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

Opioid misuse and mental health in college student populations: A national assessment

BACKGROUND

Despite growing concern about opioid misuse and mental health of college students, little is known about this population who are at high risk of co-occurrence and unmet needs. This national study aims to estimate the prevalence of opioid misuse, examine correlates with anxiety and depression symptoms, and quantify help-seeking behaviors among U.S. college students.

METHODS

Data come from students in the Healthy Minds Study between 2017 and 2020 (n = 176,191). Validated screening tools assessed mental health symptoms (PHQ-9, GAD-7). Marginal effects of logistic regression models estimate the effect of opioid misuse on mental health symptoms, help-seeking and academic performance.

RESULTS

782 students indicated past month opioid misuse. Student opioid misuse was associated with 24.1 percentage point increase in the probability of screening positive for anxiety/depression (p < 0.001) and 3.6 percentage point increase in the probability of informal help-seeking (p = 0.017). Less than half of students with opioid misuse and a positive depression/anxiety screen received any treatment in the past year.

LIMITATIONS

Limitations to this study include: possible non-response bias, as it is unknown whether students with opioid misuse may be differentially-likely to respond to the survey; differing time frame for opioid misuse and mental health questions; and data was collected prior to the COVID-19 pandemic.

CONCLUSIONS

This large, multi-campus study underlines the need for more partnership between substance use and mental health services on campus. It also highlights that college peers could receive training in ways to best help students who misuse opioids, directing them to on- or off-campus care.

Development of a Standardized Suicide Prevention Program for Gatekeeper Intervention in Korea (Suicide CARE Version 2.0) to Prevent Adolescent Suicide: Version for Teachers

OBJECTIVE

The increasing concern over adolescent suicide necessitates suicide prevention training for school teachers, as students spend a significant portion of their time at school. This study's objective is to develop a suicide prevention program tailored for teachers.

METHODS

The program was developed by a multidisciplinary research team, drawing on a review of both domestic and international suicide prevention programs, related scholarly articles, and Korean psychological autopsy interviews of adolescents. This was complemented by a survey of teachers to assess the program's practicality and usability.

RESULTS

The developed program comprises three parts, consistent with other versions: Careful Observation, Active Listening, and Risk Evaluation and Expert Referral. Careful Observation focuses on training teachers to recognize verbal, behavioral, and situational warning signs of suicidal ideation in students; Active Listening involves strategies for encouraging students to express their suicidal thoughts and techniques for being an empathetic and attentive listener; Risk Evaluation and Expert Referral provides instruction on how to assess suicide risk and assist students safely.

CONCLUSION

It is anticipated that this program will equip teachers with valuable knowledge and skills, contributing to a reduction in adolescents suicide rates.

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.

Associations between youth suicide rates and state school personnel suicide prevention training requirements

Objective

As youth spend the majority of their time in school, school personnel suicide prevention training has gained support as an approach to mitigate rising youth suicide rates. This study examined associations between state school personnel suicide prevention training requirements (i.e., mandatory/non-mandatory and annual/not annual), year of legislation enactment (2013 or earlier/2014 or later), and changes in youth suicide rates by state from 2007-09 to 2016-18.

Methods

School personnel suicide prevention training requirement data were collected through state-specific Department of Education websites while state-specific youth suicide rates were collected from the Center for Disease Control and Prevention's 2020 National Vital Statistics Report. Data were analyzed using a mixed effects linear regression model.

Results

Training is mandated in 40/50 (80 %) states; 19/50 (38 %) require annual training. All states demonstrated increases in youth suicide rates from 2007-09 to 2016-18 (mean increase 3.9/100,000 [sd = 1.8]), but the change did not differ significantly by state requirements for mandatory (p = 0.44) or annual (p = 0.70) training, nor for year of enactment of legislation (p = 0.45).

Conclusions

School personnel suicide prevention training requirements were not associated with changes in the youth suicide rate, though study results are limited in that data was not available on how successfully schools implemented the required trainings.

A Review of Systematic Reviews: Gatekeeper Training for Suicide Prevention with a Focus on Effectiveness and Findings

OBJECTIVES

Suicide prevention gatekeeper training (GKT) is considered an important component of an overall suicide-prevention strategy. The primary aim of this study was to conduct the first robust review of systematic reviews of GKT to examine the overall effectiveness of GKT on knowledge, self-efficacy, attitudes, behavioral intentions, and behavioral change. The study also examined the extent to which outcomes were retained long term, the frequency of refresher sessions, and the effectiveness of GKT with Indigenous populations and e-learning delivery.

METHODS

For this review of reviews, MEDLINE, PsycINFO, Embase; and the Cochrane Database of Systematic Reviews were searched. ROBIS was applied to assess risk of bias and findings were synthesized using narrative synthesis.

RESULTS

Six systematic reviews were included comprising 61 studies, of which only 10 were randomized controlled trials (RCTs). Immediate positive effects of GKT on knowledge, skills, and self-efficacy were confirmed, including for interventions tailored for Indigenous communities. Evidence was mixed for change in attitude; few studies measured e-learning GKT, retention of outcomes, booster sessions, behavioral intentions, and behavioral change, with some positive results.

