The SOS Suicide Prevention Program: Further Evidence of Efficacy and Effectiveness

Prevention of self-harm and suicide in young people up to the age of 25 in education settings

BACKGROUND

In 2016, globally, suicide was the second leading cause of death amongst those aged 15 to 29 years. Self-harm is increasingly common among young people in many countries, particularly among women and girls. The risk of suicide is elevated 30-fold in the year following hospital presentation for self-harm, and those with suicidal ideation have double the risk of suicide compared with the general population. Self-harm and suicide in young people are significant public health issues that cause distress for young people, their peers, and family, and lead to substantial healthcare costs. Educational settings are widely acknowledged as a logical and appropriate place to provide prevention and treatment. A comprehensive, high-quality systematic review of self-harm and suicide prevention programmes in all education settings is thus urgently required. This will support evidence-informed decision making to facilitate rational investment in prevention efforts in educational settings. Suicide and self-harm are distressing, and we acknowledge that the content of this review is sensitive as the data outlined below represents the lived and living experience of suicidal distress for individuals and their caregivers.

OBJECTIVES

To assess the effects of interventions delivered in educational settings to prevent or address self-harm and suicidal ideation in young people (up to the age of 25) and examine whether the relative effects on self-harm and suicide are modified by education setting.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Specialised Register, CENTRAL, The Cochrane Database of Systematic Reviews, Ovid MEDLINE, PsycINFO, ERIC, Web of Science Social Science Citation Index, EBSCO host Australian Education Index, British Education Index, Educational Research Abstracts to 28 April 2023.

SELECTION CRITERIA

We included trials where the primary aim was to evaluate an intervention specifically designed to reduce self-harm or prevent suicide in an education setting. Randomised controlled trials (RCTs), cluster-RCTs, cross-over trials and quasi-randomised trials were eligible for inclusion. Primary outcomes were self-harm postintervention and acceptability; secondary outcomes included suicidal ideation, hopelessness, and two outcomes co-designed with young people: better or more coping skills, and a safe environment, with more acceptance and understanding.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane. Two review authors independently selected studies, extracted data, and assessed risk of bias. We analysed dichotomous data as odds ratios (ORs) and continuous data as standardised mean differences (SMDs) with 95% confidence intervals (CIs). We conducted random-effects meta-analyses and assessed certainty of evidence using the GRADE approach. For co-designed outcomes, we used vote counting based on the direction of effect, as there is a huge variation in the data and the effect measure used in the included studies.

MAIN RESULTS

We included 51 trials involving 36,414 participants (minimum 23; maximum 11,100). Twenty-seven studies were conducted in secondary schools, one in middle school, one in primary school, 19 in universities, one in medical school, and one across education and community settings. Eighteen trials investigated universal interventions, 11 of which provided data for at least one meta-analysis, but no trials provided data for self-harm postintervention. Evidence on the acceptability of universal interventions is of very low certainty, and indicates little or no difference between groups (OR 0.77, 95% CI 0.36 to 1.67; 9 studies, 8528 participants). Low-certainty evidence showed little to no effect on suicidal ideation (SMD -0.02, 95% CI -0.23 to 0.20; 4 studies, 379 participants) nor on hopelessness (MD -0.01, 95% CI -1.98 to 1.96; 1 trial, 121 participants). Fifteen trials investigated selective interventions, eight of which provided data for at least one meta-analysis, but only one trial provided data for self-harm postintervention. Low-certainty evidence indicates that selective interventions may reduce self-harm postintervention slightly (OR 0.39, 95% CI 0.06 to 2.43; 1 trial, 148 participants). While no trial provided data for hopelessness, little to no effect was found on acceptability (OR 1.00, 95% CI 0.5 to 2.0; 6 studies, 10,208 participants; very low-certainty evidence) or suicidal ideation (SMD 0.04, 95% CI -0.36 to 0.43; 2 studies, 102 participants; low-certainty evidence). Seventeen trials investigated indicated interventions, 14 of which provided data for at least one meta-analysis, but only four trials provided data for self-harm postintervention and two reported no events in both groups. Low-certainty evidence suggests that indicated interventions may slightly reduce self-harm postintervention (OR 0.19, 95% CI 0.02 to 1.76; 2 studies, 76 participants). There is also low-certainty evidence indicating that these interventions may decrease the odds of non-suicidal self-injury (OR 0.65, 95% CI 0.24 to 1.79; 2 studies, 89 participants). Evidence of a slight decrease in acceptability in the intervention group is of low certainty (OR 1.44, 95% CI 0.86 to 2.42; 10 studies, 641 participants). Low-certainty evidence shows that indicated interventions may slightly reduce suicidal ideation (SMD -0.33, 95% CI -0.55 to -0.10; 10 studies, 685 participants) and may result in little to no difference in hopelessness postintervention (SMD -0.27, 95% CI -0.55 to 0.01; 6 studies, 455 participants). There were mixed findings regarding the effect of suicide prevention interventions on a range of constructs relevant to coping skills and safe environment. None of the trials, however, measured the impact of improvements in these constructs on self-harm or suicidal ideation.

AUTHORS' CONCLUSIONS

While this review provides an update on the evidence about interventions targeting self-harm and suicide prevention in education settings, there remains significant uncertainty about the impact of these interventions. There are some promising findings but large replication studies are needed, as are studies that examine the combination of different intervention approaches, and can be delivered in a safe environment and implemented over a long period of time. Further research is required to understand and measure outcomes that are meaningful to young people with lived experience, as they want coping skills and safety of the environment in which they conduct their everyday lives to be measured as key outcomes in future trials.

Text Messaging to Extend School-Based Suicide Prevention: Pilot Randomized Controlled Trial

BACKGROUND

Suicide is the third-leading cause of death among US adolescents aged 10-19 years, and about 10% attempt suicide each year. School-based universal prevention may reduce youth suicidal behavior. Sources of Strength uses a peer leader network diffusion model to promote healthy norms across a school population. A key challenge within schoolwide programs is reaching a large and diverse array of students, especially those less engaged with their peers. Motivated by this challenge, we developed and field-tested Text4Strength-a program of automated text messages targeting help-seeking attitudes and norms, social coping resources, and emotion regulation skills.

OBJECTIVE

This study conducted a pilot randomized controlled trial of Text4Strength in 1 high school as an extension of an ongoing schoolwide program (Sources of Strength), to test its impact on targets that have the potential to reduce suicidal behavior.

