 0.66, 95%CI [0.47, 0.91]) lower crude odds reductions for SI and SA, respectively. Effects were similar for adjusted SI (OR = 0.85, 95%CI [0.75, 0.95]) and SA (OR = 0.72, 95%CI [0.59, 0.87]) models. Within-study (0.20-9.10%) and between-study (0-51.20%) heterogeneity ranged for crude and adjusted SA models and SI heterogeneity was 0%. Moderator analyses did not vary SA effects (ps > .05).

CONCLUSIONS

This meta-analysis contributes to the PSSP evidence-base by demonstrating that PSSP targeting STBs as both primary intervention outcomes and with other health and well-being outcomes reduced SI and SA among 33,155 adolescents attending 329 schools, compared to controls. The number needed to treat estimates suggests the potential of reducing the incidence of SA and SI in one adolescent by implementing PSSP in 1-2 classrooms, supporting PSSP as a clinically relevant suicide prevention strategy. Although moderator analyses were nonsignificant and contained a small number of trials, larger SA effect sizes support particular effectiveness for interventions of a duration of ≤1 week, involving multiple stakeholders and with a 12-month follow-up.

The quality and effectiveness of Social-Emotional Learning (SEL) intervention studies in Korea: A meta-analysis

Social-emotional learning (SEL) is an educational model for improving social-emotional competences of all students and a long-term education program connecting school, home, and community. Although there has been active research to establish evidence-based practice (EBP) of SEL programs worldwide, the quality of SEL intervention studies which is an integral part of evaluating EBP was rarely investigated. In addition, prior meta-analytic studies focused only on the effectiveness of SEL programs conducted in Western society. In this sense, in order to contribute to establishing EBP of SEL programs, the current research sought to analyze both quality and effectiveness of SEL intervention studies conducted in Korea where SEL has been investigated and applied in classroom since 2010. To conduct this study, we selected 22 peer-reviewed articles (about 23 SEL programs) and analyzed their quality by Evidence-Based Intervention (EBI) indicators and calculated effect sizes using a meta-analysis. The results of the quality analysis revealed that SEL intervention studies had some limitations with a statistical analysis, use of measurement, a control group design, intervention fidelity, and external validity. The global effect size of SEL programs was 0.27, and the results from the effect size analyses by controlling variables showed that group compositions, the number of sessions, and session length were accountable for the variability of effect sizes. Based on these findings, we discussed the directions for future research and practice on the EBP of SEL programs that can be appreciated by researchers worldwide.

Effectiveness of school-based preventive programs in suicidal thoughts and behaviors: A meta-analysis

BACKGROUND

Suicidal thoughts and behaviors (STBs) among adolescents have hardly decreased despite preventative efforts. School-based prevention programs could have a great reach, yet suicide prevention is not an easy topic to address. To increase acceptability of school-based suicide prevention, it is important to evaluate whether programs that target known risk factors of STBs, such as depression, could be equally effective.

METHODS

We conducted a systematic literature search in major electronic databases. Outcomes were suicidal ideation and behaviors. Multivariate random effects meta-regression-analyses were conducted.

RESULTS

Eleven primary studies met the inclusion criteria, totalling 23,230 participants. The post-test effect size was small for both suicidal ideation (g = 0.15) and suicidal behaviors (g = 0.30). Meta-regression indicated that targeting known risk factors of STBs was not a significant modifier of effect size for ideation, indicating equal effectiveness. However, it was significant modifier of effect for behaviors, but only one intervention targeted know risk factors. Effects at follow-up (3-12 months) were also significant but small for both outcomes.

LIMITATIONS

Substantial heterogeneity between studies was noted. Only few and small sample size studies could be included that targeted known risk factors of STBs. Therefore, these results should be interpreted with caution.

CONCLUSIONS

School-based prevention of STBs shows some promise within three months post-test assessments, and potentially also have effects that are sustained over time. More studies are needed to make conclusions regarding school-based interventions that target risk factors of STBs.

African American adolescent suicidal ideation and behavior: The role of racism and prevention

Suicide is one of the most devastating, yet preventable, health disparities for African American adolescents. African American adolescent suicidal ideation and behavior may have different manifestations and risk factors relative to those of adolescents from other ethnic backgrounds that impact prevention efforts. For example, in addition to more common manifestations of suicidal ideation and behavior, African American youth may engage in violent or high-risk behaviors, use more lethal means, or report ideation at lower depression levels. The Adapted-Coping with Stress Course (A-CWS), an adaptation of Gregory Clarke and colleagues' Coping with Stress Course, was developed to address the cultural nuances of African American adolescents. The A-CWS is a 15-session cognitive-behavioral, group-based preventive intervention that aims to enhance adaptive coping skills and reduce suicidal ideation, by incorporating strategies that counter stressors associated with systemic racism that burden African American adolescents. This study evaluated the feasibility and acceptability of the A-CWS intervention, using a sample of predominantly African American ninth-grade students. Results indicated that the adolescents were very favorable and receptive to the A-CWS intervention and that the intervention could be conducted feasibly. The A-CWS intervention serves as a model to advance culturally-grounded, evidence-based preventive intervention, for an underserved sector of adolescents.