CONCLUSIONS

Evidence supports the immediate effects of GKT but highlights a need for more high-quality RCTs, particularly for Indigenous and e-learning GKT. This review identified a concerning lack of long-term follow-up assessments at multiple time points, which could capture behavioral change and a significant gap in studies focused on post-training interventions that maintain GKT effects over time.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Randomized Controlled Trial of an Online Suicide Prevention Gatekeeper Training Program

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

Psychosocial interventions for suicidal and self-injurious-related behaviors among adolescents: a systematic review and meta-analysis of Chinese practices

Background

Suicidal and self-injurious-related behaviors (SSIRBs) are a serious public health challenge in China. However, a comprehensive systematic review of psychosocial interventions for SSIRBs among Chinese adolescents has not been performed. To fill this gap, this systematic review and meta-analysis aimed to examine psychosocial interventions for SSIRBs among Chinese adolescents.

Methods

Eight international (PubMed, EMBASE, Cochrane Library, ScienceDirect, Clinical Trial, CINAHL, PsycINFO, and Web of Science) and four Chinese (Wanfang, SinoMed, CEPS, and CNKI) databases were searched from inception to 31 January 2023. Data extraction and quality assessment were independently conducted by two groups of researchers. Qualitative synthesis and meta-analysis were both used.

Results

The initial search yielded 16,872 titles. Of the 649 full texts reviewed, 19 intervention articles focusing on SSIRBs met the inclusion criteria. Thirteen out of the 19 included studies involved cognitive-behavioral therapy (CBT). Seven non-suicidal self-injury (NSSI) studies assessing self-injurious behaviors were included (six short-term studies and three long-term studies). Compared with long-term interventions [-1.30 (95% CI: -1.84, -0.76)], short-term psychosocial interventions had a higher standardized mean difference (SMD) value [1.86 (95% CI: -2.72, -0.99)]. Meta-regression showed an inverse relationship between the treatment response and sample size (slope = 0.068, Z = 2.914, p = 0.004) and proportion of females (slope = 1.096, Z = 5.848, p < 0.001). Subgroup analyses showed that compared with the "less than 1 month" group [-0.494 (-0.783, -0.205)], in the "immediate postintervention" group, the pooled estimate was significantly lower [-2.800 (-4.050, -1.550), p < 0.001].

Conclusion

Our review systematically summarized the key characteristics and effectiveness of existing psychosocial interventions for SSIRBs among Chinese adolescents. Short-term psychosocial interventions for NSSI were significantly effective in reducing self-injurious behavior scores, especially in the immediate postintervention period. More favorable treatment responses could be observed in both male and small samples.

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.

How, when and where to intervene in self-harm in youth in low- and middle-income countries: Thinking beyond healthcare systems

BACKGROUND

Low- and middle-income countries (LMICs) account for 78% of global suicides. Self-harm is the clearest antecedent of suicide. The health and social systems have struggled to provide adequate evidence based help to young people with self-harm. In addition, the negative attitudes towards those who self-harm in these settings interfere with help-seeking behaviour.

AIMS AND METHOD

In our submission of a comment, we discuss the reasons for thinking beyond healthcare systems in LMICs to address self-harm in youth and the possible ways to achieve it.

RESULTS AND CONCLUSION

We truly believe that harnessing the potential of social systems such as schools is important for addressing self-harm in LMICs. We present our arguments in favour of feasible measures that can be implemented to achieve this.

Universal prevention for non-suicidal self-injury in adolescents is scarce - A systematic review

Non-suicidal self-injury (NSSI) during adolescence is a high-risk marker for the development and persistence of mental health problems and has been recognized as a significant public health problem. Whereas targeted prevention has indeed shown to be effective in reducing NSSI and improve mental health problems, access to such programs is limited. By face validity, universal prevention of NSSI seems an ideal starting point for a stepped-care model to circumvent a lack of resources in the medical care system. However, it is yet unclear how effective such approaches are. Here, we provide a summary of existing work on universal prevention of NSSI in adolescents younger than 21 years based on a systematic literature search. We found that only seven studies are available. None of the programs evaluated was found to be effective in reducing the incidence or frequency of NSSI. After providing a comprehensive summary of the existing work, we evaluate the fact that existing work primarily focusses on selected/targeted prevention and on psychoeducational methods. We derive implications for future directions in the field of universal prevention of NSSI.

Development of the Life Gatekeeper suicide prevention training programme in China: a Delphi study

Background

Youth suicide has been a pressing public mental health concern in China, yet there is a lack of gatekeeper intervention programmes developed locally to prevent suicide among Chinese adolescents.

Aims

The current Delphi study was the first step in the systematic development of the Life Gatekeeper programme, the first gatekeeper programme to be developed locally in China that aims to equip teachers and parents with the knowledge, skills and ability to identify and intervene with students at high risk of suicide.

