Program Evaluation and Decision Analytic Modelling of Universal Suicide Prevention Training (safeTALK) in Secondary Schools

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.

Validation of a 9-item Perceived Suicide Awareness Scale (PSAS-9) for adolescents

BACKGROUND

Robust empirical data on suicide awareness are needed, to better plan and evaluate suicide prevention interventions. However, there is a lack of validated measures of suicide awareness. This is especially true for perceived suicide awareness, which focuses on perceived knowledge about suicide, willingness, and confidence to talk about suicide and get help. Using the theoretical framework of Social Cognitive Theory, this study aimed to validate a measure of perceived suicide awareness.

METHODS

We re-used data from a suicide prevention trial conducted in Swiss secondary schools (n = 366). Baseline and one-month follow-up data were used to validate the scale. The main measure was an initial 14-item Perceived Suicide Awareness Scale (PSAS). Perceived knowledge of help-seeking resources, suicide-related knowledge, and support networks were used to assess convergent validity.

RESULTS

A nine-item version, the PSAS-9, showed satisfactory psychometric properties, including high internal consistency (α = 0.78), acceptable test-retest (r = 0.68), and a one-factor structure explaining 95 % of the variance. The convergent validity was acceptable (0.19 ≤ r ≤ 0.40). The PSAS-9 was not correlated with suicide-related knowledge (r = 0.02).

LIMITATIONS

The study missed a similar construct to properly assess convergent validity and had a modest sample size. In addition, it only included secondary school adolescents, so further research in other samples of youths is needed to robustly validate the PSAS-9.

CONCLUSIONS

This study was an important step towards validating a perceived suicide awareness scale, which appears as a new dimension of suicidality, distinct from suicide-related knowledge. The PSAS-9 could be used to develop, evaluate, and improve suicide prevention efforts.

Evaluating the Effectiveness of Suicide Prevention Gatekeeper Trainings as Part of an American Indian/Alaska Native Youth Suicide Prevention Program

According to the Centers for Disease Control suicide rates in 2022 for American Indian/Alaska Native youth are 2.5 times higher than the national average. An Urban Indian Health Organization's response to this crisis was to provide community and State-wide Gatekeeper trainings between 2012 and 2019 to teach trainees (N = 810) to respond appropriately to youth at-risk of suicide. We report data on pre-, post-, and six-month follow-up surveys with trainees. Data were analyzed using generalized linear models repeated measures to test within-subject, and between-subject mean score changes on suicide prevention-related measures "knowledge," "ask directly," "respond," "comfort," and "preparedness." Results indicated improved capacity to be prepared to address suicide in the short term and that having a graduate degree enhanced baseline suicide prevention knowledge. Over time those with less education benefited the most and better retained content. Future Trainings should engage young people and those with less education to realize the largest benefit.

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

Introduction

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

Methods

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

Results

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

Discussion

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

School-based socio-emotional learning programs to prevent depression, anxiety and suicide among adolescents: a global cost-effectiveness analysis

AIMS

Preventing the occurrence of depression/anxiety and suicide during adolescence can lead to substantive health gains over the course of an individual person's life. This study set out to identify the expected population-level costs and health impacts of implementing universal and indicated school-based socio-emotional learning (SEL) programs in different country contexts.

METHODS

A Markov model was developed to examine the effectiveness of delivering universal and indicated school-based SEL programs to prevent the onset of depression/anxiety and suicide deaths among adolescents. Intervention health impacts were measured in healthy life years gained (HLYGs) over a 100-year time horizon. Country-specific intervention costs were calculated and denominated in 2017 international dollars (2017 I$) under a health systems perspective. Cost-effectiveness findings were subsequently expressed in terms of I$ per HLYG. Analyses were conducted on a group of 20 countries from different regions and income levels, with final results aggregated and presented by country income group - that is, low and lower middle income countries (LLMICs) and upper middle and high-income countries (UMHICs). Uncertainty and sensitivity analyses were conducted to test model assumptions.

RESULTS

Implementation costs ranged from an annual per capita investment of I$0.10 in LLMICs to I$0.16 in UMHICs for the universal SEL program and I$0.06 in LLMICs to I$0.09 in UMHICs for the indicated SEL program. The universal SEL program generated 100 HLYGs per 1 million population compared to 5 for the indicated SEL program in LLMICs. The cost per HLYG was I$958 in LLMICS and I$2,006 in UMHICs for the universal SEL program and I$11,123 in LLMICs and I$18,473 in UMHICs for the indicated SEL program. Cost-effectiveness findings were highly sensitive to variations around input parameter values involving the intervention effect sizes and the disability weight used to estimate HLYGs.