METHODS

Students at an upstate New York high school (N=223) received 1-2 text messages per week for 9 weeks, targeting strategies for coping with difficult feelings and experiences through clarifying emotions and focusing on positive affect concepts, awareness, and strengthening of youth-adult relationships; and positive help-seeking norms, skills, and resources. Surveys were administered at baseline, immediately post intervention and 3 months after texting ended. We measured proximal intervention targets (methods of coping during stressful events, ability to make sense of their own emotions, feelings of powerlessness during emotion management and recovery, relations with trusted adults at school, and help-seeking behaviors), symptoms and suicide ideation, and student replies to messages.

RESULTS

No significant effects were observed for any outcome at either follow-up time point. Results showed that if there is a true (but undetected) intervention effect, it is small. Students with fewer friend nominations did not interact any more or less with the text messages. Exploratory moderation analyses observed no interaction between the intervention condition and the number of friends or baseline suicide ideation at any time point.

CONCLUSIONS

In contrast to a promising previous field test, these results suggest that Text4Strength is unlikely to have impacted the outcomes of interest and that undetected moderate or large effects can be ruled out with high confidence. Although motivated by the need to reach more isolated students, students with fewer friends did not engage more or show a greater effect than other participants. This study was conducted in a single high school that was already implementing Sources of Strength, so the bar for showing a distinct effect from texting alone was high. Many further channels for reaching youth through private messaging remain unexplored. Alternative delivery systems should be investigated, such as embedding messaging in gaming chat systems and other media. More sophisticated systems drawing on chatbots may also achieve better outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03145363; https://clinicaltrials.gov/study/NCT03145363.

Potential Harms of Responding to Youth Suicide Risk in Schools

The potential harms related to interventions for adults with suicide-related risk, particularly hospitalization, have been well documented. Much less work has focused on the potential harms related to interventions with youth struggling with suicidal thoughts and behaviors. Young people are most likely to receive mental health services in schools, which are recognized as meaningful sites for effective suicide prevention work. However, no overviews have conceptualized the potential harms to youth when schools engage in ineffective suicide prevention efforts. In this article, we discuss three prominent overlapping areas of potential harms: (1) privacy-related, (2) relationship-related, and (3) mental health-related. We then discuss key factors thought to influence the development and maintenance of these potential harms. We conclude by noting ways in which school-based mental health providers may attempt to reduce unintentional harms in this area, with an overarching goal of helping support school mental health providers and the youth they serve.

Longitudinal panel networks of risk and protective factors for early adolescent suicidality in the ABCD sample

Rates of youth suicidal thoughts and behaviors (STBs) are rising, and younger age at onset increases vulnerability to negative outcomes. However, few studies have investigated STBs in early adolescence (ages 10-13), and accurate prediction of youth STBs remains poor. Network analyses that can examine pairwise associations between many theoretically relevant variables may identify complex pathways of risk for early adolescent STBs. The present study applied longitudinal network analysis to examine interrelations between STBs and several previously identified risk and protective factors. Data came from 9,854 youth in the Adolescent Brain Cognitive Development Study cohort (Mage = 9.90 ± .62 years, 63% white, 53% female at baseline). Youth and their caregivers completed an annual measurement battery between ages 9-10 through 11-12 years. Panel Graphical Vector Autoregressive models evaluated associations between STBs and several mental health symptoms, socioenvironmental factors, life stressors, and substance use. In the contemporaneous and between-subjects networks, direct associations were observed between STBs and internalizing symptoms, substance use, family conflict, lower parental monitoring, and lower school protective factors. Potential indirect pathways of risk for STBs were also observed. Age-specific interventions may benefit from prioritizing internalizing symptoms and early substance use, as well as promoting positive school and family support.

Public health measures related to the transmissibility of suicide

Transmission is an important concept in suicide prevention. It can occur when exposure to another person's death by suicide (or to suicide-related information more generally) draws attention to suicide or highlights specific suicide methods. In this paper, the fourth in a Series on a public health approach to suicide prevention, we contend that the transmissibility of suicide must be considered when determining optimal ways to address it. We draw on five examples of how transmission might occur and be prevented. The first two examples relate to transmission initiated by representations of suicide in traditional and new media. The third concerns transmission that leads to suicide clusters, and the fourth considers a specific setting in which transmission occurs, namely secondary schools. Finally, we discuss how suicide risk might be countered by the transmission of suicide prevention messages in media campaigns.

Pediatric suicide: Review of a preventable tragedy

Concepts of suicide are explored in this issue with a focus on suicide in children and adolescents. The epidemiology of pediatric suicide in the United States is reviewed; also, risk and protective factors, as well as prevention strategies, are discussed. Suicide in the pediatric athlete and the potential protective effect of exercise are examined. In addition, this analysis addresses the beneficial role of psychological management as well as current research on pharmacologic treatment and brain stimulation procedures as part of comprehensive pediatric suicide prevention. Though death by suicide in pediatric persons has been and remains a tragic phenomenon, there is much that clinicians, other healthcare professionals, and society itself can accomplish in the prevention of pediatric suicide as well as the management of suicidality in our children and adolescents.

Global public concern of childhood and adolescence suicide: a new perspective and new strategies for suicide prevention in the post-pandemic era

BACKGROUND

Suicide is the second leading cause of death in young people worldwide and is responsible for about 52,000 deaths annually in children and adolescents aged 5-19 years. Familial, social, psychological, and behavioral factors play important roles in suicide risk. As traumatic events such as the COVID-19 pandemic may contribute to suicidal behaviors in young people, there is a need to understand the current status of suicide in adolescents, including its epidemiology, associated factors, the influence of the pandemic, and management initiatives.

DATA SOURCES

We investigated global and regional suicide mortality rates among children and adolescents aged 5-19 years using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019. The suicide mortality rates from 1990 to 2019 were examined in 204 countries and territories across six World Health Organization (WHO) regions. Additionally, we utilized electronic databases, including PubMed/MEDLINE and Scopus, and employed various combinations of terms such as "suicide", "adolescents", "youth", "children", "risk factors", "COVID-19 pandemic", "prevention", and "intervention" to provide a narrative review on suicide within the pediatric population in the post-pandemic era.

RESULTS

Despite the decreasing trend in the global suicide mortality rate from 1990 to 2019, it remains high. The mortality rates from suicide by firearms or any other specified means were both greater in males. Additionally, Southeast Asia had the highest suicide rate among the six WHO regions. The COVID-19 pandemic seems to contribute to suicide risk in young people; thus, there is still a strong need to revisit appropriate management for suicidal children and adolescents during the pandemic.