Methods

The Delphi method was used to elicit a consensus of experts who were invited to evaluate the importance of training content, the feasibility of the training delivery method, the possibility of achieving the training goals and, finally, the appropriateness of the training materials. Two Delphi rounds were conducted among local experts with diversified professional backgrounds in suicide research and practice. Statements were accepted for inclusion in the adjusted training programme if they were endorsed by at least 80% of the panel.

Results

Consensus was achieved on 201 out of 207 statements for inclusion into the adapted guidelines for the gatekeeper programme, with 151 from the original questionnaire and 50 generated from comments of the panel members. These endorsed statements were synthesised to develop the content of the Life Gatekeeper training programme.

Conclusions

This Delphi study provided an evidence base for developing the first gatekeeper training programme systematically and locally in China. We hope that the current study can pave the way for more evidence-based suicide prevention programmes in China. Further study is warranted to evaluate the effectiveness of the Life Gatekeeper training programme.

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.

Referring students for professional psychological help: A qualitative study of teachers' experience in Hong Kong

Teachers have frequent interaction with students and are well positioned to refer students for mental health assistance when needed. Twelve secondary schoolteachers in Hong Kong were interviewed about their experience referring students to mental health professionals (MHPs). Using consensual qualitative research, multiple factors were found to influence teachers' referral decisions, including problem severity, students' willingness, stigma of help-seeking, parent/guardian's beliefs, teacher-parent/guardian relationship, MHPs' effectiveness and availability, quality of interaction with MHPs, and teachers' self-efficacy in handling student issues. Based on the findings, we propose a conceptual model of factors influencing teachers' referral decisions. Implications for research, practice, and training are discussed.

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

BACKGROUND

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

Barriers to School-Based Mental Health Resource Utilization Among Black Adolescent Males

Black adolescent males use available mental health services at a disproportionately lower rate compared to males of other racial groups. This study examines barriers to school-based mental health resource (SBMHR) use among Black adolescent males, as a means of addressing reduced usage of available mental health resources and to improve these resources to better support their mental health needs. Secondary data for 165 Black adolescent males were used from a mental health needs assessment of two high schools in southeast Michigan. Logistic regression was employed to examine the predictive power of psychosocial (self-reliance, stigma, trust, and negative previous experience) and access barriers (no transportation, lack of time, lack of insurance, and parental restrictions) on SBMHR use, as well as the relationship between depression and SBMHR use. No access barriers were found to be significantly associated with SBMHR use. However, self-reliance and stigma were statistically significant predictors of SBMHR use. Participants who identified self-reliance in addressing their mental health symptoms were 77% less likely to use available mental health resources in their school. However, participants who reported stigma as a barrier to using SBMHR were nearly four times more likely to use available mental health resources; this suggests potential protective factors in schools that can be built into mental health resources to support Black adolescent males' use of SBMHRs. This study serves as an early step in exploring how SBMHRs can better serve the needs of Black adolescent males. It also speaks to potential protective factors that schools provide for Black adolescent males who have stigmatized views of mental health and mental health services. Future studies would benefit from a nationally representative sample allowing for more generalizable results regarding barriers and facilitators to Black adolescent males' use of school-based mental health resources.

Educator's views on suicide prevention in high schools and what they need

Background

Suicide is the leading cause of death among youth. Although school-aged youth are surrounded by educators and professionals, little is known about what educators want to know regarding suicide.

Objective and Design

The purpose of this qualitative study was to explore the perceived learning needs of high school educators in Northwestern Ontario (NWO) regarding suicide prevention using semi-structured interviews.

Results

The results yielded educators prefer learning based on a mixture of styles that is relevant to their student needs; noting that time constraints are a barrier. Educators are interested in knowing what to say; however, limited by the unknown legalities involved. Educators expressed being comfortable talking about suicide and understood basic warning signs.

Conclusions

The findings can assist mental health professionals and school board administration in supporting educators regarding suicide prevention. Future research can include the creation of a suicide prevention program that is targeted exclusively for high school educators.

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

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

Scoping review of 30 years of suicide prevention in university students around the world: efficacy, effectiveness, and cost-effectiveness

A scoping review of systematic reviews was carried out to identify evidence of efficacy, effectiveness, and cost-effectiveness of universal and selective suicide prevention programs among university students worldwide. Five databases were reviewed using terms in English, Spanish, and Portuguese. The following were the inclusion criteria: systematic review or meta-analysis or meta-synthesis, suicide prevention in college students, evaluation of the efficacy, effectiveness and/or cost-effectiveness of interventions, and peer-reviewed studies. The quality of reviews was assessed. The field of study features three decades of publication in high-income countries. The strategy used, the components of the program, and the target audience to which they are delivered interfere with efficacy. In the psychoeducation strategy, the experiential and didactic components are more efficacious in the knowledge about suicide. And the motivational enhancement component promotes greater self-efficacy in suicide prevention. Programs that take a multimodal approach are effective in increasing short-term attitudes related to suicide and reducing rates of completed suicide. The gatekeeper strategy delivered to peer counselors is the most effective one in the outcomes, including short-term and long-term knowledge about suicide and its prevention and self-efficacy in suicide prevention. A greater number of evaluated studies of gatekeeper interventions were identified, indicating a trend in this research field. No review addressed the effects on subgroups that were classified based on sex, racial or sexual minorities, and special (indigenous) populations. Only one study addressed cost-effectiveness, pointing out that the psychoeducation and gatekeeper strategies have relevant net benefit rates, but the gatekeeper strategy has a higher cost-benefit ratio compared to the psychoeducation strategy. The findings indicate that psychoeducation and gatekeeper interventions tend to be more efficacious when they combine education and skills training to intervene in suicidal behavior. The components of the intervention and the target audience to which it is delivered influence efficacy. Multimodal interventions evaluate completed suicide outcomes, but require greater implementation efforts, in terms of human and financial resources and more time for the evaluation.

