School-wide staff and faculty training in suicide risk awareness: successes and challenges

The Effects of Suicide Prevention Gatekeeper Training on Behavioral Intention and Intervention Behavior: A Systematic Review and Meta-Analysis

To understand the current state of research, a systematic review and meta-analysis were conducted to synthesize the effects of suicide prevention gatekeeper training (GKT) on participant behavioral intention to intervene and participant suicide intervention behaviors. Included studies examined GKT with adult participants and measured either behavioral intention to conduct a suicide intervention or the utilization of suicide intervention skills. Searches yielded a total of 43 studies from 46 reports, comprising 21,720 participants. To quantify change over time, the standardized mean gain effect size metric was utilized. Large effect sizes were found for behavioral intention from pre-training to post-training (1.03, 95% CI [0.80, 1.25]) and short-term follow-up (0.78, 95% CI [0.59, 0.97]). Smaller effect sizes were found for intervention behavior from pre-training to short-term (0.33, 95% CI [0.21, 0.46]) and long-term follow-up (0.22, 95% CI [0.14, 0.30]). Although this meta-analysis reveals a positive effect for GKT on behavioral outcomes, the low methodological quality of the currently available evidence limits the ability to draw conclusions from the synthesis. This work informs policymakers and interventionists on best practices for GKT and highlights that additional, rigorous research is needed.

Leader and Provider Perspectives on Implementing Safe Alternatives for Teens and Youth - Acute (SAFETY-A) in Public School Districts Serving Racial/ethnic Minoritized Youth

Racial/ethnic minoritized (REM) youth represent a high-risk group for suicide, yet there are striking disparities in their use of mental health services (MHS) even after risk is identified in schools. Prior research suggests that school-based risk assessments and hospitalization encounters can be negatively experienced by REM youth and families, thus deterring likelihood of seeking follow-up care. The Safe Alternatives for Teens and Youth-Acute (SAFETY-A) is a brief, strengths-based, cognitive-behavioral family intervention demonstrated to increase linkage to MHS when implemented in emergency departments. With its focus on strengths and family engagement, SAFETY-A may cultivate a positive therapeutic encounter suited to addressing disparities in MHS by enhancing trust and family collaboration, if appropriately adapted for schools. Thirty-seven school district leaders and frontline school MHS providers from districts serving primarily socioeconomically disadvantaged REM communities participated in key informant interviews and focus groups. First, interviews were conducted to understand usual care processes for responding to students with suicidal thoughts and behaviors, and perspectives on the strengths and disadvantages of current practices. An as-is process analysis was used to describe current practices spanning risk assessment, crisis intervention, and follow-up. Second, focus groups were conducted to solicit perceptions of the fit of SAFETY-A for these school contexts. Thematic analysis of the interviews and focus groups was used to identify multilevel facilitators and barriers to SAFETY-A implementation, and potential tailoring variables for implementation strategies across school districts.

Effectiveness of online advanced C.A.R.E suicide prevention gatekeeper training program among healthcare lecturers and workers in national university of Malaysia: A pilot study

BACKGROUND

Suicide is a major cause of death among adolescents and young adults, especially students. This is particularly true for healthcare students with a higher risk and more access to lethal means. Thus, it is vital for healthcare educators who have regular contact with these healthcare students to be trained as gatekeepers in preventing suicide. Evidence of the effectiveness of such gatekeeper training, mainly using an online module, is lacking predominantly in Malaysia. This study aims to investigate the effectiveness of an online gatekeeper suicide prevention training program that is conducted for healthcare lecturers.

METHODS

A single-arm interventional pre-and post-pilot study was conducted on a sample of healthcare lecturers and workers who are involved in supervising healthcare students. A purposive sampling technique was used to recruit 50 healthcare educators in Malaysia. The program was conducted by trained facilitators and 31 participants completed a locally validated self-rated questionnaire to measure their self-efficacy and declarative knowledge in preventing suicide; immediately before and after the intervention.

RESULTS

Significant improvement was seen in the overall outcome following the intervention, mostly in the self-efficacy domain. No significant improvement was seen in the domain of declarative knowledge possibly due to ceiling effects; an already high baseline knowledge about suicide among healthcare workers. This is an exception in a single item that assesses a common misperception in assessing suicide risk where significant improvement was seen following the program.