CONCLUSIONS

The current narrative review integrates up-to-date knowledge on suicide epidemiology and the effects of the COVID-19 pandemic, risk factors, and intervention strategies. Although numerous studies have characterized trends in suicide among young people during the pre-pandemic era, further studies are required to investigate suicide during the pandemic and new strategies for suicide prevention in the post-pandemic era. It is necessary to identify effective prevention strategies targeting young people, particularly those at high risk, and successful treatment for individuals already manifesting suicidal behaviors. Care for suicidal children and adolescents should be improved with parental, school, community, and clinical involvement.

Suicide without warning: Results from the Army Study to Assess Risk and Resilience in Servicemembers (STARRS)

Objectives

The rate of suicide increased in members of the United States Army since 2011 after the Iraq and Afghanistan wars and continues to be a major concern. In order to reverse this disturbing trend, it is vital to understand the risk and protective factors for suicide death in servicemembers.

Methods

Data were obtained from a case-control psychological autopsy study, which compared U.S. Army suicide decedent cases (n = 135) to a probability sample of living controls (n = 255) who are also service members weighted to be representative of the Army. Interviews were conducted with next-of-kin (NOK) and supervisor (SUP) informants. Multivariable logistic regressions models were constructed using predictors significant after controlling for multiple comparisons.

Results

The most parsimonious multivariable model controlling for deployment status, as reported by SUP predicting suicide death consisted of four significant variables: a spouse or partner left him or her in the past month (OR = 28.5 [95% CI = 1.8, 442.7] χ2 = 5.72, p = .0168); a smaller social network (OR = 4.2 [95% CI = 1.0, 17.3] χ2 = 3.97, p = .0462), less likely to seek help from a mental health counselor (OR = 3.4 [95% CI = 1.2, 9.7] χ2 = 5.35, p = .0207) and more likely to be described as incautious (OR = 3.8 [95% CI = 1.2, 11.7] χ2 = 5.42, p = .0199). The AUC = .88 [95%CI = 0.82, 0.94] for this regression model suggests strong prediction.

Conclusions

Our findings suggest that recent relationship problems, especially in soldiers who are less likely to seek out support from others, may be warning signs for detection and prevention of imminent risk of suicide and according to supervisor informant surveys, had neither evidence of a mental health disorder, nor disclosed suicidal ideation or self-harm. Implications for suicide prevention are discussed.

A Guide for Schools on Student-Directed Suicide Prevention Programs Eligible for Implementation under the STANDUP Act, a Rapid Review and Evidence Synthesis

This review evaluates the strength of evidence for school-based mental health and suicide prevention programs that meet the legal eligibility criteria of the Suicide Training and Awareness Nationally Delivered for Universal Prevention Act of 2021 (STANDUP Act). Included studies were aggregated by program and a program's overall body of evidence was evaluated using the LEGEND system. Requirements for implementation were also documented. We identified 29 studies, which, when aggregated, encompassed 12 unique programs that meet the statute's evidence-based criteria. All four outcomes described in the statute were measured, with help-seeking being the most commonly measured. Two programs were assigned a high level of evidence in decreasing suicidal thoughts and behaviors. The findings serve as a resource for school officials in identifying evidence-based mental health and suicide prevention programs and understanding the resources needed for implementation.

Suicide prevention: reflections on progress over the past decade

Interest in preventing suicides has increased greatly in recent years. In this Personal View, we consider the general global developments related to suicide prevention that have occurred in the decade since The Lancet Psychiatry was first published in 2014. We then review specific advances during this period, first, in relation to public health initiatives, and second, with regard to clinical developments. Finally, we examine some of the challenges that currently confront individuals and organisations responsible for designing and implementing suicide prevention measures.

Suicide and Suicide Risk in Adolescents

Suicide is the second leading cause of death for 10- to 24-year-olds in the United States and is a global public health issue, with a recent declaration of a National State of Emergency in Children's Mental Health by the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children's Hospital Association. This clinical report is an update to the previous American Academy of Pediatrics clinical report, "Suicide and Suicide Attempts in Adolescents." Because pediatricians and pediatric health care providers are at the front line of care for adolescents amid a child and adolescent mental health crisis, and because of the chronic and severe shortage of mental health specialists, it is important that pediatric health care providers become facile with recognizing risk factors associated with suicidality and at-risk populations, screening and further assessment of suicidality as indicated, and evidence-based interventions for patients with suicidal ideation and associated behaviors. Suicide risk can be mitigated by appropriate screening, bolstering of protective factors, indicated treatment, community resources, and referrals to mental health providers when available.

Prevalence of Suicidal Behavior Among Students in South-East Asia: A Systematic Review and Meta-Analysis

OBJECTIVES

Estimation of rates of suicidal behaviors (ideation, plan, and attempt) would help to understand the burden and prioritize prevention strategies. However, no attempt to assess suicidal behavior among students was identified in South-East Asia (SEA). We aimed to assess the prevalence of suicidal behavior (ideation, plan, and attempt) among students in SEA.

METHODS

We followed PRISMA 2020 guidelines and registered the protocol in PROSPERO (CRD42022353438). We searched in Medline, Embase, and PsycINFO and performed meta-analyses to pool the lifetime, 1-year, and point prevalence rates for suicidal ideation, plans, and attempts. We considered the duration of a month for point prevalence.

RESULTS

The search identified 40 separate populations from which 46 were included in the analyses, as some studies included samples from multiple countries. The pooled prevalence of suicidal ideation was 17.4% (confidence interval [95% CI], 12.4%-23.9%) for lifetime, 9.33% (95% CI, 7.2%-12%) for the past year, and 4.8% (95% CI, 3.6%-6.4%) for the present time. The pooled prevalence of suicide plans was 9% (95% CI, 6.2%-12.9%) for lifetime, 7.3% (95% CI, 5.1%-10.3%) for the past year, and 2.3% (95% CI, 0.8%-6.7%) for the present time. The pooled prevalence of suicide attempts was 5.2% (95% CI, 3.5%-7.8%) for lifetime and 4.5% (95% CI, 3.4%-5.8%) for the past year. Higher rates of suicide attempts in the lifetime were noted in Nepal (10%) and Bangladesh (9%), while lower rates were reported in India (4%) and Indonesia (5%).

CONCLUSIONS

Suicidal behaviors are a common phenomenon among students in the SEA region. These findings call for integrated, multisectoral efforts to prevent suicidal behaviors in this group.

