Review: Adolescents' perspectives on and experiences with post-primary school-based suicide prevention as end-users, co-creators and peer helpers - a systematic review meta-ethnography.

The suicidal process is a complex phenomenon involving multiple intertwined factors, which makes its prevention particularly challenging. As evidence-based suicide prevention interventions evolve and consolidate, it becomes increasingly important to ensure that effective interventions are efficiently implemented in practice and translated into the quality programs and care that benefit people at risk of suicidal behavior.

Why Adolescent Depression Is a Global Health Priority and What We Should Do About It

Rates of suicide among youths, both in the United States and globally, remain high. Schools can serve as an important intervention setting for suicide prevention efforts because youths spend a great deal of time in school. This systematic review aimed to examine the level of evidence of specific school-based suicide prevention interventions by using established rating criteria. A search of major databases, gray literature, and evidence-based registries was conducted to identify individual studies that focused on suicide prevention interventions within school settings and that were published between 2008 and 2022. The authors rated suicide prevention intervention as having high, moderate, or low levels of evidence; ratings were based on the number and rigor of studies with positive outcomes. Of the 14 different interventions identified across 14 studies, no intervention had enough studies to be rated as having a high level of evidence; one intervention, Signs of Suicide, was rated as having moderate evidence. Improved outcomes were found for 10 interventions, including reduced suicidal ideation, suicide attempts, suicide planning, and suicidal behavior. Four studies of three interventions found positive effects on mental health outcomes such as depression, anxiety, and psychological distress. No cost data were found for Signs of Suicide to complete a cost analysis. More research is needed to build the evidence base for school-based suicide prevention interventions that demonstrate positive impacts on suicide-related and mental health outcomes. Future research should also examine the cost-effectiveness of interventions.

Mental disorders are the leading cause of disease burden among youth. Effective prevention of mental disorders during adolescence is a critical public health strategy to reduce both individual and societal harms. Schools are an important setting for prevention; however, existing universal school-based mental health interventions have shown null, and occasionally iatrogenic, effects in preventing symptoms of common disorders, such as depression and anxiety. This study aims to report the adaptation process of an established, universal, school-based prevention program for depression and anxiety, OurFutures Mental Health. Using a 4-stage process; triangulating quantitative, qualitative, and evidence syntheses; and centering the voices of young people, the revised program is trauma-informed; lesbian, gay, bisexual, transgender, nonbinary, queer, questioning, and otherwise gender and sexuality diverse (LGBTQA+) affirmative; relevant to contemporary youth; and designed to tailor intervention dosage to those who need it most (proportionate universalism). Program adaptation occurred from April 2022 to July 2023 and involved 4 stages. Stage 1 comprised mixed methods analysis of student evaluation data (n=762; mean age 13.5, SD 0.62 y), collected immediately after delivering the OurFutures Mental Health program in a previous trial. Stage 2 consisted of 3 focus groups with high school students (n=39); regular meetings with a purpose-built, 8-member LGBTQA+ youth advisory committee; and 2 individual semistructured, in-depth interviews with LGBTQA+ young people via Zoom (Zoom Video Communications) or WhatsApp (Meta) text message. Stage 3 involved a clinical psychologist providing an in-depth review of all program materials with the view of enhancing readability, improving utility, and normalizing emotions while retaining key cognitive behavioral therapy elements. Finally, stage 4 involved fortnightly consultations among researchers and clinicians on the intervention adaptation, drawing on the latest evidence from existing literature in school-based prevention interventions, trauma-informed practice, and adolescent mental health. Drawing on feedback from youth, clinical psychologists, and expert youth mental health researchers, sourced from stages 1 to 4, a series of adaptations were made to the storylines, characters, and delivery of therapeutic content contained in the weekly manualized program content, classroom activities, and weekly student and teacher lesson summaries. The updated OurFutures Mental Health program is a trauma-informed, LBGTQA+ affirmative program aligned with the principles of proportionate universalism. The program adaptation responds to recent mixed findings on universal school-based mental health prevention programs, which include null, small beneficial, and small iatrogenic effects. The efficacy of the refined OurFutures Mental Health program is currently being tested through a cluster randomized controlled trial with up to 1400 students in 14 schools across Australia. It is hoped that the refined program will advance the current stalemate in universal school-based prevention of common mental disorders and ultimately improve the mental health and well-being of young people in schools.

Moving upstream: the role of schools in improving population health

Suicide Prevention in an International Context.

