ten recommendations for effective school-based, adolescent ... · education or awareness programs...
TRANSCRIPT
REVIEW PAPER
Ten Recommendations for Effective School-Based, Adolescent,Suicide Prevention Programs
Paul W. G. Surgenor1 • Paul Quinn1 • Catherine Hughes1
Published online: 2 March 2016
� Springer Science+Business Media New York 2016
Abstract School-based suicide prevention programs are
one of the key strategies to address suicide in adolescence.
The number of programs increased rapidly during the
1980s and was largely designed for high school- or middle
school-aged students (11–18 years old), due to the vul-
nerable time and predictive risk of future suicidal ideation
or health problems in later life. However, key recommen-
dations from these studies are often obscured by the vol-
ume of such programs, resulting in significant challenges
for program designers. This study aimed to undertake a
review of the numerous suicide prevention programs
implemented globally in recent years to provide informed
recommendations for the development of effective school-
based programs for adolescents. The study employed a
scoping review process to enable the deconstruction of
large or complex issues to promote comprehension and
ease of interpretation. A search of online international
databases using combinations of key words (variations in
‘suicide,’ ‘school,’ ‘program,’ and ‘prevention’) within a
specified time frame (January 2010 to June 2015) identified
397 articles. Preferred reporting items for systematic
reviews and meta-analyses were used to identify relevant
articles at each stage of the review process, resulting in a
total of 20 studies addressing 13 different school programs.
Results were presented using established program cate-
gories (as education/awareness, gatekeeper, peer leader-
ship, skills, screening/assessment) and informed ten
recommendations that address the design, content,
delivery, and review of school-based suicide prevention
programs for adolescents.
Keywords Suicide � Prevention � School � Program �Adolescent � Scoping review
Introduction
Globally, suicide is the second leading cause of death for
15–29-year olds (World Health Organization, 2014), with
an estimated 100,000 adolescent deaths and 4 million
suicide attempts annually (World Health Organization,
2008). One of the key strategies to address this is the
increased implementation of school-based suicide preven-
tion programs (Cusimano & Sameem, 2011). This has
resulted in such a broad range of school-based adolescent
programs that identifying effective components and rec-
ommendations for future initiatives has become a signifi-
cant challenge.
School has been identified as the ideal location in which
to address adolescent suicide as it is regarded as a nexus for
teen life (Cooper, Clements & Holt, 2011), students are a
captive audience whose interactions can be mobilized
around a common theme (Miller, 2014), and school per-
sonnel are increasingly cognisant of the need to identify
and address the link between youth mental health problems
and suicidal behavior (Davidson & Linnoila, 2013; Lake &
Gould, 2011). Consequently, school-based suicide pre-
vention programs increased rapidly during the 1980s to
counter the significant rising trend in suicide rates among
15–19-year olds in many developed countries (White,
Morris, & Hinbest, 2012).
A recent systematic review highlighted five distinct
types of school-based suicide prevention programs:
& Paul W. G. Surgenor
1 Pieta House, 6 Upper Main Street, Lucan, Co., Dublin,
Ireland
123
School Mental Health (2016) 8:413–424
DOI 10.1007/s12310-016-9189-9
education or awareness; gatekeeper; peer leadership; skills
training; and screening or assessment programs (Katz et al.,
2013). Education or awareness programs familiarize stu-
dents with the signs and symptoms of suicide in themselves
and others. Gatekeeper training teaches natural helpers
(i.e., teachers, school personnel, etc.) to recognize signs
and symptoms in students and how to react effectively.
Since students are more likely to confide in their peers,
peer leadership training enables students to help by training
them to respond appropriately and refer those of concern to
a trusted adult. Skills training programs aim to indirectly
prevent suicidal behavior by increasing protective factors
such as coping, problem solving, decision making, and
cognitive skills. Screening or assessment programs involve
screening all students, identifying those at increased risk,
and then recommending further treatment. Most of these
programs and associated research have been designed for
high school- or middle school-aged students (11–18 years
old) as this is recognized as a vulnerable time that can
result in mental health and academic difficulties, increased
risk of suicidal ideation (Nadeem et al., 2011), and health
problems in later life (Patton et al., 2012).
A review of these approaches, however, has identified a
distinct lack of consensus in relation to the effectiveness
across these program types (Robinson et al., 2014a, b), due
in part to the complexity of suicide prevention, and to the
sheer volume of such programs (Balaguru, Sharma, &
Waheed, 2013; Pirruccello, 2010). In general, suicides are
rare and hard to predict, and consequently it is difficult to
measure the impact of programs on the prevention of sui-
cide. Thus, many studies have focused on proximal out-
comes such as knowledge and attitudes, which have
unspecified relationships with actual suicidal behavior.
Additionally, programs have been developed without ref-
erence to, or knowledge of, preceding interventions,
resulting in a disparate field of frequently conflicting
research that is of limited value to school personnel and
designers concerned with implementing an effective sui-
cide prevention program. The aim of this research was to
review school-based programs to identify research gaps
and best practices, in order to generate a series of key
recommendations to inform the development of more
effective suicide prevention programs.