CONCLUSION

The online Advanced C.A.R.E. Suicide Prevention Gatekeeper Training Program is promising in the short-term overall improvement in suicide prevention, primarily in self-efficacy.

Perceptions of rural high school teachers - on the frontline of youth suicide

OBJECTIVE

This study aimed to investigate the perceptions and beliefs of rural high school teachers about student suicide completion in their school and their perceived self-efficacy in identification of suicidality in students (suicidal ideation, plans and behaviours).

DESIGN

A cross-sectional survey methodology.

SETTING

Gippsland and the Loddon Mallee regions of Victoria, Australia.

PARTICIPANTS

Rural high school teachers.

OUTCOME MEASURE

A survey that aimed to obtain participants' perceptions and self-reports about students who had died by suicide in their school within the last 5 years, their perceived self-efficacy in identifying suicidal students and barriers to helping students at risk.

RESULTS

Two hundred and seventy-seven rural high school teachers participated and 86% reported that a student from their school had died by suicide within the last 5 years. Sixty-five per cent believed that more than one student had died by suicide and 70% perceived they were currently aware of students experiencing suicidality in their class. Receiving professional development about suicide and obtaining help from mental health clinicians predicted perceived self-efficacy in identification of suicidality in students. Participants perceived the barriers to help students at risk included insufficient numbers of school-based mental health professionals and community mental health services.

CONCLUSIONS

Many rural high school teachers perceive they are at the front line of the youth suicide crisis due to unmet service need in youth mental ill health. Increased access to effective services immediately after teachers become aware of suicidality may assist in reducing youth suicide in rural areas.

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

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

Non-disclosing youth: a cross sectional study to understand why young people do not disclose suicidal thoughts to their mental health professional

BACKGROUND

Prevalence of suicidal ideation increases rapidly in adolescence, and many choose not to seek help and disclose their ideation. Young people who do disclose suicidal ideation, prefer to do so with peers and family compared to mental health professionals, who are best placed to provide evidence-based treatment. This study aimed to identify key factors associated with young people's decision to, or not to disclose suicidal thoughts to their mental health practitioner.

METHODS

A community-based sample of young Australians (16 - 25 years), who had experienced suicidal ideation and engaged with a mental health professional, completed an online questionnaire (N=513) which assessed demographic characteristics, severity of depression, anxiety, psychological distress, and suicidal ideation, lifetime suicide attempts, exposure to suicide loss, personal suicide stigma, prioritisation of mental health issues, and therapeutic alliance. Logistic regression analyses were used to identify factors associated with disclosure.

RESULTS

Though the full sample had engaged in therapy, 39% had never disclosed suicidal ideation to their clinician. Those who had disclosed were more likely to report greater therapeutic alliance (OR=1.04, 95% CI=1.02-1.06), personal suicide stigma (OR=1.04, 95% CI=1.01-1.06), prioritisation of suicidal ideation (OR=.24, 95% CI=0.14-0.42), and lifetime history of suicide attempt (OR=.32, 95% CI=0.18-0.57). The most common reason for not disclosing was concern that it would not remain confidential.

CONCLUSION

These findings provide new insights into why young people may not seek help by disclosing suicidal ideation, despite having access to a mental health professional, and establish evidence to inform practice decisions and the development of prevention strategies to support young people for suicide.

Feasibility of a serious game coupled with a contact-based session led by lived experience workers for depression prevention in high-school students

BACKGROUND

Stigma and limited mental health literacy impede adolescents getting the help they need for depressive symptoms. A serious game coupled with a classroom session led by lived experience workers (LEWs) might help to overcome these barriers. The school-based Strong Teens and Resilient Minds (STORM) preventive program employed this strategy and offered a serious game, Moving Stories. The current study was carried out to assess inhibiting and promoting factors for scaling up Moving Stories once its effectiveness has been ascertained.

