Gatekeeper training for friends and family of individuals at risk of suicide: A systematic review

Evaluating the Longitudinal Efficacy of Suicide CARE (a Korean Standard Gatekeeper Training Program) in a General Community Sample: A Randomized Controlled Trial

OBJECTIVE

Suicide poses a significant public health concern with increasing prevalence in the general population, emphasizing the need for effective gatekeeper suicide prevention education. This study assesses the longitudinal effectiveness of the "Suicide CARE" gatekeeper training program within a general community sample. Suicide CARE is representative gatekeeper program in Korea. A total of 5 million individuals completed the training program of Suicide CARE in Korea to date.

METHODS

Participants were recruited through the Korea Suicide Prevention Association website, randomly assigned to the experimental (n=49) or control group (n=53). Pre- and post-training surveys, along with a 3-month follow-up, measured perceived knowledge, gatekeeper efficacy, preparedness, and attitudes toward suicide. Longitudinal effects were analyzed using repeated measures analysis of variance.

RESULTS

The experimental group showed significant improvement in perceived knowledge, gatekeeper efficacy, perceived preparedness, and some aspects of attitude towards suicide compared to the control group, with effects declining over time but remaining statistically significant at the 3-month follow-up test.

CONCLUSION

This study is the first to evaluate the longitudinal effectiveness of Suicide CARE in a community population. Strategic integration of evidence-based gatekeeper training programs like Suicide CARE can contribute to community suicide prevention initiatives.

Implementing LEARN: Comprehensive Suicide Prevention Training for High School Students, Parents, and School Personnel

BACKGROUND

Adolescent suicide is a public health issue, and school is an ideal setting for prevention activities. LEARN is a peer-led gatekeeper training for high school personnel, parents, and students. The purpose of this study was to evaluate the effectiveness of LEARN as a gatekeeper training.

METHODS

Paired t tests were used to compare pre- and post-training surveys for 4983 LEARN participants.

RESULTS

Participants reported an increased likelihood of engaging in each LEARN step: looking for signs, empathizing and listening, asking about suicide thoughts and plans, reducing danger, and connecting the person with help. Most participants were highly satisfied with the peer trainer's delivery of content.

CONCLUSIONS

LEARN gatekeeper training was successfully implemented in high schools with students, parents, and school personnel. All groups reported increases in likelihood of approaching and providing support and connections for at-risk individuals and rated the trainer as effective, indicating satisfaction with the peer-led training format.

Cross-sectional study about suicide ideation and attempts among Brazilian pre-adolescents

BACKGROUND

Suicide is a global public health problem. In childhood, the risk factors are less clear, highlighting family and individual factors. This study aims to investigate the prevalence and sociodemographic, social, family, and individual factors associated with suicide ideation and attempts in pre-adolescents in a Brazilian city.

METHODS

The sample comes from a cohort of 500 schoolchildren of a city in Rio de Janeiro/Brazil. The data are analyzed cross-sectionally. The research incorporated data from the years 2005, 2006, and 2008 to evaluate suicide ideation and attempts in childhood, as reported by parents/caregivers, teachers and children. A hierarchical logistic model evaluated the association between the explanatory variables related to sociodemographic, social, family, and individual factors and the outcome.

RESULTS

22.2% of the children (95% CI 18.0%-27.0%) had suicide ideation/attempts, reported either by their mothers, teachers, or the child at some point in a cohort. The following variables were associated with suicidal ideation/attempts in the final adjusted model: regular or poor quality of relationship with friends (OR = 1.84; 95% CI 1.31-2.58), having a family member incarcerated (OR = 1.44; 95% CI 1.07-1.92) and having worse performance in portuguese or mathematics than other students (OR = 2.05; 95% CI 1.29-3.26).

CONCLUSION

Suicidal behavior in childhood is severe and affects everyone around the case, demanding to promote friendships, helping with school activities, and providing greater support and attention to children at risk. Bad relationships with friends and incarcerated family members are particularly key risk factors for suicide ideation and attempts. It is essential to improve prevention policies and to disseminate protective behaviors. There is a critical need to augment community mental health resources, mainly in less developed countries and regions that lack these services.