Methods
This study employed a scoping review process, a method
that enables the effective deconstruction of large or com-
plex issues to promote comprehension and ease of inter-
pretation (Arksey & O’Malley, 2005). Scoping reviews
differ from systematic reviews, since the quality of inclu-
ded studies is typically not assessed. They also differ from
narrative or the literature reviews since the scoping process
requires analytical reinterpretation of the literature (Levac,
Colquhoun, & O’Brien, 2010). The goal of this study was
to identify research gaps and best practices in the existing
literature regarding suicide prevention programs in schools,
to inform recommendations for future programs. Accord-
ingly, this study followed the five-phase framework set out
by Arksey and O’Malley (2005) for this type of scoping
review: identify the research question; identify relevant
studies; study selection and criteria; chart the data; collate,
summarize, and report the results. A range of study designs
are incorporated in the review, addressing questions
beyond those related to intervention effectiveness.
Identify the Research Question
The research aimed to answer the question ‘What is known
about contemporary suicide prevention in schools and how
can this inform future programs?’ Levac et al. (2010)
recommend combining a broad research question with a
clearly articulated scope of inquiry. Within this study, this
refers to any school-based program relating to the pre-
vention of suicide among school-attending adolescents
(ages 11–18) and where details of the program were pub-
lished in an international peer-reviewed journal.
Identify Relevant Studies
The period under review extends from January 2010 to July
2015, inclusive. This timeline was chosen to ensure that
searches identified studies that reflected the most recent
and contemporary approaches to suicide prevention. Online
international databases searched included PsycINFO,
MEDLINE, CINAHL, Cochrane Library, Google Scholar,
British Education Index, Education, ERIC, OmniFile,
PsycARTICLES, Sage, PubMed, Social Sciences, and
relevant journals relating to suicide prevention and mental
health promotion in schools. Keyword combinations
(‘Suicide’ or ‘suicidal’] and [‘school’ or ‘school-based’]
and [‘program’ or ‘program’ or ‘prevention’ or ‘interven-
tion’) were used. Reference lists of relevant articles were
reviewed and key articles searched for studies focusing on
suicide prevention in schools.
Study Selection and Criteria
While systematic reviews develop inclusion and exclusion
criteria at the outset of projects, criteria for scoping reviews
are usually devised post hoc, based on increasing famil-
iarity with the literature, and then applied to all the cita-
tions to determine relevance (Arksey & O’Malley, 2005).
A total of 397 abstracts from initial searches were reviewed
iteratively based upon their relevance to suicide prevention
414 School Mental Health (2016) 8:413–424
123
in schools. In particular, review articles were identified and
analyzed in depth, allowing for the mapping of broad issues
that could potentially guide a thematic analysis. Relevant
studies cited within review articles were also included;
reviews were excluded from final analysis to minimize
bias. PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses), a tool to improve the
reporting of systematic reviews and meta-analyses (Moher,
Liberati, Tetzlaff, Altman, & The PRISMA Group, 2009),
was used for this process.
Of the initial 397 studies identified, 324 were removed
because they were not specifically relevant to suicide pre-
vention and/or students aged 11–18 years old. The
remaining 73 full articles were read and categorized based
on program focus and/or type of study. Inclusion and
exclusion criteria were then decided upon and applied to all
citations.
Studies had to fulfill five criteria to be included in the
review. Firstly, studies had to have a school-based suicide
prevention program as their main focus. This narrowed the
focus of the review since studies concerning general mental
health programs were excluded. Secondly, the target pop-
ulation of programs had be adolescents (11–18 years old)
attending schools in secondary education, regardless of
school type (e.g., military, public, private, etc.). Thirdly, to
maximize study relevance only studies from 2010 onwards
were acquired. Fourthly, studies had to be reported in
English or sufficiently translated. Finally, studies had to be
completed.
Twenty studies met these inclusion criteria. Figure 1
shows the four-phase flow diagram that depicts the dif-
ferent phases of the review process and the number of
records identified, included, and excluded at each stage.
Chart the Data
Data were extracted from studies using a descriptive ana-
lytical method employed for scoping reviews (Levac et al.,
2010). This involved synthesizing process information onto
a data charting form using an Excel spreadsheet. Data
extracted from studies included author(s), origin, design
and results, limitations, and recommendations. Data relat-
ing to specific programs were also extracted including
program name, type of program, target population, duration
and frequency, requirements, delivery, delivered by, focus,
and expected outcomes.
Collate, Summarize, and Report the Results
Studies were not distinguished by methodological criteria
or design, nor were relative weights attributed to their data
(Arksey & O’Malley, 2005). Drawing from the data
charting form and the operational definitions of the five
types of programs identified by Katz et al. (2013), all
papers were reviewed, with a focus on program imple-
mentation. Features of programs including type of pro-
gram, target population, duration and frequency, delivery,
deliverers, focus, expected outcomes, origin, and studies
are presented in Table 1.
Results
There were 20 studies that met inclusion criteria which
included 13 distinct programs. Nine programs were uni-
versal (were for all students in a given population such as
grade level, school, or district) while four were selective
(were specifically developed for at-risk students). Infor-
mation for each program category is discussed below in
terms of implementation with reference to specific studies.