Brief Interventions for Self-injurious Thoughts and Behaviors in Young People: A Systematic Review

Rates of self-injurious thoughts and behaviors (SITBs) increase sharply across adolescence and remain high in young adulthood. Across 50 years of research, existing interventions for SITBs remain ineffective and inaccessible for many young people in particular need of mental healthcare. Briefer intervention options may increase access to care. However, many traditional interventions for SITBs take 6 months or more to complete-making it difficult for providers to target SITBs under real-world time constraints. The present review (1) identifies and (2) summarizes evaluations of brief psychosocial interventions for SITBs in young people, ages 10-24 years. We conducted searches for randomized and quasi-experimental trials conducted in the past 50 years that evaluated effects of "brief interventions" (i.e., not exceeding 240 min, or four 60-min sessions in total length) on SITBs in young people. Twenty-six articles were identified for inclusion, yielding a total of 23 brief interventions. Across all trials, results are mixed; only six interventions reported any positive intervention effect on at least one SITB outcome, and only one intervention was identified as "probably efficacious" per standard criteria for evidence-based status. While brief interventions for SITBs exist, future research must determine if, how, and when these interventions should be disseminated.

Suicide in young people: screening, risk assessment, and intervention

Suicide is the fourth leading cause of death among young people worldwide and the third leading cause of death among those in the US. This review outlines the epidemiology of suicide and suicidal behavior in young people. It discusses intersectionality as an emerging framework to guide research on prevention of suicide in young people and highlights several clinical and community settings that are prime targets for implementation of effective treatment programs and interventions aimed at rapidly reducing the suicide rate in young people. It provides an overview of current approaches to screening and assessment of suicide risk in young people and the commonly used screening tools and assessment measures. It discusses universal, selective, and indicated evidence based suicide focused interventions and highlights components of psychosocial interventions with the strongest evidence for reducing risk. Finally, the review discusses suicide prevention strategies in community settings and considers future research directions and questions challenging the field.

Comparing the Effects of Victimization, School Connectedness, and Social Support on Heterosexual and Sexual Minority Adolescent Suicidality in the United States: A Partial Test of Minority Stress Theory

In the United States, sexual minority adolescents are among the subpopulations at the highest risk for suicide; yet, predictors of suicidality among this unique group remain significantly understudied. Drawing from Meyer's minority stress theory (MST), this study examines whether general stressors act as predictors of adolescent suicidality and whether differences exist in the variation of these effects between heterosexual and sexual minority adolescents. Specifically, multivariate logistic regression models were developed to examine the impact that victimization, school connectedness, and social support have on heterosexual and sexual minority adolescent suicidality using a sample of 166,176 U.S. adolescents drawn from the 2019 Minnesota Student Survey. Participants ranged from 10 to 18 years of age and identified as heterosexual, bisexual, gay or lesbian, questioning, pansexual, queer, or as none of these. Findings highlight that sexual minorities (Exp(B) = 1.870, p < .001) were roughly twice as likely to report suicidality compared to their heterosexual peers. All victimization measures were highly predictive of suicidality among heterosexual and sexual minority adolescents. Overall, adolescents who were less connected to their school setting and more socially isolated were also more likely to experience suicidality; however, such effects were not reflected uniformly in every item measuring school connectedness and social support. Findings highlight important avenues for policies implementation aimed at mitigating the effects of multiple sources of stressors on adolescents' mental health and reducing adolescents' suicide rates. Interventions tailored to the unique needs of sexual minority adolescents are needed to address their disproportionate representation among those at risk for 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.

Suicidal ideation and intentional self-inflicted injury in autism spectrum disorder and intellectual disability: An examination of trends in youth emergency department visits in the United States from 2006 to 2014

LAY ABSTRACT

Youth suicide is a major problem in the United States and globally, but little is known about suicide risk in autistic youth and youth with intellectual disability specifically. Using data from the National Emergency Department Sample, which is the largest database of emergency department visits in the United States, we found that emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis were more common in autistic youth and youth with intellectual disability than in youth without these diagnoses (i.e. the comparison group). This was true when examining both suicidal ideation diagnoses and intentional self-inflicted injury diagnoses at emergency department visits. In addition, the number of emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis increased more from 2006 to 2014 in autistic youth and youth with intellectual disability compared with the comparison group. We also found both similarities and differences when examining factors, such as age, sex, and co-occurring mental health conditions, related to emergency department visits with a suicidal ideation or intentional self-inflicted injury diagnosis across groups that may be helpful for understanding suicide risk. It is urgent that we improve our understanding, assessment, and treatment of suicidality and self-harm in these groups through more research and clinical efforts.

Deliberate self-harm in adolescents: A review of literature

Deliberate self-harm is a rising epidemic in the youth. This review examined the different self-harm behavior, approach to treatment, and the implication of such behaviors in the adolescent population in the academic literature. Using the PubMed database, we searched for specific terms related to different self-harm behaviors in Adolescents. The bibliography of the articles found relevant for the review was also screened. Each study's findings were taken with reference to our topic and findings were summarized. After reviewing the literature, we found that the prevalence of suicidal attempts was as high as 18% in the past year While the nonsuicidal attempts were as high as 31%. Risk factors associated with higher levels of suicide were bullying, loneliness and anxiety, tobacco and alcohol use, and weak family and social relationships. While the factors playing a protective role are being connected to school, having good social support, and attending school. There are very few studies focused on interventions related to suicide prevention in Adolescent and postvention programs. Out of the evidence available, the interventions are not focused on the target individuals and lack replicability. Self-harm is a major public health concern which needs to be understood holistically. The interventions aimed at preventing and managing self-harm behavior still need to be more targeted and precise. Other targets may include interventions suited to different phases of development, stopping the progression of the behavior to adulthood, including the varied population in such intervention, etc.

Life problems in children and adolescents who self-harm: findings from the multicentre study of self-harm in England

BACKGROUND

Self-harm, a significant and increasing global problem in children and adolescents, is often repeated and is associated with risk of future suicide. To identify potential interventions, we need to understand the life problems faced by children and adolescents, and by sub-groups of younger people who self-harm. Our aims were to include the following: (a) investigate the type and frequency of life problems in a large sample of children and adolescents who self-harmed. (b) Examine whether problems differ between those who repeat self-harm and those who do not.

METHODS

We analysed data for 2000 to 2013 (follow up until 2014) from the Multicentre Study of Self-harm in England on individuals aged 11 to 18 years who presented to one of the five study hospitals following self-harm and received a psychosocial assessment including questions about problems, which precipitated self-harm.

RESULTS

In 5648 patients (12,261 self-harm episodes), (75.5% female, mean age 16.1 years) the most frequently reported problems at first episode of self-harm were family problems. Problems around study/employment/study and relationships with friends also featured prominently. The types of problems that precede self-harm differed between late childhood/early adolescence. Abuse, mental health problems and legal problems significantly predicted repeat self-harm for females.

CONCLUSION

The most common problems reported by both genders were social/interpersonal in nature, indicating the need for relevant services embedded in the community (e.g. in schools/colleges). Self-harm assessment and treatment choices for children and adolescents must take age and gender into account. To prevent future self-harm, individualised supports and services are particularly needed for abuse, mental health and legal problems.