Each year approximately 1,000,000 people die by suicide, accounting for nearly 3% of all deaths and more than half (56%) of all violent deaths in the world (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). Suicide ideation and suicide attempts are strongly linked to death by suicide and powerfully predict further suicidal behavior (Institute of Medicine, 2002). There are an estimated 100–200 suicide attempts for each completed suicide in young people, and 4 attempts for each completed suicide in the elderly (Institute of Medicine, 2002). Emergency departments (EDs) are the most important site, epidemiologically speaking, for treating those who make suicide attempts. EDs in the United States, for example, record over 500,000 suicide-related visits annually (Larkin, Smith, & Beautrais, 2008). The majority of suicide attempt patients are discharged after medical stabilization and psychosocial evaluation, but carry a significant risk of recidivism (Larkin, Smith, & Beautrais, 2008). Similarly, ED patients who present with suicide ideation (without attempt) have risks of returning to the ED with further ideation or with suicide attempts which are as high as those who present with attempts (Larkin, Beautrais, Gibb, & Laing, 2008). In addition, a significant fraction of those who present to EDs for nonmental health reasons often have occult or silent suicide ideation (estimated at 8–12%) (Claassen & Larkin, 2005). The worldwide economic tsunami and sky-rocketing healthcare costs have ensured that mental health-related visits and presentations for suicidal behavior will continue to rise in the foreseeable future. The closure of psychiatric inpatient facilities, reductions in inpatient beds, moves to treat people in the community, and increased costs of general practitioner visits have coincided with – and likely account for – increased ED attendances by psychiatric and suicidal patients who previously might have been admitted or seen in primary care. The ED is now the default, de facto option for urgent and acute contact for suicidal patients within the health system – and in many countries the ED is the only access to 24/7 healthcare (Fields et al., 2001).

Literature reviews on suicide prevention programs have presented conflicting results on the efficacy of school-based prevention programs. Gatekeeper training and peer helping are both recommended as part of a comprehensive school-based prevention program, yet there is no literary evidence of the systematic evaluation of gatekeeper training for peer helpers. This study evaluated the efficacy of such training with high school peer helpers using a repeated measures design. Significant gains in knowledge about suicide and skills for responding to suicidal peers were evident immediately after training and 3 months later. There was also a significant improvement in positive attitudes toward suicide intervention following training. Although there was no control group, the research offers tentative support for the efficacy of training peer helpers in suicide risk assessment and indicates the importance of additional training for peer helpers.

Despite emerging evidence for the effectiveness of school-based suicide prevention programmes worldwide, there are few being implemented in the United Kingdom, and their social validity (i.e., the feasibility, acceptability, and utility) is not yet known. We aimed to conduct a scoping study to determine: (1) the social validity and potential benefits of school-based suicide prevention interventions, (2) the perceived need for such interventions, and (3) barriers and facilitators to implementation. A total of 46 participants took part. Semi-structured interviews were conducted with mental health professionals (N = 8), school staff (N = 8), and parents whose children had experienced suicidal ideation/behaviours (N = 3) in England. Focus groups were also completed with children and young people (N = 27) aged 15-18 across three state secondary schools. Data were analysed using thematic framework analysis. Three themes were identified: (1) the need for and importance of suicide prevention in children and young people, (2) schools as a setting for delivery, and (3) key components of suicide prevention programmes. Participants overwhelmingly agreed that there is a need for a greater and more consistent emphasis on school-based suicide prevention. School appears to be an acceptable location for suicide prevention, and participants felt discussions about suicide should begin at the start of secondary school. However, there are potential barriers that need to be considered, including tailoring for neurodiversity, challenging cultural/family beliefs and stigma, managing personal experiences of suicidal thoughts or previous bereavement from suicide, and a lack of existing training for school staff.

It Is Time We Start Asking: Handgun Carrying Among Youth in Rural Contexts

Objective: In this qualitative study, we sought to assess 3 topics of interest: (1) current status of vaping and school-based prevention; (2) school personnel’s perceptions of vaping; and (3) challenges in implementing school-based vaping prevention programs. Methods: We conducted 5 focus groups using a semi-structured interview guide during October through December 2019. School personnel (eg, principals, teachers [N = 32]) from 30 middle and high schools were recruited across diverse regions in Nebraska. Results: Eight themes arose from the thematic analysis in 3 topic areas. School personnel attributed student vaping to easy access, low perception of harm, addiction, and proliferation of stealthy products for concealed use. Whereas schools showed strong support for addressing youth vaping on school grounds, few schools had adopted a comprehensive e-cigarette prevention and cessation program. The top challenges to current school-based vaping prevention programs include lack of time, knowledge, and coordinated efforts. Participants also recognized the significance of parental engagement in the prevention effort. Conclusions: There is a considerable variation in school policies and actions to address youth vaping. An evidence based youth vaping program that involves schools, parents, students, and communities needs to be developed and disseminated in school settings.