Efficacy of an online gatekeeper program for relatives of men at risk of suicide - a randomized controlled trial

BACKGROUND

Men at risk for suicide are a challenging population group to reach with suicide prevention strategies. Gatekeepers hold a pivotal role in the prevention of male suicide, yet effective intervention requires them to have a level of knowledge and strategies to provide support.

AIM

This study aimed to examine the efficacy of an online gatekeeper program for gatekeepers in male suicide prevention, assessing knowledge, perceived preparedness, self-efficacy, and psychopathological symptoms of gatekeepers.

METHODS

Eighty-four participants were randomized to either the intervention (n = 43) or the waitlist control group (n = 41). The intervention comprised four modules providing knowledge and strategies for addressing men in suicidal crises. Outcomes included depression (PHQ-9), distress (PSS-10), burden (BAS), involvement (IEQ), as well as gatekeeper outcomes and knowledge.

RESULTS

Completer analyses revealed significant improvement of depressive symptoms (d = 0.39) and an increase in gatekeeper outcomes (d = 0.58 to d = 0.84) and knowledge (d = 0.62) from baseline to post-assessment. The effects were maintained for 3 months. No significant effects could be found for burden, distress, and involvement.

CONCLUSIONS

The findings indicate that a brief gatekeeper program can serve as a valuable resource. Future research should focus on examining the mental health of gatekeepers themselves and its long-term effects on intervention behavior.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00030758, registered on 05.12.2022.

Expanding the Question-Persuade-Refer (QPR) Evidence Base: Youth Suicide Prevention among the Mississippi Band of Choctaw Indians

Youth suicide risks have been on the rise or persistently elevated for decades, and Native American communities are especially vulnerable. This study provides a promising framework for suicide prevention among underserved populations in the U.S., especially Native American communities in states lacking strong suicide prevention supports. Our investigation reports the evaluation results of the Question-Persuade-Refer (QPR) gatekeeper training program, a key component of the SAMHSA-funded Choctaw Youth Resilience Initiative (CYRI) implemented by the Mississippi Band of Choctaw Indians (MBCI). QPR trains adult gatekeepers to identify youth at risk of suicide and refer them to certified mental health service providers. Standardized QPR pre-test and post-test training surveys were administered at in-person trainings delivered to youth-serving MBCI organization leaders and staff. Statistical analyses of all survey items indicate that QPR gatekeeper trainings significantly enhanced the knowledge of prevention practices and risk identification skills for the MBCI trainees. The robust evidence of positive changes revealed in this study suggests that QPR can be an effective suicide prevention program for underserved minority communities, especially Native American populations in rural states where suicide is a persistent and leading cause of mortality.

Suicide-Related Stigma and Social Responsibility Moderate the Effects of an Online Suicide Prevention Gatekeeper Training Program

AIM

Gatekeeper interventions are universal programs designed for use by the general public that provide brief training sessions in responding to suicidal risk. To date, the evidence base for the efficacy of gatekeeper intervention training programs has been mixed. However, little attention has been paid to potential psychological moderators of the efficacy of suicide gatekeeper interventions. We explore the potential moderating effects of suicide-related stigma and social responsibility on the efficacy of a suicide prevention gatekeeper training program.

METHODS

Participants were 179 college students with a mean age of 19.05 years (SD = 1.82, range 18-31). Participants were 71.5% women, 48.6% Hispanic, and 19.6% non-Hispanic White.

RESULTS

Results indicated that higher scores on suicide-related stigma were associated with smaller intervention effects on gatekeeper self-efficacy. In contrast, higher scores on social responsibility were associated with greater intervention effects with regard to gatekeeper preparedness and gatekeeper likelihood.

CONCLUSION

An improved understanding of the factors associated with efficacy of gatekeeper intervention programs may lead to the development of improved gatekeeper interventions. These findings may also contribute to the development of targeted gatekeeper interventions for specific cultural or occupational groups.

Social disconnection and suicide mortality among Japanese older adults: A seven-year follow-up study

BACKGROUND

Few prospective studies have examined the association between social disconnection and late-life suicide. Therefore, we conducted a large-scale prospective study of older adults in Japan to examine differences in suicide mortality according to specific aspects of social disconnectedness.