Education or Awareness Programs
Seven programs included the implementation of awareness
education into curricula and demonstrated mixed results in
terms of effectiveness. Only the Youth Aware of Mental
Fig. 1 PRISMA flow diagram for study inclusion in scoping review
School Mental Health (2016) 8:413–424 415
123
Table
1S
um
mar
yo
far
ticl
eso
nse
con
dar
ysc
ho
ol-
lev
elsu
icid
ein
terv
enti
on
pro
gra
ms
pu
bli
shed
bet
wee
n2
01
0an
d2
01
5el
igib
lefo
rin
clu
sio
nin
sco
pin
gre
vie
w
Pro
gra
mT
yp
eo
f
pro
gra
m
Tar
get
po
pu
lati
on
Du
rati
on
and
freq
uen
cy
Del
iver
yD
eliv
ered
by
Fo
cus
Ex
pec
ted
ou
tco
mes
Stu
die
s
CA
RE
(Car
e,
Ass
ess,
Res
po
nd
,
Em
po
wer
)
Sel
ecti
ve:
scre
enin
go
r
asse
ssm
ent,
skil
ls
trai
nin
g
Hig
h-r
isk
stu
den
ts
(14
–1
9y
ears
)
3–
4h
1–
2h
on
e-to
-
on
eco
mp
ute
r-
bas
ed
asse
ssm
ent
foll
ow
edb
ya
2-h
cou
nse
lin
g
sess
ion
Co
un
seli
ng
sess
ion
faci
lita
ted
by
trai
ned
soci
al
wo
rker
,n
urs
e,o
r
men
tal
hea
lth
pro
fess
ion
alw
ho
has
com
ple
ted
trai
nin
g
Co
mp
ute
r-b
ased
asse
ssm
ent.
Co
un
seli
ng
sess
ion
pro
vid
es
emp
ath
yan
dsu
pp
ort
ina
safe
env
iro
nm
ent
for
shar
ing
that
enco
ura
ges
po
siti
ve
cop
ing
and
hel
p-s
eek
ing
beh
avio
r
Dec
reas
edsu
icid
al
beh
avio
rs.
Dec
reas
ed
rela
ted
risk
fact
ors
.
Incr
ease
dp
erso
nal
and
soci
alas
sets
Ho
ov
enet
al.
(20
10
,2
01
2)
Qu
esti
on
,
Per
suad
e,
Ref
er(Q
PR
)
Un
iver
sal:
gat
ekee
per
trai
nin
g
Tea
cher
s,
sch
oo
l
per
son
nel
,o
r
adu
lts
targ
etin
gh
igh
sch
oo
l
stu
den
ts
1-h
for
gat
ekee
per
trai
nin
g;
2-h
inst
ruct
or
trai
nin
g
Lec
ture
s,
dis
cuss
ion
,
and
role
-pla
y
QP
Rin
stru
cto
rsH
ow
tore
cog
niz
eth
ew
arn
ing
sig
ns
of
asu
icid
ecr
isis
and
ho
wto
‘qu
esti
on
,p
ersu
ade,
and
refe
r’so
meo
ne
for
furt
her
asse
ssm
ent
and
care
Incr
ease
dk
no
wle
dg
e
and
atti
tud
ere
lati
ng
to
suic
ide
Cro
sset
al.
(20
11
),
Joh
nso
nan
d
Par
son
s
(20
12
),
To
mp
kin
s
etal
.(2
01
0),
Was
serm
an
etal
.(2
01
5)
Ref
ram
eIT
Sel
ecti
ve:
Ass
essm
ent,
skil
ls
trai
nin
g
Stu
den
ts
(14
–1
8y
ears
)
Eig
ht
mo
du
les
imp
lem
ente
d
on
cea
wee
k
Fac
e-to
-fac
e
asse
ssm
ent
and
aC
BT
com
pu
ter
pro
gra
msi
te
Res
earc
her
sC
BT
app
roac
h:
eng
agem
ent
and
agen
da
sett
ing
;
emo
tio
nal
reco
gn
itio
nan
d
dis
tres
sto
lera
nce
;
iden
tifi
cati
on
of
neg
ativ
e
auto
mat
icth
ink
ing
;
beh
avio
ral
acti
vat
ion
—h
elp
seek
ing
and
acti
vit
y
sch
edu
lin
g
Pro
ble
m-s
olv
ing
ori
enta
tio
nan
dco
pin
g
skil
lsas
soci
ated
wit
h
suic
idal
idea
tio
n
Het
rick
etal
.
(20
14
)
Scr
een
ing
by
pro
fess
ion
als
(Pro
fScr
een
)
Sel
ecti
ve:
Scr
een
ing
Stu
den
ts
(14
–1
6y
ears
)
On
esh
ort
qu
esti
on
nai
re
(ap
pro
x.
20
min
)
On
eb
asel
ine
qu
esti
on
nai
re.
Cli
nic
al
asse
ssm
ent
and
/or
refe
rred
tocl
inic
al
serv
ices
Men
tal
hea
lth
pro
fess
ion
als
Dec
reas
edsu
icid
e
atte
mp
ts,
idea
tio
n
Was
serm
an
etal
.(2
01
2,
20
15
),
Sig
ns
of
Su
icid
e
(SO
S)
Un
iver
sal:
edu
cati
on
,
scre
enin
g
Stu
den
ts
(13
–1
9y
ears
)
Tw
od
ays
Scr
een
ing
for
dep
ress
ion
and
suic
ide
risk
.
Vid
eo
Men
tal
hea
lth
pro
fess
ion
als
in
sch
oo
ls
Sig
ns
of
dep
ress
ion
and
suic
ide.
AC
Tm
nem
on
ic:
ack
no
wle
dg
eth
atth
ere
isa
pro
ble
m,
let
the
per
son
kn
ow
yo
uca
re,
and
tell
atr
ust
ed
adu
lt
Dec
reas
edsu
icid
e
atte
mp
ts.