Gatekeeper Training and Minimum Standards of Competency

Gatekeeper training (GKT) is one of the most widely used suicide prevention strategies. It involves training people who are not necessarily clinicians to be able to identify people experiencing suicidality and refer them to appropriate services. While there is a dearth of research that supports the causal link between GKT and reduced suicide rates, this is likely the result of a variety of factors including training design, definitions of "gatekeepers," differing populations in which the gatekeeper (GK) operates, and other variables that may influence suicide rates. Despite this, research suggests that GKT improves people's knowledge, skills, and confidence in helping individuals who experience suicidal ideation and enhances positive beliefs about the efficacy of suicide prevention. However, there is no consensus on GK competencies to allow differences in effectiveness between various training programs to be measured, that is, knowledge, skills and abilities, attitudes, and self-efficacy attributes expected of a person resulting from the training. This paper discusses challenges in developing GK competencies. It uses developments in suicide prevention competencies for clinicians, vocational education, and training sector competencies, as well as empirical work in GKT, to propose minimum GK competencies that may be examined for further research and evaluation of programs.

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.

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.

Taking Youth Suicide Prevention to the Schools: Pilot Evaluation of School-Based Clinician Outcomes and Perspectives of a Multi-Modal Program Including Post-Training Online Consultations for Management of Ongoing Suicide Risk

School-based youth-specific suicide prevention and early intervention initiatives are presently underdeveloped. The current study conducted a pilot evaluation of a multi-modal suicide prevention training program for school-based social workers, ‘Management of Youth Suicidality Training for Schools’ (MYSTS). The program comprised a two-day workshop and six fortnightly post-workshop webinar online consultations. Participants were 36 social workers (years’ experience M = 11.23, SD = 8.29) employed by the Department of Education in Tasmania, Australia. Outcomes were self-rated confidence, competence, and knowledge of self-harm in young people, and attitudes toward suicide prevention and suicide-related behaviors. Exploratory quantitative results indicated significant improvements with large effect sizes for participants’ self-reported competence (d = 1.33), and confidence (d = 1.29) to identify and respond therapeutically to youth suicidality following the workshop. Confidence remained significantly higher than baseline following the online consultations (d = 0.90). Qualitative analysis of online supervision consultations indicated key themes of accessibility, communication and information sharing, and clinical management. Participants endorsed the MYSTS package as well-presented, with relevant topics, and effective learning activities. This study highlights the need for continued supervisory or implementation support to practitioners following suicide prevention training initiatives and suggests web-based teleconference technology as a feasible strategy for this. Further evaluation of the MYSTS package, including a suitable comparison or control condition, is indicated.

Feasibility and Acceptability of the Youth Aware of Mental Health (YAM) Intervention in US Adolescents

Suicide is the second leading cause of death among US adolescents, and rates of suicide among youth have been increasing for the past decade. This study assessed the feasibility and acceptability of the universal, school-based Youth Aware of Mental Health (YAM) program, a promising mental health promotion and suicide primary prevention intervention, in US youth. Using an uncontrolled design, the feasibility and acceptability of delivering and studying YAM were assessed in Montana and Texas schools. Thirteen of 16 (81.3%) schools agreed to support YAM delivery, and five Montana and 6 Texas schools were included in analyses. Facilitators delivered YAM in 78 classes (1,878 students) as regular high school curriculum. Of the total number of students who received YAM, 519 (27.6%) provided parental consent and assent. 436 (84.0%) consented students participated in pre- and post-surveys. Students, parents, and school staff found YAM highly acceptable based on satisfaction surveys. In summary, this study found YAM feasible to implement in US schools. Results also suggest students, parents, and school staff supported school-based programs and were highly satisfied with the YAM program. A randomized controlled trial is warranted to test the efficacy of YAM in promoting mental health and preventing suicidal thoughts and behaviors in US adolescents.

The Role of the School Nurse in Suicide Interventions: An Integrative Review

Suicide rates among children and adolescents have continued to rise over the past decade indicating the need for school-based suicide prevention programs. School nurses (SNs) are well positioned to assist in assessment, early identification, and intervention of at-risk students. This integrative review aimed to (1) critically examine the role of the SN in school-based suicide interventions, (2) explore potential barriers preventing the SN from participating in suicide interventions, and (3) recommend strategies to build capacity for principles of school nursing practice in suicide intervention. The National Association of School Nurses’ Framework for 21st Century School Nursing Practice was used to categorize interventions and outcomes related to suicide prevention. Findings demonstrate a lack of reported nursing interventions directly linked to student outcomes and suggest obscurity in the role of the SN. Recommendations for future research and strategies to build capacity for principles of school nursing practice are provided.