The Impact of Bullying Victimization and Sexual Orientation on the Severity of Suicidal Behavior

Background: Lesbian, gay, and bisexual youth face a disproportionate risk of suicidal ideation and attempt compared to heterosexual counterparts. Escalation from ideation to attempt can occur quickly, and youth who survive suicide attempts are likely to pursue subsequent, riskier attempts. This study examines the effects of bullying and sexual orientation on suicidal outcomes. Methods: Data came from the national, school-administered 2017 Youth Risk Behavior Survey (N = 14,765). Bivariate associations, binomial logistic regressions, and ordinal logistic regressions were performed. Results: Lesbian/gay, bisexual, and unsure youth reported greater odds of ideation and attempts compared to heterosexual youth. For ideation, increased effects were inconsistent across bullying types and significant interactions were found for bisexual youth who were bullied in school, and for lesbian/gay youth who were cyberbullied. Conclusion: These results underscore the need to understand bullying victimization for lesbian, gay, and bisexual youth. Awareness of increasing cyberbullying and creating school environments of no-bullying tolerance in the post-pandemic era are among the challenges ahead.

Population- and Community-Based Interventions to Prevent Suicide

Background: Suicide is estimated to account for 1.4% of deaths worldwide, making it among the leading causes of premature death. Public health approaches to reduce suicide have the potential to reach individuals across the spectrum of suicide risk. Aims: To review the effectiveness of newer community-based or population-level suicide prevention strategies. Methods: We conducted a systematic review of literature published from January 2010 to November 2020 to evaluate the effectiveness of community- and population-level interventions. The US Center for Disease Control framework was used for grouping studies by strategy. Results: We included 56 publications that described 47 unique studies. Interventions that reduce access to lethal means, implement organizational policies and culture in police workplace settings, and involve community screening for depression may reduce suicide deaths. It is unclear if other interventions such as public awareness and education campaigns, crisis lines, and gatekeeper training prevent suicide. Evidence was inconsistent for community-based, multistrategy interventions. The most promising multistrategy intervention was the European Alliance Against Depression. Limitations: Most eligible studies were observational and many lacked concurrent control groups or adjustment for confounding variables. Conclusions: Community-based interventions that may reduce suicide deaths include reducing access to lethal means, implementing organizational policies in workplace settings, screening for depression, and the multistrategy European Alliance Against Depression Program. Evidence was unclear, inconsistent, or lacking regarding the impact of many other single- or multistrategy interventions on suicide deaths.

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.

Wer profitiert von einem Workshop zur Suizidprävention an Schulen?

Zusammenfassung. Um die Suizidprävention an Schulen zu verbessern, wurden psychoedukative Workshops für Schüler_innen implementiert und angeboten. N=200 Schüler_innen der 8.–10. Jahrgangsstufe wurden zufällig einer Experimental- oder Kontrollgruppe zugewiesen. Vor und nach dem Training sowie nach drei Monaten wurden sie zu ihrem hilfesuchenden und hilfegebendem Verhalten sowie ihrer depressiven Symptomatik befragt. Die Ergebnisse weisen darauf hin, dass besonders die als stärker suizidgefährdet eingestuften Jugendlichen von dem Training durch eine Abnahme ihrer depressiven Symptomatik profitierten. Schüler_innen der Kontrollgruppe verbesserten sich demgegenüber nicht signifikant in ihrer depressiven Symptomatik. Für das hilfesuchende ebenso wie das hilfegebende Verhalten zeigten sich positive Trends, die jedoch nicht statistisch signifikant wurden. Diese Ergebnisse zeigen – wenn auch mit Limitationen aufgrund von Ausfällen durch die Coronapandemie 2020 und durch ein restriktives Vor-Screening – die Wirksamkeit einer aufwändigen außerschulischen Suizidprävention auf Befinden und Verhalten.

Future Directions in Suicide and Self-Injury Revisited: Integrating a Developmental Psychopathology Perspective

The recent rise in suicide rates among children and adolescents has made suicide prevention in youth a major focus of government agencies and mental health organizations. In 2012, Nock presented future directions in the study of self-injurious thoughts and behavior (SITBs), highlighting the need to better examine which risk factors are associated with "each part of the pathway" to suicidal and non-suicidal self-injury in order to inform prevention and intervention efforts. Over the past decade, we have made important advances in understanding the development of SITBs and effective interventions. However, there are still major gaps of knowledge in our understanding of how to prevent suicide. Researchers have recently called for more studies focusing particularly on the pathway from suicidal ideation to suicidal behavior. However, we caution against prioritizing only a part of the suicide risk continuum (e.g., the transition from suicidal ideation to suicidal behavior) while minimizing research focusing on earlier developmental points of the pathway to suicide (e.g., the first development of suicidal ideation). We emphasize that childhood and adolescence represent a critical opportunity to intervene and prevent SITBs by altering developmental trajectories toward persistent and escalating SITBs over time. We advocate for integrating a developmental psychopathology perspective into future youth suicide research that focuses on how and when risk for SITBs first emerges and develops across childhood into emerging adulthood. This research is critical for informing interventions aimed at bending developmental pathways away from all SITBs. Here, we describe the need for future research that integrates key developmental psychopathology principles on 1) the identification of the continuum from developmentally typical to atypical as SITBs first emerge and develop, particularly among young children in early to middle childhood, 2) the way in which expressions of and risk for SITBs change across development, 3) how SITBs dynamically move along a continuum from typical to atypical over time, and 4) suicide prevention efforts. We also offer recommendations for future directions that focus on identifying disparities in SITBs occurring among minoritized youth within a developmental psychopathology perspective.

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

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

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.

Effects of Aerobic Exercise and High-Intensity Interval Training on the Mental Health of Adolescents Living in Poverty: Protocol for a Randomized Controlled Trial

Background

The increasing rate of mental health issues among adolescents has recently been a considerable concern in Hong Kong. In particular, adolescents with low socioeconomic status (SES) are likely to experience poor mental health, including low self-esteem and high levels of anxiety, anger, and depression. Previous research has found that physical activities have a positive impact on improving mental health outcomes among adolescents. However, approximately 96% of adolescents in Hong Kong do not engage in regular exercise, which potentially increases the risk of poor mental health.

Objective

In this study, we aim to examine whether changes in the 3 indicators (reduced ill-being, enhanced well-being, and cognitive functions) of mental health among adolescents with low SES are evident before and after exercise. In addition, this study compares the effectiveness of aerobic exercise and high-intensity interval training on these indicators among adolescents with low SES.