Incr
ease
d
kn
ow
led
ge
abo
ut
suic
ide.
To
dev
elo
p
des
irab
leat
titu
des
tow
ard
suic
ide,
dep
ress
ion
,an
dh
elp
-
seek
ing
beh
avio
rs
Orn
elas
(20
12
),
Sch
illi
ng
etal
.
(20
14
)
416 School Mental Health (2016) 8:413–424
123
Table
1co
nti
nu
ed
Pro
gra
mT
yp
eo
f
pro
gra
m
Tar
get
po
pu
lati
on
Du
rati
on
and
freq
uen
cy
Del
iver
yD
eliv
ered
by
Fo
cus
Ex
pec
ted
ou
tco
mes
Stu
die
s
So
urc
eso
f
Str
eng
th
Un
iver
sal:
pee
rle
ader
trai
nin
g,
gat
ekee
per
trai
nin
g,
skil
ls
trai
nin
g,
edu
cati
on
or
awar
enes
s
Stu
den
ts
(13
–1
9y
ears
)
Pee
rle
ader
s
mee
t
biw
eek
ly
wit
h
sup
erv
iso
rs
ov
erth
ree
or
4m
on
ths
(Up
to1
-h
each
sess
ion
)
So
urc
eso
fS
tren
gth
trai
ner
sp
rov
ide
the
pee
rle
ader
sw
ith
an
init
ial
4-h
inte
ract
ive
trai
nin
g,
wh
ich
the
adu
ltad
vis
ors
also
mu
stat
ten
d
Tra
ined
pee
r
lead
ers
Mo
dif
yn
orm
sp
rop
agat
ed
thro
ug
hco
mm
un
icat
ion
wit
hin
pee
rg
rou
ps
toal
ter
per
cep
tio
ns
of
wh
atis
typ
ical
beh
avio
ran
dth
e
soci
alco
nse
qu
ence
sfo
r
po
siti
ve
cop
ing
beh
avio
rs
Bu
ild
soci
oec
olo
gic
al
pro
tect
ive
fact
ors
.
Co
nn
ect
lead
ers
and
stu
den
tsto
pee
rs,
adu
lts,
sch
oo
l,an
dco
mm
un
ity
Pet
rov
aet
al.
(20
15),
Wy
man
etal
.
(20
10)
Su
rviv
ing
the
Tee
ns
Un
iver
sal:
edu
cati
on
or
awar
enes
s,
skil
ls
trai
nin
g,
pee
rle
ader
trai
nin
g
Stu
den
ts
(12
–1
8y
ears
)
Fo
ur
sess
ion
s
(50
min
each
)o
ver
4d
ays
Stu
den
tsre
ceiv
ea
‘Ste
ps
toL
AS
T’
mn
emo
nic
wit
h
refe
rral
sou
rces
,
ob
serv
ev
ideo
san
d
par
tici
pat
ein
lect
ure
s,in
tera
ctiv
e
acti
vit
ies
and
role
pla
yin
g
Tra
ined
inst
ruct
ors
Sig
ns
of
dep
ress
ion
and
suic
ide.
Co
mm
un
icat
ing
wit
hp
aren
tsan
dp
eers
,
ang
erm
anag
emen
t,an
d
con
flic
tre
solu
tio
n.
Man
agin
gem
oti
on
san
d
stre
ssre
acti
on
sth
rou
gh
pro
ble
mso
lvin
g,
cog
nit
ive
rest
ruct
uri
ng
,
and
use
of
rela
xat
ion
tech
niq
ues
Incr
ease
hel
p-s
eek
ing
beh
avio
rsam
on
gtr
ou
ble
d
yo
uth
and
thei
rp
eers
;
incr
ease
fam
ily
and
sch
oo
lco
nn
ecte
dn
ess;
dec
reas
esu
icid
alan
d
oth
erri
sk-t
akin
g
beh
avio
rs,
such
asil
lici
t
dru
gan
dal
coh
ol
use
;
imp
rov
est
ud
ents
’co
pin
g
skil
ls
Str
un
ket
al.
(20
14)
Un
na
med
Un
iver
sal:
skil
ls
trai
nin
g,
edu
cati
on
or
awar
enes
s
Stu
den
ts(a
pp
rox
.
mea
n
age=
16
yea
rs)
Six
sess
ion
s
(90
–1
00
min
)
Par
tici
pat
ory
sess
ion
s
con
tain
ing
dis
cuss
ion
s,
acti
vit
ies
and
,h
om
e
assi
gn
men
ts
Aft
erad
equ
ate
trai
nin
g,
ate
am
com
pri
sed
of
teac
her
s,
psy
cho
log
ists
,a
psy
chia
tric
nu
rse
and
sch
oo
ln
urs
es
imp
lem
ente
dth
e
mo
du
le
Mo
tiv
atio
n,
con
cen
trat
ion
and
imp
rov
ing
mem
ory
;
pro
ble
m-s
olv
ing
skil
ls;
pee
rp
ress
ure
and
say
ing
‘No
’to
dru
gs/
tob
acco
;
cop
ing
wit
hst
ress
,fa
cin
g
chan
ges
/pro
ble
ms;
self
-
este
em,
sen
sati
on
-see
kin
g
beh
avio
r;se
lf-a
war
enes
s;
un
der
stan
din
gd
epre
ssio
n
and
suic
ide
Pro
mo
tere
sili
ency
and
to
red
uce
vu
lner
abil
ity
to
suic
ide
amo
ng
yo
un
g
peo
ple
Jeg
ann
ath
an
etal
.