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.

School-based gatekeeper training programmes in enhancing gatekeepers' cognitions and behaviours for adolescent suicide prevention: a systematic review

Suicide is a leading cause of death in adolescence. School provides an effective avenue both for reaching adolescents and for gatekeeper training. This enables gatekeepers to recognize and respond to at-risk students and is a meaningful focus for the provision of suicide prevention. This study provides the first systematic review on the effectiveness of school-based gatekeeper training in enhancing gatekeeper-related outcomes. A total of 815 studies were identified through four databases (Ovid Medline, Embase, PsycINFO and ERIC) using three groups of keywords: 'school based', 'Suicide prevention programme' and 'Gatekeeper'. Fourteen of these studies were found to be adequate for inclusion in this systematic review. The improvement in gatekeepers' knowledge; attitudes; self-efficacy; skills; and likelihood to intervene were found in most of the included studies. Evidence of achieving improvement in attitudes and gatekeeper behaviour was mixed. Most included studies were methodologically weak. Gatekeeper training appears to have the potential to change participants' knowledge and skills in suicide prevention, but more studies of better quality are needed to determine its effectiveness in changing gatekeepers' attitudes. There is also an urgent need to investigate how best improvements in knowledge and skills can be translated into behavioural change.

What is in It for Them? Understanding the Impact of a 'Support, Appreciate, Listen Team' (SALT)-Based Suicide Prevention Peer Education Program on Peer Educators

Youth suicide is a public health problem in India, and young people in school, particularly adolescents, experience heavy psychological burden. Prevention programs, involving peer educators (PEs), have proved useful strategies to address this problem, but their impact on the PEs is less understood, particularly in India. This qualitative study aims to explore the changes observed in PE students who were involved in a ‘mindfulness’ and ‘Support-Appreciate-Listen–Team’ (SALT)-based peer education program to address suicidal behavior in Indian school students. One hundred and fourteen students were trained as PEs in six high schools in Pune to identify and respond to the needs of students in distress. By listening to the narratives of the PEs, their parents, school authorities, and the associated NGO team, we reflect on perceived social, emotional, behavioral, and cognitive changes in PEs. The PEs demonstrated enhanced caring for those in distress both inside and outside school by improved listening skills, self-awareness, care, and empathy. Furthermore, the program had a positive impact on their broad emotional intelligence and PEs expressed increased ownership of life, taking action, and seeking support where needed. The study concludes that mindfulness and SALT-based peer education (PE) programs are valuable for the PEs. This could be used to motivate PEs to volunteer in such programs. Other results are discussed and further research areas are suggested.

Latina Adolescents Health Risk Behaviors and Suicidal Ideation and Suicide Attempts: Results from the National Youth Risk Behavior Survey 2001-2013

Suicidal ideation and suicide attempts are more common in Latina adolescents than White or African-American adolescents. Several health risk behaviors have been identified as being associated with Latina adolescent suicides. However, to date, no study has identified the consistency and stability of these risk behaviors over time. This study utilized the national Youth Risk Behaviors Survey from 2001 to 2013 to estimate the prevalence of suicidal ideation, suicide attempts, and health risk behaviors associated with suicidal behaviors in Latina adolescents. Our analysis found the prevalence of suicidal ideation and suicide attempts varied significantly over the 13-year study span, decreasing from 2001 to 2009 and increased from 2011 to 2013. The analyses found 11 health risk behaviors that were significantly associated with both suicidal ideation and suicide attempts that did not vary over time. The stability of these 11 health risk behaviors associated with suicidal behaviors could be useful to school personnel to identify early at risk Latina adolescents who may benefit from school and community mental health resources.

Preventing Suicide in Montana: A Community-Based Theatre Intervention

PURPOSE

This study examined whether a community-based suicide prevention project could increase willingness to seek professional help for suicidal ideation among eastern Montana youth.

DESIGN

Online surveys were administered at baseline (N = 224) and six months post-test (N = 217) consisting of the Risk Behavior Diagnosis Scale (RBD), self-report questions on suicidality, willingness to engage with suicide prevention resources, and willingness to communicate with peers, family members, teachers or counselors about suicide.

FINDINGS

A comparison of means within groups from pre- to post-test showed increases in self-efficacy for communicating about suicidal concerns with a teacher, school counselor or social worker; increases in self-efficacy for helping others; and increases in response-efficacy of interpersonal communication about suicide with a teacher, school counselor or social worker.

PRACTICAL IMPLICATIONS

Young adults need to be willing and able to intervene in life-threatening situations affecting their peers. In step with narrative empowerment education, personal experiences can be used to communicatively reduce peer resistance to behavior change.