METHODS

Moving Stories was offered in three steps: (1) introductory classroom session, (2) students playing the game for five days, (3) debriefing classroom session led by lived experience worker. Data was collected on the number of participating students, costs of offering Moving Stories, and was further based on the notes of the debriefing sessions to check if mental health first aid (MHFA) strategies were addressed.

RESULTS

Moving Stories was offered in seven high-schools. Coverage was moderate with 982 participating students out of 1880 (52%). Most participating students (83%) played the Moving Stories app three out of the five days. Qualitative data showed that the MHFAs were discussed in all debriefing sessions. Students showed great interest in lived experience workers' stories and shared their own experiences with depression.

CONCLUSIONS

Bringing Moving Stories to scale in the high-school setting appears feasible, but will remain logistically somewhat challenging. Future implementation and scale-up of Moving Stories could benefit from improved selection and training of LEWs that played such an important role in grabbing the full attention of students and were able to launch frank discussions about depressive disorder and stigma in classrooms.

TRIAL REGISTRATION

The study is registered in the Dutch Trial Register: Trial NL6444 (NTR6622: https://www.trialregister.nl/trial/6444).

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

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

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

Objective

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

Methods

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

Results

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

Conclusion

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

Comparing the Effectiveness of Brief Versus In-Depth Gatekeeper Training on Behavioral Outcomes for Trainees

BACKGROUND

A common suicide prevention strategy is training gatekeepers to identify at-risk individuals and refer them to services.

AIMS

The study aimed to examine whether differences in training outcomes were observed for brief versus in-depth gatekeeper trainings for trainees from varied professional settings while controlling for differences in trainee characteristics and community context.

METHOD

Trainees' identification and referral behavior 3 months after gatekeeper training was compared with a sample of respondents matched on individual- and community-level variables using propensity score-based techniques. The value was estimated, in terms of additional identification and associated costs, of adopting in-depth training.

RESULTS

A higher proportion of trainees who participated in in-depth trainings from K-12 and community settings identified at-risk youth, and a higher proportion of in-depth trainees from mental health settings referred youth to services compared with participants of brief trainings from the same setting and with similar characteristics. The effect of training type on outcomes varied by professional role and community context.

LIMITATIONS

Self-report measures were used to assess outcomes. Similar measures are used in other studies; their validity has not been conclusively established.

CONCLUSION

Findings suggest certain individuals may benefit from in-depth training more than others, which favors targeting this intervention to particular gatekeepers.

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

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

The prevalence and correlates of suicidal behaviours (ideation, plan and attempt) among adolescents in senior high schools in Ghana

Suicide is recognised as the third leading cause of death among adolescents globally. There is however limited data on the prevalence and factors associated with suicide particularly in Ghana. To explore the prevalence and risk and protective factors associated with suicide in Ghana, a nationwide Global School-based Student Health Survey data collected among senior high school adolescents in Ghana was used. The prevalence of suicidal behaviours was 18.2%, 22.5% and 22.2% for suicidal ideation, suicidal plan and suicidal attempt respectively. In the final analysis, anxiety increases the odds of suicidal behaviour, even after controlling for other variables. Loneliness increases the odds of suicidal behaviour but after adjusting for other factors the odds remained for only suicidal plan. Being bullied, physically attacked, involved in a physical fight and food insecurity remained risk factors for suicidal behaviour (i.e. ideation, plan and attempt) after adjusting for other factors. Truancy was found as a risk factor for both suicidal ideation and plans but such effect diminished for suicidal plan after adjusting for other variables. Increasing number of close friends remained a risk factor for both suicidal plan and attempt but such effect diminished for suicidal ideation after adjusting for other variables. Parental understanding of adolescents’ problems and worries remained a significant protective factor for all the indices of suicidal behaviour after adjusting for other variables. Parental respect for privacy was protective of suicidal attempt but was not significant after adjusting for other variables. Early identification and intervention for at-risk adolescents in senior high schools, for example those experiencing different forms of physical abuse, drug and substance use and hunger can potentially reduce the prevalence of suicide among this population in Ghana.

•

The study showed high prevalence of suicidal behaviour among school-going adolescents.

•

Anxiety, loneliness, hunger, physical abuse, bullying and the lack of parental understanding were strongly related suicidal behaviour.