(20
14)
Un
na
med
Sel
ecti
ve:
scre
enin
g,
skil
ls
trai
nin
g
stu
den
ts(m
ean
age=
15
.8y
ears
)
A2
-hse
ssio
n,
twic
ea
wee
k,
for
sev
en
con
secu
tiv
e
wee
ks
(15
sess
ion
sin
tota
l)
Gro
up
sess
ion
s:se
lf-
exam
inat
ion
thro
ug
h
self
-qu
esti
on
ing
tech
niq
ues
,ac
tiv
ity
exer
cise
s,an
d
gro
up
-dir
ecte
d
dis
cuss
ion
s.
Bra
inst
orm
ing
and
role
-pla
y
Tw
oth
erap
ists
Dis
cuss
and
iden
tify
stu
den
ts’
pro
ble
ms
rela
tin
gto
a)se
xu
alit
y,
b)
sub
stan
ceab
use
,c)
emo
tio
nal
dis
tres
s.
Tea
chin
gan
dp
rom
oti
ng
cop
ing
skil
ls
Red
uce
suic
ide
risk
(id
eati
on
and
atte
mp
ts)
Lan
dg
rav
e
and
Go
mez
-
Maq
ueo
(20
11)
School Mental Health (2016) 8:413–424 417
123
Table
1co
nti
nu
ed
Pro
gra
mT
yp
eo
f
pro
gra
m
Tar
get
po
pu
lati
on
Du
rati
on
and
freq
uen
cy
Del
iver
yD
eliv
ered
by
Fo
cus
Ex
pec
ted
ou
tco
mes
Stu
die
s
Un
na
med
Un
iver
sal:
edu
cati
on
or
awar
enes
s
Un
spec
ified
‘sec
on
dar
y
sch
oo
l
stu
den
ts’
Fo
ur
full
blo
cks
(on
e
and
ah
alf
ho
urs
each
)
of
clas
sro
om
tim
e
Bri
efle
ctu
res,
smal
lg
rou
p
dis
cuss
ion
san
dac
tiv
itie
s,
and
the
pre
sen
tati
on
of
a
20
-min
DV
D
Tw
otr
ain
ed
faci
lita
tors
Info
rmat
ion
on
suic
ide
and
hel
pse
ekin
g;
sou
rces
of
dis
tres
sam
on
gy
ou
th;
cop
ing
and
stre
ss
man
agem
ent
skil
ls;
reco
gn
izin
gw
arn
ing
sig
ns
and
resp
on
din
gto
suic
ide
risk
Incr
ease
kn
ow
led
ge
aro
un
dsu
icid
e.In
crea
se
hel
pse
ekin
g
Wh
ite
etal
.
(20
12
)
Yel
low
Rib
bo
n
Su
icid
e
Pre
ven
tio
n
Pro
gra
mm
e
(YR
SP
P)
Un
iver
sal:
edu
cati
on
or
awar
enes
s,
gat
ekee
per
trai
nin
g;
pee
rle
ader
trai
nin
g
Stu
den
ts
(11
–1
8y
ears
)
1-h
stu
den
t
lead
ersh
ip
trai
nin
g;
on
ean
da
hal
fh
ou
r
staf
f
trai
nin
g;
25
–5
0-m
in
sch
oo
l
asse
mb
ly
Lec
ture
inv
olv
ing
awar
enes
sed
uca
tio
n
Sch
oo
lM
enta
l
Hea
lth
(SM
H)
staf
fm
emb
er
Em
ph
asiz
esh
elp
-see
kin
g
beh
avio
r.T
each
es
war
nin
gsi
gn
s,ri
skan
d
pro
tect
ive
fact
ors
.
Tea
ches
abo
ut,
and
iden
tify
,re
sou
rces
.
Incl
ud
esap
pro
pri
ate
sup
po
rtp
erso
nn
el(i
.e.,
cou
nse
lors
,sp
ecia
list
s,
fait
hle
ader
s,et
c.).
Do
esn
’tp
rese
nt
des
crip
tio
ns
of
met
ho
ds
of
suic
ide.
Do
esn
’tg
lori
fy
or
rom
anti
cize
suic
ide
Incr
ease
dk
no
wle
dg
eo
f
war
nin
gsi
gn
s,ri
skan
d
pro
tect
ive
fact
ors
of
suic
ide.
Incr
ease
d
un
der
stan
din
go
fh
elp
-
seek
ing
beh
avio
r;h
elp
seek
ing
.In
crea
sed
kn
ow
led
ge
of
reso
urc
es
and
cris
isco
nta
ct.
Incr
ease
dem
po
wer
men
t
of
stu
den
ts’
ow
nab
ilit
ies
Fre
eden
thal
(20
10
),
Sch
mid
t
etal
.