Methods

A total of 78 participants from low-income families aged between 12 and 15 years from 3 to 4 secondary schools will be recruited for this study. They will be randomly assigned to either an aerobic exercise group (26/78, 33%), a high-intensity interval training group (26/78, 33%), or a control group (26/78, 33%). Participants in the first 2 groups will take part in a 10-week training program period. Participants in the control group will participate in other physical activities during the same intervention period. The training sessions will be conducted 3 times per week on nonconsecutive days. A range of neuropsychological tests and psychometric scales will be used to measure the executive functions and indicators of psychological well-being and ill-being, including enjoyment, self-efficacy, mood, depression, anxiety, and stress at pretest, posttest, and follow-up assessments.

Results

The project was funded in 2021 by the Research Matching Grant Scheme, through the University Grants Committee of the Hong Kong Special Administrative Region Government. Ethical approval has been obtained from the author’s institution. Participant recruitment will begin in January 2022 and continue through to April 2022. Data collection and follow-up are expected to be completed by the end of 2022. The results are expected to be submitted for publication in 2023.

Conclusions

The findings will help inform policy makers and practitioners in promoting the importance of physical exercise to enhance mental health.

Trial Registration

ClinicalTrials.gov NCT050293888; https://clinicaltrials.gov/ct2/show/record/NCT05029388

International Registered Report Identifier (IRRID)

PRR1-10.2196/34915

Hispanic Child Suicides in the United States, 2010-2019

Suicides in Hispanic adolescents have been increasing significantly. Less clear is the extent of suicides in Hispanic children younger than 12 years of age. The purpose of this study was to explore the trends and methods of suicides in Hispanic children from 2010 to 2019 (latest data available across the United States). Suicide is the 7th leading cause of death for Hispanic children. Hispanic child suicides statistically significantly increased during the decade. From 2010 to 2019, Hispanic child suicide rates increased by 92.3%. The suicide deaths were primarily in boys (59.6%) and among those 10-12 years of age (94.9%). Hispanic child suicides were most common in the West and South and least common in the Northeastern US The method used to commit suicide was overwhelmingly (76-85%) hanging/strangulation/suffocation. To help assure Hispanic children flourish and mature into healthy adults, it is essential that policymakers commit more resources for access to healthcare for all youths and that research funding for minorities include research regarding Hispanic children's suicide risk factors, protective factors, and effective interventions to reduce suicides of Hispanic children.

Equitable suicide prevention for youth impacted by the juvenile legal system

Suicide is the second leading cause of death for adolescents in the United States. Despite the already alarmingly high rates of suicide attempts among adolescents, youth involved in the juvenile legal system (JLS) are up to three times more likely to have suicide attempts than their peers not impacted by the JLS. This public health crisis is also a matter of health equity, knowing that ethnoracially minoritized youth, mainly Black and Latinx youth, have disproportionate contact with the JLS. In order to disrupt the current elevated rates of suicide among Black and Latinx youth involved in the JLS, there needs to be more concerted efforts to improve assessment and suicide prevention efforts in the JLS. There are various potential touch points of care for suicide prevention and the Sequential Intercept Model (SIM), which outlines community-based responses to the involvement of people with mental and substance use disorders in the criminal justice system, can be used as a strategic planning tool to outline possible equitable interventions across these various touch points. Our purpose is to provide a comprehensive picture of gaps and equitable opportunities for suicide prevention across each intercept of the SIM. We provide recommendations of priorities to promote health equity in suicide prevention for ethnoracially minoritized youth impacted by the JLS.

A Social-Emotional Learning Program for Suicide Prevention through Animal-Assisted Intervention

Simple Summary

Youth suicide is a global public health problem. According to data from the World Health Organization (WHO), suicide is the fourth leading cause of death in the age group between 15 and 29 years, after injuries due to traffic accidents, tuberculosis, and interpersonal violence. For this reason, the reduction of mortality by suicide is one of the WHO’s priority objectives. Here we describe a pilot study evaluating the OverCome-AAI program, a pioneering animal-assisted intervention for preventing suicidal behavior. After the intervention, the young people showed reductions in suicidal behavior and non-suicidal self-harm, as well as a greater predisposition to seek help. Mental pain was less intense, although no changes in symptoms of hopelessness or depression were found. The results of this pilot study suggest that the inclusion of specially prepared and trained animals can promote socio-emotional learning for preventing suicidal behavior in high-risk populations.

Abstract

The aim of the study was to carry out a pilot implementation and evaluation of the OverCome-AAI program, a pioneering program for the prevention of suicidal behavior through animal-assisted interventions for young people with high risk factors for suicidal behavior. The study sample consisted of 30 adolescents (11 boys and 19 girls) aged between 14 and 17 years (Mean age = 15.50, SD = 1.60) from the Basque Country (Northern Spain). After the intervention, subjects presented reductions in suicidal ideation, suicide plans, and non-suicidal self-harm, as well as a greater predisposition to seek help. A reduction in the intensity of mental pain was also found, although no differences were observed in indicators of hopelessness and depression. The preliminary results obtained in this pilot study suggest that the OverCome-AAI program may be effective in reducing suicidal behavior and non-suicidal self-harm in young people in residential care who present high risk factors for suicide.

Prior health care utilization among adolescents treated for a suicide attempt at a rural ED

PURPOSE

To characterize prior contact with a rural academic health system among young people treated for a suicide attempt in the system's emergency departments (EDs).

METHODS

We retrospectively examined electronic medical records from a health system serving 29 medically underserved rural counties in the Southeastern United States. Patients ages 10-25 years were included in the study if they were admitted to the ED for a suicide attempt in 2015-2018. Patients were stratified according to whether they had any encounter in the same health system in the 12 months prior to the attempt.

FINDINGS

Of 236 patients meeting inclusion criteria, only 10% had contact with the health system in the 12 months prior to ED treatment for a suicide attempt. Patients who lived farther than 25 km from the flagship hospital were less likely to have had prior contact (odds ratio [OR]: 0.10, 95% confidence interval [CI]: 0.02-0.34). Young adults ages 19-25 years were also less likely to have prior contact than adolescents (OR: 0.27, 95% CI: 0.08-0.76).

CONCLUSIONS

Few adolescents and young adults in this rural region received prior health care from the same health system where they were treated for a suicide attempt. Hospitals operating in rural areas need to partner with community health care providers to ensure adequate reach of screening and treatment programs to prevent youth suicide and reduce care fragmentation.