Analysis of Attempted Suicide in a Pediatric Setting: Extracted Notes for Clinical Practice and Complexity of Help

Background and Objectives: Suicidality among adolescents is a global mental health issue. However, the post-suicidal care of minors is insufficient and lacks complexity, as repeated attempts occur. Further, little is known about the social (i.e., family setting) and psychological (for example, exposure to bullying, suicidality, or addiction within a close environment) backgrounds of minors who engage in suicidal behavior in Lithuania. Thus, the aim of our study was to evaluate and compare psychosocial factors that may influence minors’ decisions to attempt suicide for the first time and then repeatedly and to extract notes for future clinical practice. Materials and Methods: Data from 187 cases of suicide attempts by minors treated at the Children’s Hospital of Vilnius University Santara Clinics from January 2011 to January 2018 was obtained and analyzed. Results: The data showed that 48.7% of minors hospitalized because of a suicide attempt had a history of previous suicide attempts. Minors who attempted suicide repeatedly were more often engaged in non-suicidal self-injurious behavior (p = 0.033). Further, a small number had experienced suicide within their close surroundings (p = 0.045). The comparative analysis did not reveal any significant differences in psychosocial backgrounds between first-time attempters and those who attempted suicide for at least a second time. Conclusions: Social and psychological support after a suicide attempt in a pediatric setting is lacking efficiency, as minors who repeatedly attempt suicide suffer from similar psychosocial burdens. Complex and targeted follow-up care is needed.

Teachers as Youth Suicide Prevention Gatekeepers: An Examination of Suicide Prevention Training and Exposure to Students at Risk of Suicide

Background

Teachers are important gatekeepers in suicide prevention for children and youth, yet little is known about factors that contribute to suicide prevention training effectiveness and the influence of student suicidality on teachers' role as gatekeepers.

Objective

This study examined teachers' attitudes and self-efficacy in suicide prevention including an examination of suicide prevention training and exposure to student suicidality. Researchers examined incremental prediction of the relationship between teachers' self-efficacy, outcome expectations, and outcome values following prevention training.

Methods

Participants included teachers in PreK-12th grade schools in the United States (N = 505). Researchers used non-parametric statistics to examine group level differences and a structural equation model (SEM) to test the proposed theoretical model.

Results

Teachers who experienced a student death by suicide reported significantly higher levels of gatekeeper reluctance than teachers who had not experienced a student death by suicide (p < 0.01). Similarly, teachers who encountered students with suicidal thoughts reported greater levels of gatekeeper reluctance (p < 0.01) and higher self-efficacy to engage in suicide prevention (p < 0.05) compared to teachers who had not had this exposure. Results of the SEM indicated an adequate goodness of fit and fit statistics [χ2 (87) = 194.420, p = 0.000; CFI = 0.95; RMSEA = 0.05]. The model remained in-tact when exposure to student suicide was added.

Conclusions

Findings support the importance of supporting teachers continued engagement in youth suicide prevention and prevention training that targets specific outcomes in teachers' attitudes and efficacy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10566-022-09699-5.

Characteristics of Korean Children and Adolescents Who Die by Suicide Based on Teachers' Reports

We analyzed the clinical characteristics and suicide-related factors of students who died by suicide in Korea in 2016–2020, based on teachers’ reports. Using data on total suicide deaths (N = 654, mean age = 16.0, 52.6% boys) collected by the Ministry of Education of Korea, we investigated the demographic and clinical characteristics and suicide-related factors of suicide deaths in students aged 9–18 years. Considering gender, more boys (52.6%, N = 344) died by suicide than girls (47.4%, N = 310). About 425 (65.0%) of the suicides were among high school students. The most common suicide method was jumping from a high place (70.6%, N = 454), followed by hanging (25.7%, N = 165). Additionally, 9.4% (N = 48) of the students who died by suicide had a history of attempted suicide, 13.4% (N = 73) had attempted self-harm, and 12.8% (N = 48) were acquainted with someone who had died by suicide. Teachers observed 20.6% (N = 120) of the suicide warning signs at school. Girls tended to have higher rates of attempted suicide, emotional problems, and psychiatric disorders than boys. This study was conducted with the largest sample of Korean suicide students observed at school. Effective suicide-related mental health training for teachers could contribute to suicide prevention in students.