(20
15
)
Yo
uth
Aw
are
of
Men
tal
Hea
lth
Pro
gra
mm
e
(YA
M)
Un
iver
sal:
edu
cati
on
or
awar
enes
s,
skil
ls
trai
nin
g
Stu
den
ts
(14
–1
6y
ears
)
Fiv
e1
-h
sess
ion
sin
4w
eek
s
3h
of
role
-pla
yse
ssio
ns
wit
hin
tera
ctiv
e
wo
rksh
op
sco
mb
ined
wit
h
32
-pag
eb
oo
kle
tth
at
stu
den
tsca
nta
ke
ho
me,
6
edu
cati
on
alp
ost
ers,
and
two
1-h
rin
tera
ctiv
e
lect
ure
sat
beg
inn
ing
and
end
of
inte
rven
tio
n
Inst
ruct
ors
trai
ned
thro
ug
ha
det
aile
d3
1-p
age
inst
ruct
ion
man
ual
Rai
sem
enta
lh
ealt
h
awar
enes
sab
ou
tth
eri
sk
and
pro
tect
ive
fact
ors
asso
ciat
edw
ith
suic
ide,
incl
ud
ing
kn
ow
led
ge
abo
ut
dep
ress
ion
and
anx
iety
,an
den
han
ce
skil
lsn
eed
edto
dea
lw
ith
adv
erse
life
even
ts,
stre
ss,
and
suic
idal
beh
avio
rs
Red
uce
dsu
icid
eid
eati
on
and
suic
ide
atte
mp
t
Was
serm
an
etal
.
(20
12
,
20
15
)
Yo
uth
Su
icid
e
Pre
ven
tio
n
Pro
gra
m
(YS
PP
)
Un
iver
sal:
gat
ekee
per
trai
nin
g
Sch
oo
lst
aff
targ
etin
g
mid
dle
sch
oo
l
stu
den
ts
(10
–1
4y
ears
)
An
nu
al
90
-min
trai
nin
g
Tra
inin
gfo
rsc
ho
ol
cris
is
team
mem
ber
s.M
ater
ials
fro
mtr
ain
ing
incl
ud
e
han
do
uts
for
yo
uth
,
par
ents
,an
dsc
ho
ol
staf
f
that
add
ress
risk
,si
gn
s,
and
acti
on
sto
tak
e
Dir
ecto
ro
fS
uic
ide
Pre
ven
tio
n
Ser
vic
esfo
r
ann
ual
trai
nin
g.
Sch
oo
lcr
isis
team
mem
ber
s
then
shar
e
info
rmat
ion
wit
h
sch
oo
lst
aff
Pro
vid
ing
app
rop
riat
e
sup
po
rt,
reso
urc
es,
and
refe
rral
sto
stu
den
tsan
d
fam
ilie
s
Incr
ease
kn
ow
led
ge,
chan
ge
atti
tud
es,
and
dev
elo
psk
ills
in
det
ecti
on
Nad
eem
etal
.
(20
11
),
Ste
inet
al.
(20
10
)
418 School Mental Health (2016) 8:413–424
123
Health Program (YAM) was shown to reduce suicide
attempts and suicidal ideation (Wasserman et al., 2015).
This program was specifically developed for the SEYLE
project which aimed to investigate the efficacy of three
preventative interventions for 11,110 students in 168
schools across Europe. It was facilitated in five 1-h sessions
across 4 weeks focusing on raising awareness about the
risk and protective factors associated with suicide,
including knowledge about depression and anxiety, and
skills enhancement for adverse life events, stress, and
behaviors. Two programs reported improved awareness of
factors associated with suicide and suicide prevention.
‘Signs of Suicide’ utilized video and guided classroom
discussions over 2 days for military middle school students
(Schilling, Lawless, Buchanan, & Aseltine, 2014), and
‘Surviving the Teens’ entailed four 50-min sessions over
4 days to educate students on the signs of depression and
suicide through observational videos, lectures, interactive
activities, and role-play. The programs also incorporate
elements of screening and gatekeeper components and
were feasible with support from school personnel.
An underlying assumption of education and awareness
programs is that awareness of suicide is sufficient to pre-
vent suicidal behavior. Although these programs were
designed to discourage suicide and destigmatize the use of
mental health services (Freedenthal, 2010; Schmidt,
Iachini, George, Koller, & Weist, 2015), knowledge and
attitude changes did not necessarily correlate with changes
in behavior, indicating a limitation of this design (White
et al., 2012). Few studies included information on specific
protocols for responding to sensitive issues or in-class
crises, or on the sociopolitical contexts underlying imple-
mentation (such as relations among involved teachers,
counselors, community educators, and funders).
Gatekeeper Training
Four programs involving gatekeeper training were
explored in ten studies (Cross et al., 2011; Freedenthal,
2010; Johnson & Parsons, 2012; Nadeem et al., 2011;
Petrova, Wyman, Schmeelk-Cone, & Pisani, 2015; Sch-
midt et al., 2015; Stein et al., 2010; Tompkins, Witt, &
Abraibesh, 2010; Wasserman et al., 2015; Wyman et al.,
2010).
Two qualitative studies (Nadeem et al., 2011; Stein
et al., 2010) were conducted on the ‘Youth Suicide
Prevention Program,’ an intervention delivered to almost
688,000 students in 900 schools. These identified chal-
lenges around adequate training for events during (warning
signs, classroom behavior interventions, crisis manage-
ment) and after the program (post-crisis challenges, limited
post-referral communication), and the need for regular
refresher training and information on external resources.
Mixed results were reported for the Question, Persuade,
Refer program. The positive post-training findings on
attitudes, knowledge, and beliefs regarding suicide were
found to be moderated by a number of factors, including
age, professional role, prior training, and contact with
suicidal youths (Tompkins et al., 2010), while Wasserman
et al. (2015) did not find any post-training reduction in the
number of suicide attempts.