•

Interventions for suicide prevention should take into consideration the school and family settings.

Outcomes of a Suicide Prevention Gatekeeper Training Program Among School Personnel

BACKGROUND

Gatekeeper suicide prevention programs train staff to increase the identification and referral of suicidal individuals to the appropriate resources.

AIMS

We evaluated Act on FACTS: Making Educators Partners in Youth Suicide Prevention (MEP), which is an online training program designed to enhance the knowledge of suicide risk factors and warning signs as well as improve participants' attitudes and self-efficacy/confidence.

METHOD

School personnel (N = 700) completed a survey administered before and immediately after the training to assess gains in training outcomes and to evaluate participants' satisfaction with the training.

RESULTS

Results indicated that MEP participants demonstrated significant increases in suicide knowledge, attitudes, and self-efficacy. Moreover, exploratory analyses revealed moderating effects of professional role on pre-/posttest changes in self-efficacy, but not suicide knowledge or attitudes. Specifically, guidance counselors demonstrated significantly smaller increases in self-efficacy/confidence compared with teachers and classroom aids, whereas teachers demonstrated significantly larger increases in self-efficacy/confidence compared with administrators. The majority of school personnel who completed the MEP program were satisfied with the training content and experience.

CONCLUSION

Although the current findings are promising, more rigorous evaluations employing randomized controlled research designs are warranted to adequately determine the effectiveness of the MEP program.

Dying online: live broadcasts of Chinese emerging adult suicides and crisis response behaviors

BACKGROUND

Social media and online environments are becoming increasingly popular and integral to modern lives. The online presentation of suicidal behaviors is an example of the importance of communication technologies, and the need for professionals to respond to a changing world. These types of behaviors, however, have rarely been scientifically analyzed. This study aimed to examine the behaviors of both suicide broadcasters and their audience, with attention on prevention/crisis opportunities.

METHODS

Multiple case studies were employed to explore live-broadcast suicide by Chinese emerging adults (aged 18-25 years). Six cases were selected (four males, two females; aged 19-24, M = 21.60, SD = 2.25), retrieved from 190 public documents (case range = 5 to 32; M = 11.50, SD = 10.37). A qualitative study based on grounded theory was adopted. Information on case background, stages, participants and their behaviors were collected.

RESULTS

(1) Five stages of blogcast suicide incidents were revealed, including: Signaling, Initial reactions, Live blogcast of suicide attempts, Crisis responses, and Final outcomes. (2) Common behavioral trends (e.g., comforting, verbal abuse) were identified from the blogcast participants (e.g., active audience, peers, parents and police). (3) Suicide blogcasters exhibited tendencies to communicated signs of pain and cries for help.

CONCLUSIONS

This multi-case study found live presentations of suicidal behaviors offered unique opportunities to respond to suicidal crises, and also to learn more about the relationships between suicidal people and potential help sources. Findings showed many audience members wanted to be helpful but lacked appropriate skills or knowledge. Others engaged in suicide cyberbullying. The social media is an environment in the making. This study revealed that increasing knowledge and skills for crisis response and suicide prevention is needed. Such efforts could lead to empowered netizens and a more hospitable online world.

Brief gatekeeper training for suicide prevention in an ethnic minority population: a controlled intervention

BACKGROUND

Suicide is a critical public health problem around the globe. Asian populations are characterized by elevated suicide rates and a tendency to seek social support from family and friends over mental health professionals. Gatekeeper training programs have been developed to train frontline individuals in behaviors that assist at-risk individuals in obtaining mental health treatment. The purpose of this study is to assess the efficacy of a brief, multi-component gatekeeper intervention in promoting suicide prevention in a high-risk Asian community in the United States.

METHODS

We adapted an evidence-based gatekeeper training into a two-hour, multi-modal and interactive event for Japanese-Americans and related stakeholders. Then we evaluated the intervention compared to an attention control using mixed methods.

RESULTS

A sample of 106 community members participated in the study. Intervention participants (n = 85) showed significant increases in all three types of intended gatekeeper behavior, all four measures of self-efficacy, and both measures of social norms relevant to suicide prevention, while the control group (n = 48) showed no significant improvements. Additional results showed significantly higher satisfaction and no adverse experiences associated with the gatekeeper training. The separate collection of qualitative data, and integration with the quantitative survey constructs confirmed and expanded understanding about the benefits of the intervention.