CONCLUSIONS

The results of this analysis suggest that universal and indicated SEL programs require a low level of investment (in the range of I$0.05 to I$0.20 per head of population) but that universal SEL programs produce significantly greater health benefits at a population level and therefore better value for money (e.g., less than I$1,000 per HLYG in LLMICs). Despite producing fewer population-level health benefits, the implementation of indicated SEL programs may be justified as a means of reducing population inequalities that affect high-risk populations who would benefit from a more tailored intervention approach.

Young people's help-giving actions towards a peer with a mental health problem: A systematic review and narrative synthesis

AIMS

Young people often seek help from their peers for mental health problems. However, little is known about young people's experiences of helping a peer with a mental health problem. The aim of this study was to systematically review the literature on young people's help-giving actions, highlight any gaps in the research and examine the evidence for interventions designed to increase and improve help-giving. The secondary aim was to compare findings between help-giving in face-to-face and online settings.

METHODS

Embase, SCOPUS, PsycINFO and MEDLINE electronic databases were searched for English studies published from 2003 onwards. Studies focusing on the help-giving actions of young people (aged 12-25 years) towards a peer with a mental health problem were included. Risk of bias was assessed using the Joanna Briggs Institute quality appraisal tools. Data were synthesized using thematic and narrative analysis.

RESULTS

Twenty-one studies (3440 participants) were included. The most frequently reported help-giving themes were encouraging professional and adult support and providing emotional support. Although limited studies reported on online help-giving, online settings allowed for immediate help to be provided despite time or location. Both positive and negative outcomes for helping were identified. Improvements in the quality of help-giving were found after training; however, help-giving for mental health crises was poor.

CONCLUSIONS

Further research regarding the young people's help-giving actions to peers online is required. Training programs need to consider how to further improve the quality of help-giving among young people and to increase the trainees' confidence in helping, particularly in a mental health crisis.

Modelling in economic evaluation of mental health prevention: current status and quality of studies

BACKGROUND

The present study aimed to identify and critically appraise the quality of model-based economic evaluation studies in mental health prevention.

METHODS

A systematic search was performed on MEDLINE, EMBASE, EconLit, PsycINFO, and Web of Science. Two reviewers independently screened for eligible records using predefined criteria and extracted data using a pre-piloted data extraction form. The 61-item Philips Checklist was used to critically appraise the studies. Systematic review registration number: CRD42020184519.

RESULTS

Forty-nine studies were eligible to be included. Thirty studies (61.2%) were published in 2015-2021. Forty-seven studies were conducted for higher-income countries. There were mainly cost-utility analyses (n = 31) with the dominant primary outcome of quality-adjusted life year. The most common model was Markov (n = 26). Most of the studies were conducted from a societal or health care perspective (n = 37). Only ten models used a 50-year time horizon (n = 2) or lifetime horizon (n = 8). A wide range of mental health prevention strategies was evaluated with the dominance of selective/indicate strategy and focusing on common mental health problems (e.g., depression, suicide). The percentage of the Philip checkilst's criteria fulfilled by included studies was 69.3% on average and ranged from 43.3 to 90%. Among three domains of the Philip checklist, criteria on the model structure were fulfilled the most (72.1% on average, ranging from 50.0% to 91.7%), followed by the data domain (69.5% on average, ranging from 28.9% to 94.0%) and the consistency domain (54.6% on average, ranging from 20.0% to 100%). The practice of identification of 'relevant' evidence to inform model structure and inputs was inadequately performed. The model validation practice was rarely reported.

CONCLUSIONS

There is an increasing number of model-based economic evaluations of mental health prevention available to decision-makers, but evidence has been limited to the higher-income countries and the short-term horizon. Despite a high level of heterogeneity in study scope and model structure among included studies, almost all mental health prevention interventions were either cost-saving or cost-effective. Future models should make efforts to conduct in the low-resource context setting, expand the time horizon, improve the evidence identification to inform model structure and inputs, and promote the practice of model validation.

Healthcare staff's views on responding to suicide and self-harm: Part II

PURPOSE

To report on healthcare staff's views of the barriers to preventing suicide and self-harm.

DESIGN AND METHODS

Using a qualitative approach, data were collected through "World Café" discussion forums and written submissions, and analyzed using reflexive thematic analysis.

FINDINGS

Healthcare staff, including psychiatric nurses, perceived that a whole of society approach was needed for suicide and self-harm prevention. Support for those at the front line is needed as well as clear referral pathways and interagency working.