It was suggested that gatekeepers would benefit from
additional training in identifying and responding to dis-
tressed students, and from clear and collaborative proce-
dural guidelines for referral and follow-up (Nadeem et al.,
2011).
Peer Leadership
Research into programs such as ‘Sources of Strength’
(Wyman et al., 2010) and ‘Surviving the Teens’ (Strunk,
King, Vidourek, & Sorter, 2014) reported improved per-
ceptions of adult support for suicidal youths and the
acceptability of seeking help, and improved adaptive norms
in relation to suicide. One factor contributing to the success
of the former was the duration of the intervention, which
involved biweekly 30–60-min peer-supervisor meetings
over a 4 months period.
Peer support components in other suicide prevention
programs have been associated with positive outcomes
(Strunk et al., 2014; Wyman et al., 2010), including
improved self-efficacy for students in need and their sup-
porting peers (Miller, 2014), more positive coping norms
and the ability to respond appropriately and associate with
a trusted adult (Katz et al., 2013). Petrova et al. (2015)
report that friends of youths who completed suicide
demonstrate a unique awareness of risk factors, and posit
that positive peer modeling is a promising alternative to
communications that habitually focus on negative conse-
quences and directives. However, the identification,
selection, and retention of peer leaders, particularly from
high-risk groups, need to be considered in future program
design and studies.
Skills Training
Seven programs used a skills training approach for reduc-
ing risk factors and increasing protective factors (Hooven,
Herting, & Snedker, 2010; Hooven, Walsh, Pike, & Hert-
ing, 2012; Jegannathan, Dahlblom, & Kullgren, 2014;
Landgrave & Gomez-Maqueo, 2011; Schmidt et al., 2015;
Strunk et al., 2014; Wasserman et al., 2015; Wyman et al.,
2010). Although this approach did not directly target sui-
cide, the goal is to prevent the development of suicidal
behavior by targeting risk factors and by giving youth
important skills.
School Mental Health (2016) 8:413–424 419
123
Several used a longer-term intervention to indirectly
influence attitudes toward suicide by promoting positive
mental health in a variety of contexts. One employed a
multi-disciplinary team to deliver the program over six
weekly 100-min interactive and engaging sessions involv-
ing discussions, activities, and home assignments (Jegan-
nathan et al., 2014), while another involved eight weekly
modules that integrated a cognitive behavior therapy
computer program alongside face-to-face assessments
(Hetrick et al., 2014). The ‘Care Assess Respond
Empower’ program successfully incorporated computer-
assisted suicide assessment interview and a resilience-
based coping and support program delivery by a mental
health professional to reduce suicide risk factors and
increase protective factors (Hooven et al., 2012).
Screening or Assessment
Five programs involved a screening or assessment com-
ponent in their design (Hetrick et al., 2014; Hooven et al.,
2012; Landgrave & Gomez-Maqueo, 2011; Schilling et al.,
2014; Wasserman et al., 2015), in order to identify at-risk
students and ensure they received additional support if
required. In each case, these were administered only once,
before the program began. While the screening process
itself did not reduce suicide attempts or suicidal ideation
(Wasserman et al., 2015), the ability to identify and refer
those in need was identified as beneficial.
There were several issues identified with screening
students. A single pre-program assessment has potential for
generating false positive (Katz et al., 2013), drawing
resources and attention to students who may not need it at
the expense of those who may require support as the pro-
gram unfolds, and other iatrogenic effects (Gould, Green-
berg, Velting, & Shaffer, 2003). The process also poses
considerable legal and ethical concerns (Miller, 2014), and
Jacob (2009) states that schools are responsible for deter-
mining whether screening results are ‘valid, fair, and useful
for identification of students at risk for suicidal behaviors,
and whether the potential benefits of such screenings out-
weigh possible harm’ (p. 241).
Recommendations
Based on the combination of the issues identified through
previous analysis and existing best practices, key issues
and considerations were utilized to generate ten recom-
mendations for designers to consider when considering a
school-based adolescent suicide prevention program.
R1: Employ longer-term strategies It is well established
that unless the learner has an opportunity to reflect on the
material being presented and to make it applicable to their
own experiences it is unlikely to have an impact (Lonka &
Ahola, 1995). For this reason, most mental health educa-
tion and skills training programs last a minimum of four
sessions. However, as noted from the review, targeted
gatekeeper programs are often delivered in one or two
sessions. Research revealed only one such program that
lasted longer than two sessions (Wyman et al., 2010) and
which, accordingly, demonstrated effective outcomes.
Taken in conjunction with a recent review by Fountoulakis,
Gonda, and Rihmer (2011), there is clear evidence that
suicide programs with very short duration are not effective
in reducing levels of suicide.
R2: Be aware of contextual factors As reported in
reviews of the Question, Persuade, Refer program, the
context and manner in which suicide prevention programs
are delivered directly impact on how participants share and
use the training (Cross et al., 2011; White et al., 2012).
One-off courses delivered by a non-specialist to the class as
a whole will therefore be received differently to smaller,
more interactive groups or discussions facilitated by a
specialist in this area. These contextual factors need to be
considered when deciding upon the aims and focus of
programs.