ORIGINALITY

Health communicators tend to rely on overly didactic education and awareness-raising when addressing suicide prevention. This research shows the importance of direct and personal forms of influence advocated by social marketing professionals.

A Theater Intervention to Promote Communication and Disclosure of Suicidal Ideation

Young adults from Montana have a higher rate of suicide than their national counterparts. There is a clear need for targeted interventions to address this disparity. The authors evaluate a community-based, narrative theater project designed to increase awareness and use of suicide prevention resources among eastern Montana youth. As a first step, seven group interviews with Montana young adults (n = 27) were conducted to identify current perceptions about suicide and suicide prevention. Interviews were conducted before and after subjects were exposed to a community-based theater production about suicide. Emergent thematic categories were organized using the four main constructs of the extended parallel process model. After the performance, participants expressed increased awareness of prevention resources; perceived susceptibility to the threat of suicide and depression; and self-efficacy for accessing help and assisting others. There were mixed results for perceived response efficacy. Implications and recommendations for intervention development are discussed.

Developing a school-based preventive life skills program for youth in a remote Indigenous community in North Australia

Purpose

– The purpose of this paper is to describe the process of development and the pilot implementation of a preventive life skills curriculum for Indigenous middle school students in a very remote community college in the West Arnhem region of North Australia. The curriculum integrates proven educational and psychological techniques with culturally informed notions of relatedness and was developed as a contribution to efforts to prevent alarming rates of suicide among remote Indigenous youth. In this paper, the term, Indigenous refers to Australians of Aboriginal or Torres Strait Islander descent.

Design/methodology/approach

– Based on reviews of research literature on school-based suicide prevention and social and emotional learning in both general and Indigenous populations, and following detailed community consultations, a 12 week curriculum was drafted and implemented in two middle school classes (combined years 7-9). Lessons were videotaped and later analyzed and detailed commentary was sought from participating school staff.

Findings

– The pilot program has yielded important insights into requirements of a curriculum for young people with low English literacy levels and with variable school attendance patterns. It confirmed the need to adjust both pedagogical approach and curriculum content for the program to have resonance with students from this linguistic and cultural background and with varying levels of exposure to multiple stressors in disadvantaged community settings.

Practical implications

– The project has identified and resolved key questions for sustainable implementation of a preventive curriculum in challenging community circumstances.

Originality/value

– There are to date no examples of the systematic adaptation and design of a universal preventive intervention specifically for remote Australian Indigenous youth. The project is the first step toward the formal evaluation of the efficacy of a classroom-based approach to suicide prevention in remote community schools.

Development and Validation of the Gatekeeper Behavior Scale

Abstract. Background: Community-based gatekeeper trainings are effective tools in increasing gatekeeper skills but few validated measures assess impact. Aims: This study aimed at determining the validity of an 11-item Gatekeeper Behavior Scale (GBS) to assess gatekeeper skills that predict behavior. Method: To validate the scale, 8,931 users were administered GBS surveys at pretraining, posttraining, and follow-up periods. The training was one of five from the suite of online At-Risk mental health learning simulations for university faculty/staff or students or high/middle school educators. Results: A confirmatory factor analysis revealed the three-factor model based on the subscales of preparedness, likelihood, and self-efficacy fit the data best. Factor loadings showed all items correlated highly with theoretical constructs (r ≥ .84, p < .001). The GBS had high internal consistency (α = 0.93). Criterion-related validity for likelihood to discuss concerns at posttraining was significantly related to approaching students believed to be in psychological distress (r = .219, p < .001). Likelihood to refer significantly correlated with the number of students referred (r = .235, p < .001). Convergent validity was established via a correlation between self-efficacy in motivating someone to seek help and general self-efficacy (r = .519, p < .001). Conclusion: The GBS appears to be a valid tool in measuring the impact of online gatekeeper training simulations and holds promise for assessing other delivery methods.

Measuring the effect of ethnic and non-ethnic discrimination on Europeans' self-rated health

OBJECTIVES

The study of perceived discrimination based on race and ethnic traits belongs to a long-held tradition in this field, but recent studies have found that non-ethnic discrimination based on factors such as gender, disability or age is also a crucial predictor of health outcomes.

METHODS

Using data from the European Social Survey (2010), and applying Boolean Factor Analysis and Ordered Logistic Regression models, this study is aimed to compare how ethnic and non-ethnic types of discrimination might affect self-rated health in the European context.

RESULTS

We found that non-ethnic types of discrimination produce stronger differences on health outcomes. This result indicates that the probabilities of presenting a poor state of health are significantly higher when individuals feel they are being discriminated against for social or demographic conditions (gender, age, sexuality or disability) rather than for ethnic reasons (nationality, race, ethnicity, language or religiosity).