PRACTICE IMPLICATIONS

Formalized support for staff working in healthcare should be given with a flexible and inclusive approach to service delivery adopted.

[How Should We Approach Nurse Suicide in Korea: With the Aspect of Prevention-Intervention-Postvention Management]

Recently, nurse suicide has emerged as one of the major issues. We tried to review the status of nurse suicide and its management in Korea through inspecting related web sites, news articles, and research. However, there were no sufficient reports or statistics along with the research throughout the country. Moreover, there were no organized nurse suicide management systems or programs including suicide prevention, suicide intervention, suicide postvention management. In other countries, there were various trials and successful experiences about nurse suicide programs, and those have been managed in organized and integrated ways. It gave us a lot of implications. To effectively prevent and manage the nurse suicide in Korea, nursing workforce, nursing managers, and nursing researchers should be concerned about nurse suicide. Furthermore, discussions and the research must be made actively. Based on such efforts, appropriate programs, organized manage systems, and policies must be devised at institution and national level.

Cost-effectiveness evidence of mental health prevention and promotion interventions: A systematic review of economic evaluations

BACKGROUND

The prevention of mental disorders and promotion of mental health and well-being are growing fields. Whether mental health promotion and prevention interventions provide value for money in children, adolescents, adults, and older adults is unclear. The aim of the current study is to update 2 existing reviews of cost-effectiveness studies in this field in order to determine whether such interventions are cost-effective.

METHODS AND FINDINGS

Electronic databases (including MEDLINE, PsycINFO, CINAHL, and EconLit through EBSCO and Embase) were searched for published cost-effectiveness studies of prevention of mental disorders and promotion of mental health and well-being from 2008 to 2020. The quality of studies was assessed using the Quality of Health Economic Studies Instrument (QHES). The protocol was registered with PROSPERO (# CRD42019127778). The primary outcomes were incremental cost-effectiveness ratio (ICER) or return on investment (ROI) ratio across all studies. A total of 65 studies met the inclusion criteria of a full economic evaluation, of which, 23 targeted children and adolescents, 35 targeted adults, while the remaining targeted older adults. A large number of studies focused on prevention of depression and/or anxiety disorders, followed by promotion of mental health and well-being and other mental disorders. Although there was high heterogeneity in terms of the design among included economic evaluations, most studies consistently found that interventions for mental health prevention and promotion were cost-effective or cost saving. The review found that targeted prevention was likely to be cost-effective compared to universal prevention. Screening plus psychological interventions (e.g., cognitive behavioural therapy [CBT]) at school were the most cost-effective interventions for prevention of mental disorders in children and adolescents, while parenting interventions and workplace interventions had good evidence in mental health promotion. There is inconclusive evidence for preventive interventions for mental disorders or mental health promotion in older adults. While studies were of general high quality, there was limited evidence available from low- and middle-income countries. The review was limited to studies where mental health was the primary outcome and may have missed general health promoting strategies that could also prevent mental disorder or promote mental health. Some ROI studies might not be included given that these studies are commonly published in grey literature rather than in the academic literature.

CONCLUSIONS

Our review found a significant growth of economic evaluations in prevention of mental disorders or promotion of mental health and well-being over the last 10 years. Although several interventions for mental health prevention and promotion provide good value for money, the varied quality as well as methodologies used in economic evaluations limit the generalisability of conclusions about cost-effectiveness. However, the finding that the majority of studies especially in children, adolescents, and adults demonstrated good value for money is promising. Research on cost-effectiveness in low-middle income settings is required.

TRIAL REGISTRATION

PROSPERO registration number: CRD42019127778.

Economic and epidemiological impact of youth suicide in countries with the highest human development index

This research estimates the economic and epidemiological impact of youth suicide in countries with the highest human development index. The study relied on secondary analysis of suicide mortality data for youth aged between 15-24 years in countries with the highest human development index-Norway, Australia, Switzerland, Germany, Denmark, Singapore, Netherlands, Ireland, Canada and the United States. The impact of youth suicide is measured using years of life lost, years of productive life lost and present economic value of lost productivity. Costs are expressed in 2014 International dollars. Future earning potential is estimated using adjusted gross domestic product per capita, employment potential and historical trends in productivity and real interest rates. In 2014, an estimated 6,912 young people living in the most developed countries in the world lost their lives to suicide. These preventable deaths resulted in a loss of 406,730 years of life at a cost of $5.53 billion in lost economic income with the average cost of suicide estimated at $802,939. The United States stands out as a country with the most significant youth suicide problem accounting for 77% of total costs. Reducing youth suicide requires a multifaceted approach and significant investment by governments.