METHODS

We conducted a nationwide baseline survey of functionally independent older adults (age ≥65 years) from 12 municipalities in Japan from 2010 to 2011. We followed the participants (n = 46,144) for cause of death through December 2017 using vital statistics. Social disconnection was assessed based on the indicators of eating alone, a lack of instrumental/emotional support, no participation in community activities, and no contact with friends. We adopted Cox regression models with multiple imputation for missing values and calculated the population-attributable fraction (PAF).

RESULTS

A total of 55 suicide deaths were recorded during an average follow-up of 7 years. Older adults with social disconnection had a marginally increased risk of suicide. The hazard ratio for eating alone vs. eating together was 2.81 (95% confidence interval [CI]: 1.47-5.37). The direction of these associations and point estimations did not largely change after controlling for depressive symptoms, an evident risk factor for suicidal behavior. The PAF indicated that eating alone was attributable to around 1800 (29%) of the suicide deaths among older adults annually in Japan.

CONCLUSION

Avoidance of not only depressive symptoms, but also social disconnection including eating alone, is useful in suicide prevention among older adults.

Considering the importance of 'Communities of Practice' and Health Promotion Constructs for Upstream Suicide Prevention

Background

Suicide is a serious and growing health inequity for Alaska Native (AN) youth (ages 15-24), who experience suicide rates significantly higher than the general U.S. youth population. In low-resourced, remote communities, building on the local and cultural resources found in remote AN communities to increase uptake of prevention behaviors like lethal means reduction, interpersonal support, and postvention can be more effective at preventing suicide than a risk-referral process. This study expands the variables we hypothesize as important for reducing suicide risk and supporting wellbeing. These variables are: 1) perceived suicide prevention self-efficacy, 2) perceived wellness self-efficacy, and 3) developing a 'community of practice' (CoP) for prevention/wellness work.

Method

With a convenience sample (N = 398) of participants (ages 15+) in five remote Alaska Native communities, this study characterizes respondents' social roles: institutional role if they have a job that includes suicide prevention (e.g. teachers, community health workers) and community role if their primary role is based on family or community positioning (e.g. Elder, parent). The cross-sectional analysis then explores the relationship between respondents' wellness and prevention self-efficacy and CoP as predictors of their self-reported suicide prevention and wellness promotion behaviors: (1) working together with others (e.g. community initiatives), (2) offering interpersonal support to someone, (3) reducing access to lethal means, and (4) reducing suicide risk for others after a suicide death in the community.

Results

Community and institutional roles are vital, and analyses detected distinct patterns linking our dependent variables to different preventative behaviors. Findings associated wellness self-efficacy and CoP (but not prevention self-efficacy) with 'working together' behaviors, wellness and prevention self-efficacy (but not CoP) with interpersonal supportive behaviors; both prevention self-efficacy and CoP with higher postvention behaviors. Only prevention self-efficacy was associated with lethal means reduction.

Conclusions

The study widens the scope of suicide prevention. Promising approaches to suicide prevention in rural low-resourced communities include: (1) engaging people in community and institutional roles, (2) developing communities of practice for suicide prevention among different sectors of a community, and (3) broadening the scope of suicide prevention to include wellness promotion as well as suicide prevention.

Engagement in meaningful activities post suicide loss: A scoping review protocol

RATIONALE

Each day, more than 10 Canadians die by suicide. Each suicide leaves entire communities to manage the traumatic aftermath of this loss. Individuals bereaved by suicide loss are at a higher risk of experiencing negative mental health outcomes. Current research suggests that engagement in meaningful activities may be an avenue to protecting mental health. It is important to understand if this is also the case for those experiencing bereavement post suicide loss. To date, there has not been a synthesis of the literature examining suicide loss and the nature and extent of engagement in meaningful activities post loss.

OBJECTIVES

1) To describe the nature and extent of the peer-reviewed suicide loss and bereavement literature related to engagement in meaningful activities; and 2) to identify facilitators and barriers that may impact engagement in meaningful activities post loss.