CONCLUSIONS

This study offers a clear comparison of health inequalities based on ethnic and non-ethnic types of discrimination in the European context, overcoming analytical based on binary indicators and simple measures of discrimination.

A Youth Suicide Prevention Plan for Canada: A Systematic Review of Reviews

OBJECTIVE

We conducted an expedited knowledge synthesis (EKS) to facilitate evidence-informed decision making concerning youth suicide prevention, specifically school-based strategies and nonschool-based interventions designed to prevent repeat attempts.

METHODS

Systematic review of review methods were applied. Inclusion criteria were as follows: systematic review or meta-analysis; prevention in youth 0 to 24 years; peer-reviewed English literature. Review quality was determined with AMSTAR (a measurement tool to assess systematic reviews). Nominal group methods quantified consensus on recommendations derived from the findings.

RESULTS

No included review addressing school-based prevention (n = 7) reported decreased suicide death rates based on randomized controlled trials (RCTs) or controlled cohort studies (CCSs), but reduced suicide attempts, suicidal ideation, and proxy measures of suicide risk were reported (based on RCTs and CCSs). Included reviews addressing prevention of repeat suicide attempts (n = 14) found the following: emergency department transition programs may reduce suicide deaths, hospitalizations, and treatment nonadherence (based on RCTs and CCSs); training primary care providers in depression treatment may reduce repeated attempts (based on one RCT); antidepressants may increase short-term suicide risk in some patients (based on RCTs and meta-analyses); this increase is offset by overall population-based reductions in suicide associated with antidepressant treatment of youth depression (based on observational studies); and prevention with psychosocial interventions requires further evaluation. No review addressed sex or gender differences systematically, Aboriginal youth as a special population, harm, or cost-effectiveness. Consensus on 6 recommendations ranged from 73% to 100%.

CONCLUSIONS

Our EKS facilitates decision maker access to what is known about effective youth suicide prevention interventions. A national research-to-practice network that links researchers and decision makers is recommended to implement and evaluate promising interventions; to eliminate the use of ineffective or harmful interventions; and to clarify prevention intervention effects on death by suicide, suicide attempts, and suicidal ideation. Such a network could position Canada as a leader in youth suicide prevention.

Psychosocial correlates of suicidal ideation in rural South African adolescents

Suicide is a prevalent problem among young people in Southern Africa, but prevention programs are largely absent. This survey aimed to identify the behavioral and psychosocial correlates of suicidal ideation among adolescents in Limpopo. A two-stage cluster sample design was used to establish a representative sample of 591 adolescents. Bivariate correlations and multiple linear regression analyses were conducted. Findings show that suicidal ideation is prevalent among adolescents. The psychosocial factors perceived social support and negative feelings about the family and the behavioral factors forced sexual intercourse and physical violence by the partner were found to increase the risk of suicidal ideation. Depression mediated the relationship between these psychosocial and behavioral risk factors and suicidal ideation. This study increased our understanding of the psychosocial and behavioral predictors of adolescent suicidal ideation. The findings provide target points for future intervention programs and call for supportive structures to assist adolescents with suicidal ideation.

School-based suicide prevention: content, process, and the role of trusted adults and peers

Suicide is a leading cause of preventable death in youth, and numerous curricula and other prevention and intervention programs have been developed in the last 15 years. Comprehensive suicide prevention planning should include the 4 components of health promotion, prevention/education, intervention, and postvention. School-based suicide prevention and mental health education programs have become more common as an efficient and cost-effective way to reach youth. Process considerations that are based on the principles of therapeutic engagement with patients and families can provide mental health professionals with strategies that can assist education professionals, students, and the larger school community simultaneously.

Interventions for primary prevention of suicide in university and other post-secondary educational settings

BACKGROUND

Suicide is a leading cause of death among post-secondary students worldwide. Suicidal thoughts and planning are common among post-secondary students. Previous reviews have examined the effectiveness of interventions for symptomatic individuals; however, many students at high risk of suicide are undiagnosed and untreated.

OBJECTIVES

We evaluated the effect on suicide and suicide-related outcomes of primary suicide prevention interventions that targeted students within the post-secondary setting.

SEARCH METHODS

We searched the following sources up to June 2011: Specialised Registers of two Cochrane Groups, Cochrane Central Register of Controlled Trials, and nine other databases, trial registers, conference proceedings, and websites of national and international organizations. We screened reference lists and contacted authors of included studies to identify additional studies. We updated the search in November 2013; we will include these results in the review's next update.