Suicidal behaviour in adolescents: Educational interventions in Mexico

Suicide in adolescents constitutes a public health problem throughout the world. The objective of this study was to identify the prevalence of suicidal behaviour in a public middle school in Mexico and to implement appropriate educational interventions in the school and community contexts. Our work took place from September 2017 to July 2018. We conducted a quasi-experimental, mixed-methodology study with 12-year-old students in first year of middle school (n = 29), using an educational intervention approach within the frame of the Life Skills Education methodology. We included family members and academic staff in the study with the view of sensitising them to suicidal behaviour. At the community level, we worked with the adolescent and adult populations to form 'gatekeepers' (guardians). We administered a questionnaire on psychosocial indicators of depression and suicide risk to 383 students in their first-to-third years of middle school. Other questionnaires were applied, and life skills focus groups (FGs) were organised with the educational intervention participants. The questionnaires addressed suicidal behaviour in adolescents, alcohol consumption, life skills and prosociality. Prevalence of attempted suicide cases came to 14.1% (95 CI% 10.7-17.9), the average age of those who reported having hurt themselves with the purpose of taking their lives was 12.9 years, 75% of those who had attempted suicide were female and 64.8% had consumed alcohol. The educational intervention with students achieved a statistically significant increase in the life skills of participants, specifically as regards self-awareness and overall scores. The family members in the FGs developed greater awareness of suicidal behaviour, and the adolescents engaged at the community level significantly broadened (p < .05) their knowledge of depression. In developing countries such as Mexico, it is essential not only to increase the number of interventions for preventing suicidal behaviour in adolescents, but also to improve instruments for measuring the extent of the problem.

Examining the Post-High School Effects of a Primary Prevention Program on Exposure to Bullying and Sexual Violence among Emerging Adults

Emerging adulthood (EA) is a time of self-exploration as new opportunities for independence and autonomy arise. Yet, for some youth, this may also contribute to instability, uncertainty, and anxiety. Consequently, evidence suggests that rates of exposure to various forms of violence increase in EA. This study examined changes in experiences of bullying and sexual violence (SV) victimization among a sample of post-high school emerging adults who were exposed to a primary prevention program, Sources of Strength (Sources). We also examined whether Sources skills (e.g., healthy coping and help-seeking) buffer against these experiences. Participants were 102 emerging adults (73.5% identifying as female, 36.3% as Latinx, and 22.6% as LGBQ), who completed surveys at three time points: 1 month prior to graduation and at 6- and 12-months post-graduation. Results suggest that as youth transition into emerging adulthood, experiences of bullying victimization were relatively low and slightly decreased whereas experiences of SV were also relatively low, but stable over time. Notably, bullying victimization was lower when female-identifying participants, relative to males, had higher levels of healthy coping. In addition, SV victimization for participants identifying as non-white was higher at lower levels of coping than those identifying as white; however, at higher levels of coping, non-white participants reported lower rates of SV victimization, while rates were relatively stable for white participants at high and low levels of coping. These findings provide some support for the Sources program model where engaging in healthy coping may protect young women from bullying exposure and buffer against SV victimization for racial and ethnic minoritized young adults. Implications for violence prevention are discussed.

High School Educator Training by Simulation to Address Emotional and Behavioral Concerns in School Settings: A Randomized Study

The purpose of this study is to examine the impact of an online virtual human role-play simulation in teaching high school educators and staff to identify, talk to, and if necessary, refer students in psychological distress to support services. High school educators (N = 31,144) from 43 US states and 5 American territories completed a baseline survey and then randomly assigned to a wait-list control or treatment group. Participants in the treatment group completed the training simulation which included active learning strategies to teach evidenced-based communication strategies such as motivational interviewing to build skills and shift attitudes. Immediately after the training, treatment group participants completed a post-survey and then a 3-month follow-up survey. Baseline and post-surveys included the validated gatekeeper behavior scale measures which assess attitudinal constructs that predict helping behaviors. Self-reported helping behaviors were collected at baseline from both groups and at the 3-month follow-up for the treatment group. The treatment group participants' post and follow-up data were compared to the control group's baseline measures. The treatment group post-training scores were significantly higher (p < .001) than the control group's baseline scores for all gatekeeper behavior scale attitudinal constructs of preparedness, likelihood, and self-efficacy to engage in helping behaviors. A teacher subsample reported significant increases (p < .001) in the number of students referred to mental health support services when compared to baseline measures of the control group. Role-play simulations hold promise in teaching educators to become the "eyes and ears" of student mental health by empowering them to identify students in psychological distress, engage them in effective conversations about their concerns, and if necessary, make a referral to behavioral health support services. Future studies need to implement measures that document students entering counseling as a result of self-reported referrals and examine the impact of the training on the overall mental health culture within schools. Such studies could lead to simulations being widely adopted to support public health initiatives that address student mental health and wellness.

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.

Gatekeeper Training and Minimum Standards of Competency

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

Systematic review and narrative synthesis of suicide prevention in high-schools and universities: a research agenda for evidence-based practice

Background

Youth suicide prevention in high-schools and universities is a public health priority. Our aim was to propose a research agenda to advance evidence-based suicide prevention in high-schools and universities by synthesizing and critically reviewing the research focus and methodologies used in existing intervention studies.