METHODS

This paper describes a scoping review protocol that will be completed using stages identified by Arksey and O'Malley and updated by Levac and colleagues. Joanna Briggs Institute framework will also guide this review. Four electronic databases will be searched for suicide bereavement/loss concepts. Two reviewers will apply inclusion and exclusion criteria to identify articles discussing engagement in meaningful activities of everyday living post loss. Data will be descriptively summarized and analyzed using inductive content analysis. Results will be reported following PRISMA Extension for Scoping Reviews.

EXPECTED RESULTS

A descriptive summary and conceptual map describing the current state of the peer-reviewed literature will be constructed.

CONCLUSION

Experiencing a suicide loss increases the risk of negative mental health outcomes. A synthesis of literature is required to map the current available evidence related to suicide bereavement and engagement in meaningful activities, with potential implications for improving supports and services for those bereaved. This protocol is register with Open Science Framework Registries (10.17605/OSF.IO/M2NES).

Randomized Controlled Trial of an Online Suicide Prevention Gatekeeper Training Program

Background: Suicide prevention gatekeeper training programs offer a unique opportunity to increase knowledge about suicide prevention, enhance risk identification, and reduce suicide-related stigma. Aims: This study evaluated the efficacy of an online suicide prevention gatekeeper training program in a randomized trial. Method: Participants were US college students (N = 388). Participants (69.3% women) had a mean age of 19.01 years and identified primarily as Hispanic/Latinx (52.1%) and non-Hispanic White (22.4%). Participants completed pre- and posttest surveys and were randomly assigned to either the ASK About Suicide to Save a Life (AS + K?) suicide prevention gatekeeper training program or an information-only comparison intervention. Results: Participants in the AS + K? condition reported significantly greater gatekeeper preparedness and self-efficacy, and lower stigmatized attitudes at posttraining, as compared with those in the comparison condition. There were no significant differences in likelihood of using gatekeeper skills or suicide-related knowledge across groups. Limitations: This short-term study was not able to assess behavioral change resulting in use of gatekeeper skills over time. Conclusions: Completion of gatekeeper training resulted in increases in preparedness and self-efficacy for engaging in gatekeeper behaviors, as well as a reduction in suicide-related stigma. Despite small intervention effects, the online AS + K? training appears to be a promising program.

Effectiveness of Gatekeeper Training for Families of People With Mental Disorders in Korea: A Randomized Controlled Trial

OBJECTIVE

Given the high suicide risk among people with schizophrenia and other mental disorders and the significance of intervention in the daily life setting, tailored gatekeeper training is necessary for families of people with mental disorders. This study evaluated the effectiveness of a suicide prevention education program for families of people with mental disorders (SPEM-F), developed by the Korea Foundation for Suicide Prevention.

METHODS

Fifty-nine family members of people with mental disorders were recruited from eight community psychiatric rehabilitation centers in Korea and enrolled in a cluster randomized controlled trial. Four facilities were randomized to the experimental group (n=30) and four to the control group (n=29). The study parameters were measured at baseline, post-intervention, and 1-month follow-up; the effects of SPEM-F (90 minutes, conducted offline) were analyzed using repeated-measures analysis of variance. The dependent variables were suicide-related knowledge, attitude, self-efficacy, preventive behavioral intention, and family problem-solving communication.

RESULTS

The experimental group showed significant increases in suicide-related knowledge (p<0.001), self-efficacy (p<0.05), and preventive behavioral intention (p<0.01) compared with the control group until the 1-month follow-up, including an upward trend in improved family problem-solving communication (p=0.069).

CONCLUSION

The results confirm that SPEM-F is an effective evidence-based gatekeeper training program for families of people with mental disorders, as it focuses on knowledge, self-efficacy, preventive behavioral intention, and communication improvement. As families of people with mental disorders including schizophrenia, are both highly motivated and close to people at high risk for suicide, SPEM-F can effectively promote suicide prevention and gatekeeper activities.