Suicide in African American Adolescents: Understanding Risk by Studying Resilience

Historically, suicide rates for African American adolescents have been low,relative to rates for youth of other racial-ethnic backgrounds. Since 2001, however, suicide rates among African American adolescents have escalated: Suicide is now the third leading cause of death for African American adolescents. This disturbing trend warrants focused research on suicide etiology and manifestation in African American adolescents, along with culturally sensitive and effective prevention efforts. First, we revisit leading suicide theories and their relevance for African American adolescents. Next, we discuss health promotive and protective factors within the context of African American youth development. We also critique the current status of suicide risk assessment and prevention for African American adolescents. Then, we present a heuristic model of suicide risk and resilience for African American adolescents that considers their development within a hegemonic society. Finally, we recommend future directions for African American adolescent suicidology. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

The Youth Aware of Mental Health program in Australian Secondary Schools: 3- and 6-month outcomes

OBJECTIVE

The evidence base for suicide prevention programs in Australian schools is limited. The aim of this study was to examine the impact of a universal, mental health promotion and suicide prevention program-Youth Aware of Mental Health (YAM)-on suicidal ideation, mental health, and help-seeking in Australian secondary school students from baseline to post-intervention and 6-month follow up.

METHODS

Using a single-arm design, the YAM program was delivered to Year 9 students (13-16 years) in secondary schools located within four regions across New South Wales, Australia. A structured self-report questionnaire using validated scales was administered at each time point. Linear mixed-effects modelling was used to examine differences in suicidal ideation scores across time, while accounting for random effects of individual schools.

RESULTS

Suicidal ideation reduced significantly from baseline to post, and from baseline to follow-up (p < 0.001). Depression severity declined (p < 0.001) and help-seeking intentions increased (p < 0.001) at post-intervention and 6- months following the intervention period. No suicide deaths were reported for any study participants.

CONCLUSION

The current findings provide preliminary evidence that the YAM program is a promising preventive intervention for Australian schools, particularly for reducing suicidal ideation, depression and increasing help-seeking intentions in young people. The implementation of YAM in a large number of schools across New South Wales demonstrates the feasibility, and acceptability by schools, of implementing this program at scale.

TRIAL REGISTRATION

ANZCTR, ACTRN12619000338167. Registered 5 March 2019-Retrospectively registered, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376989&isReview=true .

Childhood Suicide Trends in the United States, 2010-2019

Suicides are among the 10 leading causes of death in U.S. children 12 years of age and younger. The purpose of this study was to examine trends and methods of suicide in children by race and gender from 2010 to 2019, the most recent years of data available from the Centers for Disease Control and Prevention. Child suicides statistically significantly increased for black (95%), white (158%), male (95%), and female (300%) children during the decade. Additionally, the methods children used to commit suicide did not significantly differ by race or gender. The leading method of suicide used by children was strangulation/suffocation depending on race and gender (67%-85%). The second most common method of suicide was by the use of a firearm, again depending on race and gender (11%-30%). Northeastern states had the fewest child suicides during the decade and Texas and California had the most child suicides. Policymakers need to commit more resources and research funding to better detect risk factors, protective factors, and effective interventions for reducing child suicides.

Promotion of Mental Health Literacy in Adolescents: A Scoping Review

In recent years, there has been an important commitment to the development of programs to promote mental health literacy (MHL) among adolescents, due to the prevalence of mental health problems and the low level of MHL that affects this group. The aim of this study was to map the structure and context of programmes/interventions for promoting MHL among adolescents in school settings. A scoping review was conducted following the guidelines of The Joanna Briggs Institute. We searched for studies on programmes/interventions promoting at least one of the components of MHL of adolescents, written in Portuguese, English or Spanish, published from 2013 to 2020, in MEDLINE, CINAHL Plus with Full Text, SciELO, SCOPUS, OpenGrey, RCAAP and in the article reference lists. This review included 29 articles. The majority of programmes/interventions addressed one or more of the four components of MHL, with the knowledge of mental disorders and stigma reduction components being the most covered; were taught by adolescent's regular teachers; used face to face interventions; had a height variable duration; used non-validated instruments; were implemented in a classroom environment; and showed statistically significant improvements in adolescent's MHL levels. More research is needed to implement/construct programmes/interventions promoting adolescents' MHL concerning knowledge on how to obtain and maintain good mental health.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Effectiveness of a Continuity-of-Care Model to Reduce Youth Suicidality

Background: Suicidal ideation and recent suicide attempts greatly increase the risk of suicide among youth. Many youth experiencing suicidality are not adequately connected to in-person treatment. Aims: This study aimed to determine the efficacy of a continuity-of-care approach in reducing suicide attempts, ideation, and related hospital and emergency department (ED) visits among youth at high risk for suicide. Method: Data on suicidal ideation, attempts, and related hospital and ED visits were collected over a 6-month period for youth under age 25 (n = 376). One-way repeated measures ANOVA and Cochran's Q tests assessed change from intake at the 3- and 6-month follow-up. Results: Youth had significantly fewer suicide attempts and related hospital and ED visits at both 3- and 6-month timepoints. Suicidal ideation decreased to 52% from intake to 6-month follow-up. Limitations: This study lacked a comparison population to examine continuity-of-care versus treatment-as-usual. Furthermore, the study did not extend beyond 6 months, limiting the ability to assess the intervention's long-term effectiveness. Conclusion: This youth-focused continuity-of-care model reduced suicidal ideation and related behaviors. Further studies should utilize control groups to confirm the validity of these results.

Implementing Dialectical Behavior Therapy Skills Training for Emotional Problem Solving for Adolescents (DBT STEPS-A) in a Low-Income School

Adolescents living in low-income areas often have high need for mental health supports due to experiences of poverty and trauma, coupled with limited access and availability of such supports. This study investigated the implementation of a socio-emotional learning curriculum titled, “Dialectical Behavior Therapy Skills Training for Emotional Problem Solving for Adolescents (DBT STEPS-A),” which was integrated into health classes in a low-income high school. While preliminary evidence suggests that DBT STEPS-A can be effective in reducing mental health symptoms in high school students, this study is the first to explore the program’s acceptability, appropriateness, and feasibility when implemented in a low-income school. The implementation presented here also diverged from recommended training protocols due to time and cost limitations. Quantitative and qualitative data were collected from 29 school stakeholders prior to implementation and from 23 school stakeholders post-implementation. Our results indicate that DBT STEPS-A is acceptable and feasible for teachers involved in offering the program and that more work is needed to address appropriateness of the content for racially and socio-economically diverse students, ease of implementing lessons, and support for teachers using DBT STEPS-A skills outside of class. We conclude with a discussion of key implementation challenges and solutions generated.