Background/Objectives: This study assessed the effectiveness of a school-based suicide prevention program in Hong Kong. Methods: 105 secondary school students aged 14-16, identified as having high levels of depression and suicidal ideation. Participants were divided into three intervention groups: one for adolescents only, another for adolescents with peers, and a third for adolescents with parental involvement. All groups engaged in weekly online exercises. Repeated measures ANOVA was used to analyze the within-group and between-group differences in the levels of adolescents' suicidal ideation, depression and anxiety. Results: The results indicated a statistically significant reduction in suicidal ideation, depression and anxiety levels after participation in all three groups. No statistically significant between-group differences were identified, meaning the effects of the three interventions on the measured outcomes were similar. Conclusions: This study demonstrates the promise of implementing school-based suicide prevention programs in the Hong Kong context.

School-based youth-specific suicide prevention and early intervention initiatives are presently underdeveloped. The current study conducted a pilot evaluation of a multi-modal suicide prevention training program for school-based social workers, ‘Management of Youth Suicidality Training for Schools’ (MYSTS). The program comprised a two-day workshop and six fortnightly post-workshop webinar online consultations. Participants were 36 social workers (years’ experience M = 11.23, SD = 8.29) employed by the Department of Education in Tasmania, Australia. Outcomes were self-rated confidence, competence, and knowledge of self-harm in young people, and attitudes toward suicide prevention and suicide-related behaviors. Exploratory quantitative results indicated significant improvements with large effect sizes for participants’ self-reported competence (d = 1.33), and confidence (d = 1.29) to identify and respond therapeutically to youth suicidality following the workshop. Confidence remained significantly higher than baseline following the online consultations (d = 0.90). Qualitative analysis of online supervision consultations indicated key themes of accessibility, communication and information sharing, and clinical management. Participants endorsed the MYSTS package as well-presented, with relevant topics, and effective learning activities. This study highlights the need for continued supervisory or implementation support to practitioners following suicide prevention training initiatives and suggests web-based teleconference technology as a feasible strategy for this. Further evaluation of the MYSTS package, including a suitable comparison or control condition, is indicated.

IntroductionConcerns over suicide among military veterans has been as issue of major public and policy concern, particularly by the Veterans Health Administration (VHA), which is the largest integrated health care system in the United States.Objectives and aimsThe reasons for suicide risk and means to reduce risk in this population have been under active investigation and implementation. The aim of this presentation is to review recent trends in suicide risk assessment and suicide prevention interventions within the VHA in the United States.MethodsA literature review consisting of an electronic database search of PubMed, “gray literature” search, and manual search for articles related to suicide in military personnel and veterans was conducted.ResultsIn recent years, annual VHA rates of completed suicide have ranged from approximately 34 to 40 suicides per 100,000 person-years, rates significantly higher than the general US population. Risk assessment methods examined in military veteran populations have primarily included self-report instruments, scales, and checklists. Recently, “big data” approaches to analysis of electronic medical records have shown promise in stratifying veterans into high- and low-risk groups. VHA suicide prevention initiatives have included extensive staff hiring, development of research centers and data-sharing agreements focused on suicide, a national telephone crisis line, routine suicide risk assessment and screening, and suicide safety plans.ConclusionsMilitary veterans in the US receiving care in the VHA have a variety of risk factors for suicide and continue to be at elevated risk despite implementation of numerous suicide prevention initiatives.Disclosure of interestThe author has not supplied his declaration of competing interest.

To the Editor. Child death by suicide is a serious and growing problem. A steep rise in the rate of suicide now makes it one of the leading causes of death for adolescents and young adults, and the available data may be underreported if, as many experts believe, numerous “accidental” deaths are actually suicides.1 Since 1990, 72 children <19 years old have died by suicide in Cuyahoga County, Ohio,2 reflecting the fact that, like politics, child suicide is a very local problem. As early as 1990, the American Academy of Pediatrics Committee on School Health recommended that pediatricians work with local school personnel to implement suicide-reduction strategies. The Committee observed that successful prevention programs would have to involve community school personnel, physicians, students, and their parents.3 The recent suicide of a Cleveland school child who was under medical care for depression prompted the belated question as to why the physicians and mental health professionals who were treating the child for depression did not notify the school, and involve school professional personnel in surveillance of the child's behavior and performance. Should we, then, be notifying the schools when we recognize that a patients is at risk of suicide? Are the schools really willing and able to help? What are the pros and cons of school notification, and what are the …