SELECTION CRITERIA

We included studies that tested an intervention for the primary prevention of suicide using a randomized controlled trial (RCT), controlled before-and-after (CBA), controlled interrupted time series (CITS), or interrupted time series (ITS) study design. Interventions targeted students within the post-secondary setting (i.e. college, university, academy, vocational, or any other post-secondary educational institution) without known mental illness, previous suicide attempt or self-harm, or suicidal ideation. Outcomes included suicides, suicide attempts, suicidal ideation, changes in suicide-related knowledge, attitudes and behavior, and availability of means of suicide.

DATA COLLECTION AND ANALYSIS

We used standardized electronic forms for data extraction, risk of bias and quality of evidence determination, and analysis. We estimated standardised mean differences (SMD) with 95% confidence intervals (CIs). We analysed studies by intervention type and study design. We summarized RCT effect sizes using random-effects models meta-analyses; and analysed statistical heterogeneity using the Chi(2) test and I(2) statistic. We described narratively the results from studies that used other study designs.

MAIN RESULTS

Eight studies met inclusion criteria. They were heterogeneous in terms of participants, study designs, and interventions. Five of eight studies had high risk of bias. In 3 RCTs (312 participants), classroom-based didactic and experiential programs increased short-term knowledge of suicide (SMD = 1.51, 95% CI 0.57 to 2.45; moderate quality evidence) and knowledge of suicide prevention (SMD = 0.72, 95% CI 0.36 to 1.07; moderate quality evidence). The effect on suicide prevention self-efficacy in one RCT (152 participants) was uncertain (SMD = 0.20, 95% CI -0.13 to 0.54; low quality evidence). One CBA analysed the effects of an institutional policy that restricted student access to laboratory cyanide and mandated professional assessment for suicidal students. The incidence of student suicide decreased significantly at one university with the policy relative to 11 control universities, 2.00 vs. 8.68 per 100,000 (Z = 5.90; P < 0.05). Four CBAs explored effects of training 'gatekeepers' to recognize and respond to warning signs of emotional crises and suicide risk in students they encountered. The magnitude of effect sizes varied between studies. Gatekeeper training enhanced short-term suicide knowledge in students, peer advisors residing in student accommodation, and faculty and staff, and suicide prevention self-efficacy among peer advisors. There was no evidence of an effect on participants' suicide-related attitudes or behaviors. One CBA found no evidence of effects of gatekeeper training of peer advisors on suicide-related knowledge, self-efficacy, or gatekeeper behaviors measured four to six months after intervention.

AUTHORS' CONCLUSIONS

We found insufficient evidence to support widespread implementation of any programs or policies for primary suicide prevention in post-secondary educational settings. As all evaluated interventions combined primary and secondary prevention components, we were unable to determine the independent effects of primary preventive interventions. Classroom instruction and gatekeeper training increased short-term suicide-related knowledge. We found no studies that tested the effects of classroom instruction on suicidal behavior or long-term outcomes. Limited evidence suggested minimal longer-term effects of gatekeeper training on suicide-related knowledge, while no evidence was found evaluating its effect on suicidal behavior. A policy-based suicide intervention reduced student suicide, but findings have not been replicated. Our findings are limited by the overall low quality of the evidence and the lack of studies from middle- and low-income countries. Rigorously designed studies should test the effects of preventive interventions on important health outcomes, including suicidal ideation and behavior, in varying post-secondary settings.

Suicide Prevention

Suicide is a public health problem affecting people across the lifespan. It is currently the 10th leading cause of death, with rates having remained relatively flat for the past century. This article summarizes the problem of suicide and suicidal behavior along with suicide prevention efforts in the United States. Part 1 provides an overview of the epidemiology of suicide, including groups most at risk of suicide and suicidal behavior. Part 2 provides a review of common risk factors, organized by developmental life stage. A brief discussion of the lesser well-researched area of protective factors follows. Part 3 provides an overview of suicide prevention today, including the major types of prevention strategies, their successes, including means restriction, quality improvement in behavioral services, and comprehensive programs; and limitations to date, such as a lack of evidence for impact on actual deaths or behavior, small sample sizes, and low base rates. Finally, part 4 discusses challenges and future directions with an eye toward the great many opportunities that exist for prevention.

The public health approach to reducing suicide: opportunities for curriculum development in psychiatry residency training programs

The authors review the current status of suicide prevention curricula in psychiatry training programs, describe the public health approach to suicide prevention, discuss public health strategies for reducing suicides and the unique role played by psychiatrists with respect to suicide prevention, and offer public health-oriented suicide prevention curriculum guidelines for psychiatry residents.