Methods

Fourteen databases were systematically searched to identify studies which evaluate suicide prevention interventions delivered on high-school or university campuses, with before and after measures. Data from included studies (n = 43) were extracted to identify what, where, how and for whom interventions have been tested. Narrative synthesis was used to critically evaluate research focus and methodology. Study quality was assessed.

Results

Research has focused primarily on selective interventions, with less attention on indicated and universal interventions. Most evidence comes from North America and high-income countries. The target of interventions has been: non-fatal suicidal behaviour; confidence and ability of staff/students to intervene in a suicidal crisis; suicide-related knowledge and attitudes; and suicide-related stigma. No studies included suicide deaths as an outcome, evaluated eco-systemic interventions, explored how context influences implementation, used multisite study designs, or focused explicitly on LGBTQ+ youth. Two studies evaluated digital interventions. Quality of the majority of studies was compromised by lack of methodological rigour, small samples, and moderate/high risk of bias. Interventions often assume the existence of an external well-functioning referral pathway, which may not be true in low-resource settings.

Conclusion

To advance evidence-based suicide prevention in educational settings we need to: conduct more high-quality clinical and pragmatic trials; promote research in low- and middle-income countries; test targeted interventions for vulnerable populations (like LGBTQ+ youth), evaluate interventions where death by suicide is the primary outcome; include translational studies and use implementation science to promote intervention uptake; evaluate the potential use of digital and eco-systemic interventions; and conduct multisite studies in diverse cultural settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11124-w.

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.

What responses do people at risk of suicide find most helpful and unhelpful from professionals and non-professionals?

BACKGROUND

People at risk of suicide frequently communicate suicidal thoughts to professionals and non-professionals. These groups, therefore, need to be aware of how best to respond.

AIMS

We aimed to identify helpful and unhelpful responses to communications of suicide risk from the perspective of those at risk to inform suicide prevention messaging and education.

METHOD

We conducted an online survey (n = 141) of members of an online reference group for an Australian mental health organisation with a history of suicide risk.

RESULTS

Most respondents had repeatedly considered and attempted suicide. Indirect suicide communications were more common than direct communications. Listening without judgement was the most common helpful response and "minimizing" responses to suicidal thoughts and feelings, the most common unhelpful responses.

CONCLUSION

We make recommendations for suicide prevention messages and professional education content based on these findings.

Living Conditions of Adolescents Who Have Attempted Suicide in Mexico

Suicidal behavior represents a complex public health problem, with a rising number of suicide attempts registered among Mexican adolescents. We undertook a qualitative study in order to understand the living conditions of adolescents who had attempted to take their lives in five Mexican states. We interviewed 37 adolescents who had engaged in suicide attempts in the year prior to our study. To code and analyze the information, we defined the following three categories of living conditions as social determinants of health for adolescents: poverty and vulnerability, education, and health care. To this end, we followed the methodology proposed by Taylor and Bogdan, and used Atlas.ti 7.5.18 software for analyses. Among our findings, we noted that poverty, manifested primarily as material deprivation, rendered the daily lives of our interviewees precarious, compromising even their basic needs. All the young people analyzed had either received medical, psychological, and/or psychiatric care as outpatients or had been hospitalized. School played a positive role in referring adolescents with suicidal behavior to health services; however, it also represented a high-risk environment. Our findings highlight the urgent need to implement a national intersectoral strategy as part of comprehensive public policy aimed at improving the health of adolescents in Mexico.

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

BACKGROUND

Universal suicide education and awareness training in schools are promising suicide prevention initiatives. This study aims to evaluate a suicide awareness training (safeTALK) and to model potential return on investment (ROI) on a population basis. SafeTALK, comprises a 3-h education session, and has been delivered to secondary school students (aged 15-16 years) in Mackay, located in the Australian state of Queensland.

METHODS

Evaluation consisted of two phases, ex-post and ex-ante. Phase I was a pre-post, follow-up analysis using a mixed-method questionnaire administered immediately prior (Time 1), immediately after (Time 2), and 4 weeks after training (Time 3). Phase II involved decision analytic modelling comparing safeTALK to the status quo. ROI was modelled using Markov chains for a hypothetical population of students aged 15-19 years in Mackay (n = 2561; suicide rate 78.1 per 100,000), Queensland (n = 296,287; 10.2) and Australia (n = 1,421,595; 8.3). Model parameters, including rates of hospitalised self-harm and suicide, cost implications and effectiveness of safeTALK were drawn from published literature. The baseline model adapted a health and justice system's perspective, with an alternative model incorporating a societal perspective. All costs were adjusted to reflect AU$2017-2018.