Risk Factors of Suicide Attempt among Adolescents with Suicide Ideation in Low- and Middle-Income Countries across the Globe

Suicide is a serious public health problem for adolescents. Based on the framework of ideation-to-action, it is important to examine the factors associated with the translation from suicide ideation to suicide attempt. The present study aimed to investigate the risk factors of suicide attempts among adolescents with suicide ideation in low-income and middle-income countries (LMICs). We analyzed data of students aged 12-18 years who participated in the 2009-2013 Global School-based Health Surveys (GSHS) in 39 LMICs. The Chi-square test was used to compare the prevalence of suicide attempts among participants with suicide ideation, the multilevel logistic regression model was used to identify significant factors associated with suicide attempts among suicide ideators. Among 22,655 adolescents with suicide ideation, 55.1% of them reported having made a suicide attempt in the past year. Loneliness, anxiety, alcohol use, and drug use were risk factors for suicide attempts among suicide ideators. Strategies should be implemented to reduce the likelihood of adolescents acting on their suicidal thoughts, such as community psychological crisis line, school-based mental health and skills training programs, and family support for adolescents with psychological problems.

The Certified QPR Pathfinder Training Program: A Description of a Novel Public Health Gatekeeper Training Program to Mitigate Suicidal Ideation and Suicide Deaths

Suicide represents a significant public health concern. One approach to reducing suicide rates is to train gatekeepers-community members who, through their day-to-day practices, interact with a substantial proportion of the population-to detect individuals at elevated suicide risk and refer them to appropriate mental health care services. One of the most well-known community gatekeeper training programs is Question, Persuade, and Refer (QPR), which has been delivered to millions worldwide. Gatekeeper training, including QPR, shows considerable promise in reducing suicide risk. However, one limitation of existing gatekeeper training programs is that they rely on referrals to mental health services, which are often non-existent, understaffed, and/or undertrained regarding suicide risk. As such, novel approaches are needed to equip community gatekeepers with primary mental health first aid and suicide-focused counseling. This article describes, for the first time, the fundamental concepts of a newly developed and more expansive version of QPR, the QPR Pathfinder Training. The QPR Pathfinder Training is web-based training program designed to create a cadre of "super gatekeepers" to address suicide at scale. The QPR Pathfinder Training will equip communities to address the critical shortage of mental health care services around the globe and, in turn, reduce mental health morbidities and decrease the suicide rates.

Beyond human expertise: the promise and limitations of ChatGPT in suicide risk assessment

ChatGPT, an artificial intelligence language model developed by OpenAI, holds the potential for contributing to the field of mental health. Nevertheless, although ChatGPT theoretically shows promise, its clinical abilities in suicide prevention, a significant mental health concern, have yet to be demonstrated. To address this knowledge gap, this study aims to compare ChatGPT's assessments of mental health indicators to those of mental health professionals in a hypothetical case study that focuses on suicide risk assessment. Specifically, ChatGPT was asked to evaluate a text vignette describing a hypothetical patient with varying levels of perceived burdensomeness and thwarted belongingness. The ChatGPT assessments were compared to the norms of mental health professionals. The results indicated that ChatGPT rated the risk of suicide attempts lower than did the mental health professionals in all conditions. Furthermore, ChatGPT rated mental resilience lower than the norms in most conditions. These results imply that gatekeepers, patients or even mental health professionals who rely on ChatGPT for evaluating suicidal risk or as a complementary tool to improve decision-making may receive an inaccurate assessment that underestimates the actual suicide risk.

Can We Notice the Suicidal Warning Signs of Adolescents With Different Psychometric Profiles Before Their Death?: Analysis of Teachers' Reports

BACKGROUND

This study aimed to analyze the suicidal warning signs of Korean students with different psychometric profiles based on teacher reports.

METHODS

This was a retrospective cohort study based on Korean school teachers' responses to the Student Suicide Report Form. In total, 546 consecutive cases of student suicide were reported from 2017 to 2020. After missing data were excluded, 528 cases were included. The report consisted of demographic factors, the Korean version of the Strengths and Difficulties Questionnaire (SDQ) for teacher reporting, and warning signs of suicide. Frequency analysis, multiple response analysis, the χ² test, and Latent Class Analysis (LCA) were performed.