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

AIMS

Gatekeeper training (GKT) is an important suicide prevention strategy. Studies have evaluated the effectiveness of GKT in different populations, often neglecting family and friends who play a vital role in caring for people with suicide risk. This review evaluated GKT programs targeting family and friends to determine their effectiveness in this specific population.

METHODS

Academic databases were searched for studies on GKT programs. Programs involving family and friends caring for people with suicide risk were assessed for any impact on knowledge, self-efficacy, attitudes, and suicide prevention skills.

RESULTS

Seventeen studies were reviewed. GKT showed significant gains on outcomes of interest. Three studies targeted family and friends, with one involving them in program creation and conduction and another adjusting the program after their input.

CONCLUSIONS

GKT programs have potentially positive effects on family and friends caring for people with suicide risk. Few programs address the specific needs of this group, and programs adapted specifically for them are scarce. Future program development recommendations are discussed.

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.

The Impact of a Harry Potter-Based Cognitive-Behavioral Therapy Skills Curriculum on Suicidality and Well-being in Middle Schoolers: A Randomized Controlled Trial

OBJECTIVE

To evaluate the impact of a Harry Potter-based mental health literacy curriculum, imparting cognitive behavioral therapy (CBT) skills, on suicidality and well-being in middle-schoolers.

METHODS

Students (aged 11-14; grades 7-8) who received a 3-month teacher-delivered intervention embedded in the language arts curriculum (N=200) were compared to a wait-list control group (N=230) in the largest urban school board in Canada. Suicidality defined as a composite measure of self-reported suicidal ideation and attempts [primary outcome], self-reported emotion dysregulation, interpersonal chaos, confusion about self, and impulsivity [Life Problems Inventory (LPI)] and self-reported depression and anxiety symptoms [Revised Child Anxiety and Depression Scale (RCADS)] were the outcomes of interest. Measurements occurred prior to and after curriculum delivery with independent t-tests used to compare mean change scores between groups clustered by class.

RESULTS

Thirty-seven English teachers in 46 classes across 15 schools comprised the planned study cohort. Composite suicidality scores were significantly worse in the control than intervention group at endpoint (0.05±0.54 vs. 0.17±0.47, t= -2.60, df=428, p=0.01). There were also significant improvements in LPI and RCADS scores in the intervention group compared to controls (LPI:-3.74±7.98 vs. 1.16±10.77 t=5.28, df=428, p<.001; RCADS: (-3.08±5.49 vs. -1.51±6.53 t=2.96, df=429, p=0.01). Sub-analyses revealed that these improvements were largely driven by a significant difference in scores in girls.

LIMITATIONS

Sample size constraints as study terminated prematurely during COVID pandemic.

CONCLUSIONS

This study demonstrates significant improvement in suicidality, emotional regulation, self-concept, interpersonal difficulties, depression and anxiety in youth, particularly girls following this intervention. Replication studies in larger samples are needed to confirm these results.

['Dites Je Suis Là', a platform to guide the relatives of suicidal people]

The purpose of the 'Dites Je Suis Là' platform is to disseminate a simple, clear and scientifically validated message to the general public to raise awareness of the warning signs of suicide. This awareness-raising campaign complements the existing support systems for suicidal people. Their loved ones can find tools for understanding and questioning their potential as caregivers. If they are willing to support a person in pain, six steps guide them in how to act to prevent suicide. Lifting the taboo around suicidal thoughts, encouraging the use of help and care, and maintaining a sincere and warm relationship are among the key elements.

Saving Lives: Recognizing and Intervening with Youth at Risk for Suicide

Suicide is the second leading cause of death for youth in the United States. Fortunately, substantial advances have been achieved in identifying and intervening with youth at risk. In this review, we first focus on advances in proactive suicide risk screening and psychoeducation aimed at improving the recognition of suicide risk. These strategies have the potential to improve our ability to recognize and triage youth at risk who may otherwise be missed. We then review recent research on interventions for youth at risk. We consider a broad range of psychotherapeutic interventions, including crisis interventions in emergency care settings. Though empirical support remains limited for interventions targeting suicide risk in youth, effective and promising approaches continue to be identified. We highlight evidence-based screening and intervention approaches as well as challenges in these areas and recommendations for further investigation.

Efficient interaction selection for clustered data via stagewise generalized estimating equations

Model selection in the presence of interaction terms is challenging as the final model must maintain a hierarchy between main effects and interaction terms. This work presents two stagewise estimation approaches to appropriately select models with interaction terms that can utilize generalized estimating equations to model clustered data. The first proposed technique is a hierarchical lasso stagewise estimating equations approach, which is shown to directly correspond to the hierarchical lasso penalized regression. The second is a stagewise active set approach, which enforces the variable hierarchy by conforming the selection to a properly growing active set in each stagewise estimation step. The effectiveness in interaction selection and the superior computational efficiency of the proposed techniques are assessed in simulation studies. The new methods are applied to a study of hospitalization rates attributed to suicide attempts among 15 to 19 year old at the school district level in Connecticut.

The Youth Aware of Mental Health Intervention: Impact on Help Seeking, Mental Health Knowledge, and Stigma in U.S. Adolescents

PURPOSE

Suicide is a leading cause of death among U.S. youth aged 12-18 years. Youth Aware of Mental Health (YAM), a promising, universal, school-based mental health promotion/suicide primary prevention intervention for adolescents, has been evaluated in Europe but not in the U.S. The present study used an uncontrolled, pretest/post-test design to document the potential for YAM to reduce suicidal ideation, attempt, and suicide. A demonstration that help seeking behaviors, mental health literacy, and mental health stigmatizing attitudes improve after the intervention would suggest that the program is promising in the U.S., as well as in Europe, and that further investigation is merited.

METHODS

YAM was delivered to 1,878 students in 11 schools as part of regular school curricula. A subset of these students (n = 436) completed surveys before and 3 months postdelivery. Surveys included five questions about help seeking behaviors, a measure of intent to seek help (General Help Seeking Questionnaire), two mental health literacy scales, and two mental illness stigma scales (Reported and Intended Behavior Scale and Personal Stigma and Social Distance Scale). Both McNemar's test and repeated measures linear models were used to determine whether the survey outcomes changed after YAM delivery.

RESULTS

Among the 436 adolescents (286 and 150 in Montana and Texas, respectively), significant increases were found pre- to post-intervention in three of five help seeking behaviors, along with improved mental health literacy and decreased mental health-related stigma. Intent to seek help was unchanged.

CONCLUSIONS

Several help seeking behavioral factors, mental health knowledge, and stigma improved post-YAM intervention. All three domains are likely protective against suicide. A randomized controlled trial testing the efficacy of YAM in preventing suicidal behaviors is warranted.