RESULTS

Students reported seeking help mostly from friends (79%) or parents (68%); in the last 6 months 61% considered another student's behaviour as suicidal, but only 21% reported asking about this. The main barriers to help-seeking were (i) being too embarrassed, (ii) shy or (iii) being judged. Students who attended safeTALK gained suicide-related knowledge (p < 0.001), confidence (p < 0.001), willingness (p = 0.006), and likelihood of seeking help (p = 0.044) and retained these up until follow-up assessment 4 weeks later with the exception of seeking help. From a health and justice system's perspective, the model estimated a cumulative return of AU$1.45 per AU$1 invested in safeTALK in Mackay; AU$0.19 in Queensland; AU$0.15 across Australia. From a societal perspective, ROI increased to AU$31.21, AU$4.05 and AU$3.28, respectively.

CONCLUSION

Results strengthen the premise that safeTALK is feasible to implement within a school setting. The economic case for implementation of safeTALK is promising on a population basis, especially in high-risk communities, but further research is required to confirm the study results.

Mental health literacy programs for school teachers: A systematic review and narrative synthesis

AIM

The prevalence of mental disorders increases sharply during adolescence. Therefore, school teachers are in a good position to provide initial assistance to students with mental health problems. Although effects of a number of mental health literacy programs aimed at teachers have been reported, they have not yet been reviewed in a systematic manner. This study conducted a systematic review of the effectiveness of mental health literacy programs for teachers.

METHODS

PubMed, PsycINFO, CINAHL, ERIC, Web of Science and reference lists of included studies were searched in September 2018. Studies that quantitatively measured at least one of the main components of mental health literacy, including (a) knowledge of mental illnesses, (b) stigma towards mental illnesses, (c) confidence in helping students, and (d) behaviour of helping students, were included regardless of study design. Risk of bias was rated for each included study according to the Cochrane tool for randomized studies and the Cochrane tool, for raondomized studies, and the Risk of Bias Assessment Tool for Nonrandomized Studies (RoBANS), for nonrandomized studies.

RESULTS

Sixteen studies met the inclusion criteria, including 1 randomized controlled trial (RCT), 2 cluster RCTs, 1 controlled before-and-after study and 12 case series. Most of the studies claimed significant improvement of knowledge, attitudes, behaviour and/or confidence. However, the overall quality for all outcomes was relatively low; 15 studies had high/unclear risk of bias due to lack of allocation concealment, not controlling for confounders, and/or inadequate analysis for attrition.

CONCLUSIONS

More high quality evidence is required before the effectiveness of mental health literacy programs for teachers can be established.

Wesley LifeForce Suicide Prevention Gatekeeper Training in Australia: 6 Month Follow-Up Evaluation of Full and Half Day Community Programs

Background and Objective: Wesley Mission LifeForce training is an Australian suicide prevention gatekeeper program which has not been formally evaluated. The aims of this evaluation were to (1) determine the short- and medium- term impacts of the training on worker capabilities (perceived and declarative knowledge), attitudes, and reluctance to intervene measures; and (2) compare the impact of the half and full day workshops on these measures. Method: 1,079 Australian community workers of diverse professional backgrounds completed a pre-workshop questionnaire as part of registration for the Wesley LifeForce suicide prevention training between 2017 and 2019. Of these, 299 participants also completed the post workshop questionnaires (matched sample). They attended either half day (n = 97) or full day workshops (n = 202) and completed also a 3- and 6- month follow-up questionnaire. We used linear mixed-effect modeling for repeated measures to analyze data. Results: LifeForce training participants experienced an increase in perceived capability, declarative knowledge, more positive attitudes and reduced reluctance to intervene, at least in the short term. The program is particularly well targeted for community gatekeepers with no prior training, albeit those with prior training in this study also experienced positive and significant gains on most measured constructs. Conclusions: We found evidence of effectiveness of the Wesley LifeForce training over time, without difference between the short (half day) and longer (full day) formats of delivery. Nevertheless, the latter format offers skills-based and skills rehearsal opportunities, the impacts of which we were unable to measure in this evaluation and should be estimated in the future.

Short- and Long-Term Impact of an Undergraduate Suicidology Course

OBJECTIVE

Suicide prevention models emphasize the importance of education as a foundational element for success. Yet, courses on suicidology are rare and those that do exist focus on clinical intervention skills at the graduate level, missing a critical population of undergraduate students. The current study evaluated the short and long-term impact of a semester long liberal education undergraduate course in suicidology.

METHOD

Students enrolled in either the experimental (Understanding Suicide) or control course completed pre- post- and 4-month follow-up surveys assessing objective knowledge about suicide, suicide stigma, attitudes towards suicidal persons, and suicide prevention advocacy.

RESULTS

Mixed repeated measures ANCOVAs indicated significant interactions between course enrollment over time for all the outcome variables. Students in the suicidology course showed significant pre- to post- increases in knowledge and suicide prevention advocacy, alongside reductions in suicide stigma and negative attitudes compared to students in the control course, who showed no significant pre-/post changes. All effects were maintained over time.

CONCLUSION

Providing general education undergraduate courses in suicidology may be an important avenue for building a motivated and informed public that can sustain suicide prevention efforts in their communities.