RESULTS

Based on the scores of the Korean version of the teacher-reported SDQ, the group was divided into nonsymptomatic (n = 411) and symptomatic (n = 117) groups. Based on the LCA results, four latent hierarchical models were selected. The four classes of deceased students showed significant differences in school type (χ² = 20.410, P < 0.01), physical illness (χ² = 7.928, P < 0.05), mental illness (χ² = 94.332, P < 0.001), trigger events (χ² = 14.817, P < 0.01), self-harm experience (χ² = 30.618, P < 0.001), suicide attempts (χ² = 24.072, P < 0.001), depressive symptoms (χ² = 59.561, P < 0.001), anxiety (χ² = 58.165, P < 0.001), impulsivity (χ² = 62.241, P < 0.001), and social problems (χ² = 64.952, P < 0.001).

CONCLUSION

Notably, many students who committed suicide did not have any psychiatric pathology. The proportion of the group with a prosocial appearance was also high. Therefore, the actual suicide warning signals were similar regardless of students' difficulties and prosocial behaviors, so it is necessary to include this information in gatekeeper education.

Helping intentions toward suicidal people among young adults: Patterns, transitions, and influencing factors

BACKGROUND

Public involvement is an essential element of effective suicide prevention. However, few studies have investigated laypeople's intentions and behaviors in supporting suicidal people, especially within Chinese contexts. This study was conducted among young adults in Hong Kong to identify categories of helping intentions toward suicidal people, and to understand whether, and why, youth transitioned over time between helping intention categories.

METHODS

A total of 807 Hong Kong young adults (18-35 years) participated in this two-wave study across 2018 (W1) and 2019 (W2). Latent class analyses were conducted to identify categories of helping intentions toward suicidal people. A latent transition analysis was applied to explore the stability of the categories over time, and the factors that influenced stability.

RESULTS

Three categories were identified in both waves: 1) dedicated helpers (W1: 28.38 %, W2: 28.50 %), 2) willing helpers (W1: 30.24 %, W2: 33.83 %), and 3) inconsistent helpers (W1: 41.39 %, W2: 37.67 %). 73.48 % of the young adults stayed in the same category across two years. Gender, and attitudes toward suicide victims were related to category membership and transitions between categories.

LIMITATIONS

Measurement of helping intentions may not be thorough. Further studies are required to examine whether the findings can be generalized to the other population.

CONCLUSIONS

Effective community engagement is essential for suicide prevention. Young adults in Hong Kong exhibited different helping intentions toward suicidal people, that were moderately stable over a two-year period. Understanding how and why young adults behave differently toward suicidal people is important when planning effective suicide prevention programs.

Feasibility of brief online gatekeeper training for Japanese university students: A randomized controlled trial

Gatekeeper training for university students is a promising suicide prevention approach. However, there is a lack of comparative studies with control groups and the effectiveness of online gatekeeper training programs is unclear. We investigated the effectiveness of brief online gatekeeper training for Japanese university students. Participants were divided into two groups (training or control) and answered surveys at three time points (pretest, posttest, follow-up). The gatekeeper training improved students' knowledge. Skills were also improved post-training but returned to baseline level at follow-up. A brief online program may improve knowledge, but the effect is limited.

Intervening to prevent suicide at railway locations: findings from a qualitative study with front-line staff and rail commuters

BACKGROUND

For every suicide on the British railway network, at least six potential attempts are interrupted by front-line staff or rail commuters. However, the factors that maximise or hinder the likelihood and effectiveness of such interventions are poorly understood.

AIMS

The aim of the current study was to shed light on the experience of intervening to prevent a suicide at a railway location, including how and why people intervene, and their feelings and reflections in the aftermath.

METHOD

In-depth interviews were carried out with rail commuters (n = 11) and front-line railway staff (n = 10) who had intervened to stop a suicide by train. Data were analysed thematically.

RESULTS

Participants had intervened to prevent suicide in several ways, both from afar (e.g. by calling a member of staff) and more directly (verbally or non-verbally), in some cases with no prior training or experience in suicide prevention, and often as a 'quick, gut reaction' given the limited time to intervene. In more 'reasoned' interventions, poor confidence and concerns around safety were the greatest barriers to action. Although often privy to their final outcome, most participants reflected positively on their intervention/s, stressing the importance of training and teamwork, as well as small talk and non-judgemental listening.

CONCLUSIONS

Suicides in railway environments can present bystanders with little time to intervene. Potential interveners should therefore be resourced as best as possible through clear infrastructure help/emergency points, visibility of station staff and training for gatekeepers.