CONCLUSIONS

A brief, multi-modal gatekeeper training is efficacious in promoting positive gatekeeper behaviors and self-efficacy for suicide prevention in an at-risk ethnic minority population of Japanese Americans.

THE CHALLENGES OF SCHOOL-BASED YOUTH SUICIDE PREVENTION: EXPERIENCES AND PERCEPTIONS OF MENTAL HEALTH PROFESSIONALS IN SOUTH AFRICAN SCHOOLS

Youth suicidal behaviour poses a significant public health concern. Mental health care professionals working in schools have an important role to play in youth suicide prevention initiatives, although little is known of the experiences of this group of professionals in the developing world. The aim of this study was to explore the experiences of mental health professionals working in South African schools and document their insights, attitudes and beliefs regarding youth suicidal behaviour. In-depth semi-structured interviews were conducted with seven school-based mental health care professionals and data were analysed using Thematic Analysis. Participants reported that they relied on a reactive strategy by responding to youths who were in crisis. They were challenged by a lack of support from faculty staff, lack of access to resources, and heavy caseloads. Findings highlight the need for a proactive and collaborative approach to suicide prevention among mental health care professionals, teachers and parents in South African schools and improved training and supervision.

Suicide Prevention E-Learning Modules Designed for Gatekeepers

Background: E-learning modules can be a useful method for educating gatekeepers in suicide prevention and awareness. Aims: To review and provide an overview of e-learning modules on suicide prevention designed for gatekeepers and assess their effectiveness. Method: Two strategies were used. First, articles were systematically searched in databases of PubMed, Web of Science, and PsycINFO. Second, Google search was used to find e-learning modules on the Web. Results: The literature search resulted in 448 papers, of which none met the inclusion criteria of this study. The Google search resulted in 130 hits, of which 23 met the inclusion criteria of this review. Organizations that owned the modules were contacted, of which 13 responded and nine were included in this study. The effectiveness of two e-learning modules is currently being tested in a randomized controlled trial (RCT), one organization is planning to test the effectiveness of their module, and one organization has compared their face-to-face training with their online training. Furthermore, the included modules have different characteristics. Conclusion: There is a need for RCTs to study the effectiveness of online modules in this area and to understand which characteristics are essential to create effective e-learning modules to educate gatekeepers in suicide prevention.

Effectiveness of adolescent suicide prevention e-learning modules that aim to improve knowledge and self-confidence of gatekeepers: study protocol for a randomized controlled trial

Background

Providing e-learning modules can be an effective strategy for enhancing gatekeepers’ knowledge, self-confidence and skills in adolescent suicide prevention. The aim of this study was to test the effectiveness of an online training program called Mental Health Online which consists of eight short e-learning modules, each capturing an important aspect of the process of recognition, guidance and referral of suicidal adolescents (12–20 years). The primary outcomes of this study are participant’s ratings on perceived knowledge, perceived self-confidence, and actual knowledge regarding adolescent suicidality.

Methods/Design

A randomized controlled trial will be carried out among 154 gatekeepers. After completing the first assessment (pre-test), participants will be randomly assigned to either the experimental group or the waitlist control group. One week after completing the first assessment the experimental group will have access to the website Mental Health Online containing the eight e-learning modules and additional information on adolescent suicide prevention. Participants in both conditions will be assessed 4 weeks after completing the first assessment (post-test), and 12 weeks after completing the post-test (follow-up). At post-test, participants from the experimental group are asked to complete an evaluation questionnaire on the modules. The waitlist control group will have access to the modules and additional information on the website after completing the follow-up assessment.

Discussion

Gatekeepers can benefit from e-learning modules on adolescent suicide prevention. This approach allows them to learn about this sensitive subject at their own pace and from any given location, as long as they have access to the Internet. Given the flexible nature of the program, each participant can compose his/her own training creating an instant customized course with the required steps in adolescent suicide prevention.

Trial registration

Netherlands Trial Register NTR3625