Data-informed targets for suicide prevention: a small-area analysis of high-risk suicide regions in Australia

PURPOSE

To investigate small-area variation in risks associated with suicide deaths across four regional communities in New South Wales, Australia, and to determine whether these areas have unique demographic and socioeconomic risk profiles that could inform targeted means restriction suicide prevention efforts.

METHODS

Archival data on suicide mortality for all deaths in New South Wales, Australia, over the period 2006-2015 were geospatially attributed to four high-risk priority regions. Deaths in the four regions were compared to each other, and to NSW, on demographic factors, indicators of economic deprivation, and suicide means.

RESULTS

Priority means restriction targets were identified for all sites. In Murrumbidgee, suicide deaths were significantly more likely to involve firearms and older males (p < 0.001). The Central Coast had a greater proportion of overdose deaths (p < 0.001), which were associated with being female and unemployed. Suicide deaths in Newcastle were associated with being younger (p = 0.001) and involving 'jumping from a height' (p < 0.001), while economic deprivation was a major risk for suicide death in Illawarra Shoalhaven (p < 0.001).

CONCLUSIONS

Local regions were significantly differentiated from each other, and from the State, in terms of priority populations and means of suicide, demonstrating the need for locally based, targeted interventions. There were, however, also some risk constancies across all sites (males, hanging, economic deprivation), suggesting that prevention initiatives should, optimally, be delivered within multilevel models that target risk commonalities and provide tailored initiatives that address risk specific to a region.

Improving Schools' Readiness for Involvement in Suicide Prevention: An Evaluation of the Creating Suicide Safety in Schools (CSSS) Workshop

Schools have an important role to play in combatting suicide, a significant public health problem that disproportionately affects adolescents and young adults. Schools can work to reduce youth suicidality by adopting policies that align with best practice recommendations pertaining to suicide prevention, intervention, and postvention. This study examined the impact of a one-day training, the Creating Suicide Safety in Schools (CSSS) workshop, on the readiness of school personnel to improve their schools’ suicide-related policies and procedures. Participants (N = 562) consisted predominantly of school-based mental health professionals working in communities of low or mixed socioeconomic status in New York State. Survey data were collected according to a one-group pre-test—post-test design with a 3-month follow-up. Workshop participants demonstrated improvements from pre-test to post-test in their attitudes about the importance of school-based suicide prevention, knowledge of best practices, perceptions of administrative support, and feelings of empowerment to work collaboratively to enhance their schools’ suicide safety. At follow-up, participants reported barriers to implementing changes, most commonly in the form of insufficient time and stigma surrounding the topic of suicide. The results of this study provide preliminary evidence for the effectiveness of the CSSS workshop as a promising method for improving schools’ suicide safety, yet additional research using randomized controlled trials needs to be conducted.

Evaluation of A Suicide Prevention Program in Switzerland: Protocol of A Cluster Non-Randomized Controlled Trial

Suicide is a major public health concern, which disproportionally affects young people. Therefore, effective prevention strategies are needed, but there is a dearth of controlled trials on this topic. Our study will evaluate the effectiveness of a suicide prevention program in Switzerland, where data are scarce. It will test whether the prevention program (1) increases knowledge of suicide and awareness of suicidal risks, (2) provides resources to seek/offer help, (3) increases communication skills related to suicide, (4) increases coping skills, (5) is acceptable, and (6) reduces suicidal ideation and psychological distress. The project will be a single-center cluster non-randomized controlled trial designed to compare an intervention group benefitting from the suicide prevention program with a control group. The potential benefits include a better understanding and evaluation of suicide prevention programs, which may lead to improved primary and secondary prevention practices.

Gatekeeper training for suicidal behaviors: A systematic review

BACKGROUND

Gatekeeper training (GKT) is a common intervention aiming to prevent suicidal behavior. We investigated updated evidence for the effectiveness of GKT in suicide prevention using data from randomized controlled trials (RCTs) and intervention studies, and we also describe variations in existing GKT programs.

METHODS

We performed a systematic review. The literature search was conducted using PubMed, PsycINFO, CINAHL, the Cochrane databases, and reference lists from previous reviews. RCTs or intervention studies utilizing prospective or quasi-experimental designs were included.

RESULTS

The search terms identified 343 articles. Ten randomized clinical trials and six intervention studies were identified as eligible for inclusion. Among the eligible studies, a number of different types of GKT were identified, including Question, Persuade, and Refer, Applied Suicide Intervention Skills Training, OSPI, Youth Aware of Mental Health, and approaches based on e-learning. For the RCTs, the effects of GKT remained unclear in relation to knowledge, appraisals, and self-efficacy after training, though some supportive evidence was found in the uncontrolled pre-post studies. The overall quality for each RCT was rated as either low or unclear.

LIMITATIONS

We could not perform a meta-analysis because comparable outcomes could not be identified across studies.

CONCLUSIONS

The effects of GKT remain unclear. There are many variations in GKT and there is a need to replicate studies in target populations. Future research should examine the effectiveness of a standardized GKT program using high-quality RCTs which include the evaluation of pre-specified primary outcomes in comparison with appropriate control groups.