'Plue plun' male, 'kath klei' female: gender differences in suicidal behavior as expressed by young people in Cambodia

Few studies from low- and middle-income countries use qualitative methodology to explore suicidal behavior among young people. In Cambodia, young people face the challenge of rapidly changing times and are vulnerable for suicidal behavior as revealed by research in transitional economies. This study seeks to gain a deeper understanding of the suicidal phenomena from a gender, psychosocial and cultural perspective. Six focus-group discussions were conducted among boys and girls, aged 15-19 years, in two secondary schools in a suburban area close to Phnom Penh, the capital city. The data was analyzed using thematic analysis approach. The participants highlighted the gender difference in suicidal behavior by describing the suicide-prone, acting-out male as 'plue plun', while suicide-prone females were described as caught in constricted, tunneled-thinking behavior, expressed as 'kath klei'. Parental attitude and family environment were also pointed out as the chief causes of discontent and there was a strong wish on the part of young people to find space for modern values within the traditional family. The young people's awareness of their challenges in everyday life suggests that school-based programs to prevent suicidal behavior ought to be gender-sensitive and peer-focused.

Suicide Ideation and Attempts and Bullying in Children and Adolescents

Background: Studies of the relationship between bullying and suicide behavior yield mixed results. Aims: This is the first study comparing frequencies of suicide behavior in four bullying groups (bully, victim, bully/victim, and neither) in two large psychiatric and community samples of young children and adolescents. Method: Maternal ratings of bullying and suicide ideation and attempts were analyzed for 1,291 children with psychiatric disorders and 658 children in the general population 6–18 years old. Results: For both the psychiatric and community samples, suicide ideation and attempt scores for bully/victims were significantly higher than for victims only and for neither bullies nor victims. Differences between victims only and neither victims nor bullies were nonsignificant. Controlling for sadness and conduct problems, suicide behavior did not differ between the four bullying groups. All children with suicide attempts had a comorbid psychiatric disorder, as did all but two children with suicide ideation. Conclusion: Although the contribution of bullying per se to suicide behavior independent of sadness and conduct problems is small, bullying has obvious negative psychological consequences that make intervention imperative. Interventions need to focus on the psychopathology associated with being a victim and/or perpetrator of bullying in order to reduce suicide behavior.

Outcome of a school-based intervention to promote life-skills among young people in Cambodia

BACKGROUND

Most of the school-based interventions to prevent suicide are from high income countries and there is a need for evidence based interventions in resource-poor settings. The aim of this study is to evaluate the outcome of a school based intervention to reduce risk factors for suicide among young people in Cambodia by promoting life skills.

METHOD

Six classes were randomly selected from two schools each, one designated as experimental and the other as control school, respectively. In experimental school 168 young people (M=92, F=76) received 6 sessions of life skills education and in the control school 131 students (M=53, F=78) received three general sessions on health. We looked at the pre-post differences on Life-Skills Development Scale Adolescent Form (LSDS-AF)- and Youth Self-Report (YSR) questionnaire to measure the effect size (ES) from the intervention after 6 months. We analyzed the data by stratifying for gender and for those who reported more severe suicidal expressions at baseline (high-risk group).

RESULTS

The girls showed improvement in Human Relationship (ES=0.57), Health Maintenance (ES=0.20) and the Total Life Skills Dimensions (ES=0.24), whereas boys with high-risk behavior improved on Human Relationship (ES=0.48), Purpose in Life (ES=0.26) and Total Life Skills Dimensions (ES=0.22). Effect size for YSR-syndrome scores among all individuals showed no improvement for either gender. Among high-risk individuals boys had a small to moderate effect size from intervention on Withdrawn/Depressed (ES=0.40), Attention problems (ES=0.46), Rule breaking behavior (ES=0.36), Aggressive behavior (ES=0.48) and Externalizing syndrome (ES=0.64).

CONCLUSION

Promoting life skills in schools may enhance the overall mental health of young people, indirectly influencing suicide, particularly among boys with high-risk behavior in Cambodia.

Effectiveness of the surviving the Teens® suicide prevention and depression awareness program: an impact evaluation utilizing a comparison group

Youth suicide is a serious public health issue in the United States. It is currently the third leading cause of death for youth aged 10 to 19. School-based prevention programs may be an effective method of educating youth and enhancing their help-seeking. Most school-based suicide prevention programs have not been rigorously evaluated for their effectiveness. This evaluation employs a comparison group to measure whether program group participants differed significantly from comparison group participants on pretest-posttest measures while assessing the immediate impact of the Surviving the Teens® Suicide Prevention and Depression Awareness Program. Findings indicate several positive outcomes in program group students' suicide and depression knowledge, attitudes, confidence, and behavioral intentions compared with the comparison group. Suicide prevention specialists and prevention planners may benefit from study findings.

The impact of universal suicide-prevention programs on the help-seeking attitudes and behaviors of youths

BACKGROUND

While the ultimate goal of adolescent suicide-prevention efforts is to decrease the incidence of death by suicide, a critical intermediary goal is directing youths toward effective sources of assistance.

AIM

To comprehensively review the universal prevention literature and examine the effects of universal prevention programs on student's attitudes and behaviors related to help-seeking.

METHOD

We systematically reviewed studies that assessed help-seeking outcomes including prevention efforts utilizing (1) psychoeducational curricula, (2) gatekeeper training, and (3) public service messaging directed at youths. Of the studies reviewed, 17 studies evaluated the help-seeking outcomes. These studies were identified through a range of sources (e.g., searching online databases, examining references of published articles on suicide prevention).

RESULTS

The results of this review suggest that suicide-prevention programming has a limited impact on help-seeking behavior. Although there was some evidence that suicide-prevention programs had a positive impact on students' help-seeking attitudes and behaviors, there was also evidence of no effects or iatrogenic effects. Sex and risk status were moderators of program effects on students help-seeking.

CONCLUSIONS

Caution is warranted when considering which suicidal prevention interventions best optimize the intended goals. The impact on adolescents' help-seeking behavior is a key concern for educators and mental-health professionals.

Emotionally Troubled Teens’ Help-Seeking Behaviors

Many school-based suicide prevention programs do not show a positive impact on help-seeking behaviors among emotionally troubled teens despite their being at high risk for suicide. This study is a secondary analysis of the Surviving the Teens® program evaluation to determine its effect on help-seeking behaviors among troubled youth. Results showed significant increases in mean scores of the Behavioral Intent to Communicate with Important Others Regarding Emotional Health Issues subscale ( p < .0005) from pretest to 3-month follow-up. There was a significant increase ( p = .006) in mean scores of the Behavioral Intent Regarding Help-Seeking Behaviors when Suicidal subscale from pretest to posttest, but not at 3-month follow-up. Also, there was a significant increase ( p = .016) in mean scores in the item “I would tell an adult if I was suicidal” from pretest to 3-month follow-up. These findings suggest that the Surviving the Teens program has a positive effect on help-seeking behaviors in troubled youth.

A systematic review of school-based suicide prevention programs

OBJECTIVE

Suicide is one of the leading causes of death among youth today. Schools are a cost-effective way to reach youth, yet there is no conclusive evidence regarding the most effective prevention strategy. We conducted a systematic review of the empirical literature on school-based suicide prevention programs.

METHOD

Studies were identified through MEDLINE and Scopus searches, using keywords such as "suicide, education, prevention and program evaluation." Additional studies were identified with a manual search of relevant reference lists. Individual studies were rated for level of evidence, and the programs were given a grade of recommendation. Five reviewers rated all studies independently and disagreements were resolved through discussion.

RESULTS

Sixteen programs were identified. Few programs have been evaluated for their effectiveness in reducing suicide attempts. Most studies evaluated the programs' abilities to improve students' and school staffs' knowledge and attitudes toward suicide. Signs of Suicide and the Good Behavior Game were the only programs found to reduce suicide attempts. Several other programs were found to reduce suicidal ideation, improve general life skills, and change gatekeeper behaviors.

CONCLUSIONS

There are few evidence-based, school-based suicide prevention programs, a combination of which may be effective. It would be useful to evaluate the effectiveness of general mental health promotion programs on the outcome of suicide. The grades assigned in this review are reflective of the available literature, demonstrating a lack of randomized controlled trials. Further evaluation of programs examining suicidal behavior outcomes in randomized controlled trials is warranted.

Perceived discrimination and self-rated health in Europe: evidence from the European Social Survey (2010)

INTRODUCTION

Studies have shown that perceived discrimination has an impact on our physical and mental health. A relevant part of literature has highlighted the influence of discrimination based on race or ethnicity on mental and physical health outcomes. However, the influence of other types of discrimination on health has been understudied. This study is aimed to explore how different types of discrimination are related to our subjective state of health, and so to compare the intensity of these relationships in the European context.

METHODS

We have performed a multilevel ordered analysis on the fifth wave of the European Social Survey (ESS 2010). This dataset has 52,458 units at individual level that are grouped in 26 European countries. In this study, the dependent variable is self-rated health (SRH) that is analyzed in relationship to ten explanatory variables of perceived discrimination: color or race, nationality, religion, language, ethnic group, age, gender, sexuality, disability and others.

RESULTS

The model identifies statistically significant differences in the effect that diverse types of perceived discrimination can generate on the self-rated health of Europeans. Specifically, this study identifies three well-defined types of perceived discrimination that can be related to poor health outcomes: (1) age discrimination; (2) disability discrimination; and (3) sexuality discrimination. In this sense, the effect on self-rated health of perceived discrimination related to aging and disabilities seems to be more relevant than other types of discrimination in the European context with a longer tradition in literature (e.g. ethnic and/or race-based).

CONCLUSION

The present study shows that the relationship between perceived discrimination and health inequities in Europe are not random, but systematically distributed depending on factors such as age, sexuality and disabilities. Therefore the future orientation of EU social policies should aim to reduce the impact of these social determinants on health equity.