R3: Clearly define learning outcomes Although best
pedagogic practices state that ‘increased knowledge’ is not
a viable learning outcome (Anderson et al., 2001), analysis
of existing programs revealed this to be one of the most
commonly cited goals of suicide prevention programs
(Johnson & Parsons, 2012; Schilling et al., 2014; Strunk
et al., 2014; Tompkins et al., 2010). Suicide programs need
to have clearly specified learning outcomes that state
exactly what will change and/or be evident in the learner
following the intervention. This clarity can only be
achieved by adherence to effective pedagogic techniques
such as the use of established taxonomies (Bloom, Engel-
hart, Furst, Hill, & Krathwohl, 1956) and constructive
alignment (Biggs & Tang, 2011).
Clearly defined and observable outcomes also enable the
effective evaluation of a program, a continuing challenge
in suicide awareness training. Given the complexity of the
issue, existing studies with poorly defined outcomes have
subsequently struggled to definitely establish the impact of
their programs (White et al., 2012). However, the evalua-
tion component can be simplified by defining a small
number of concise and succinct outcomes at the outset of
the program design and determining if these have or have
not been achieved.
R4: A preparatory phase is essential As reported by
Wasserman et al. (2012), a preparatory phase is an essen-
tial, but often overlooked component. This provides an
420 School Mental Health (2016) 8:413–424
123
opportunity for a site visit by the program facilitator prior
to delivery to raise awareness, identify and troubleshoot
potential difficulties, ensure all stakeholders are aware of
the agreed-upon protocols, and to establish context
(Wasserman et al., 2012). This also enables the school
principal and administrators to discuss and endorse the
program and to clarify its aims (Stein et al., 2010) and to
affirm the importance attributed to the training. The
preparatory phase also provides an opportunity to invite
student feedback and input in order to directly identify and
address their specified needs.
R5: Design and delivery should be flexible Stein et al.
(2010) report that programs should be designed to be flexible
and to accommodate issues as they arise within the specified
structure. Inbuilt flexibility permits adoption of alternative
strategies to reflect unique circumstances and to tailor the
program to more accurately address the needs of the audi-
ence. Accordingly, this flexibility should be incorporated
into the design and delivery of the program. While there is a
need to address clearly defined aims, the content should be
responsive to issues that arise during delivery.
One key concern is the resistance or tension associ-
ated with discussions relating to suicide. Although this
undoubtedly requires sensitivity and care (Wasserman
et al., 2012), exploring this can provide ‘fertile ground
or a more critically engaged pedagogy: one that invites
students to consider the multiple meanings that might
be available for thinking about suicide, self-other rela-
tions, [and] moral responsibility’ (White et al., 2012,
p. 353).
R6: Use external, expert facilitators instead of staff Since
students are more reluctant to accept and to engage in
teacher-driven interventions (Petrova et al., 2015; Wyman
et al., 2010), it is recommended that, where possible,
intervention programs should be delivered by external
specialists or facilitators (Wasserman et al., 2015). There
are several reasons for this. Firstly, related to the issue of
context, it assures the students that this is being treated as a
serious issue which the school wishes to take seriously.
Secondly, the expertise of the specialist will ensure that
any difficult questions can be answered and revelations
managed in an appropriate manner. The use of a specialist
facilitator may also address the issues surrounding student
screening, by providing continuous observational evalua-
tion of students’ participation and responses, and ensuring
suitable interventions in conjunction with the school when
deemed necessary. Finally, from an ethical perspective the
specialist is in a better position to identify and support
students who are affected by any issues raised during the
session.
The detachment afforded by an external facilitator also
provides a buffer for both the student (who can discuss
issues more openly) and the teacher (who is removed from
discussions and personal revelations). If staff members are
involved in design and delivery, there is a need for suit-
able training and consultation (Hetrick et al., 2014; Land-
grave & Gomez-Maqueo, 2011), regular review of
outcomes and materials (White et al., 2012), and supervi-
sion (Jegannathan et al., 2014) to avoid issues such as
burnout, compassion fatigue, and vicarious traumatization
(Erbacher, Singer, & Poland, 2014).
R7: Don’t be restrictive Given the complexity and
interaction of factors that may lead to suicidal ideation,
prevention programs should move beyond prioritizing and
addressing single issues. Several studies reviewing skills-
based training advocated targeting a broader range of fac-
tors to develop skills and awareness among adolescents.
Suggestions include the need to promote awareness of the
interactive nature of factors such as the psychodemo-
graphics associated with mental health and suicide, com-
mon myths and misconceptions, and information about
national and local supports and resources (Miller, 2014;
Wasserman et al., 2012). Other issues in school programs
may include recognizing emotions, relationships, examin-
ing the link between thinking, feeling and acting,
assertiveness training, self-talk and positive thinking, brain
development (psychoeducation), issues around social
media, and (un)healthy coping strategies.
R8: Don’t over-emphasize risk factors The review of
existing studies demonstrated the preponderance of risk
factors associated with increased suicidal ideation,
including mental health difficulties (Davidson & Linnoila,
2013), bullying (Klomek et al., 2011), sexual orientation
(Mustanski & Liu, 2013), body image (Brausch &
Gutierrez, 2009), stress (Wilbum & Smith, 2005), loss or
bereavement (Harrison & Harrington, 2001), alcohol and
substance abuse, victimization, and school problems
(Borowsky, Ireland, & Resnick, 2001). Over-emphasizing
specific risk factors, however, may result in overlooking
others, or in under-identifying those who are at risk of
making impulsive suicidal attempts (Spokas, Wenzel,
Brown, & Beck, 2012).
Furthermore, while knowledge of risk factors is a vital
component of prevention programs, age, gender, or sexual
orientation will not change by participating in suicide
prevention training. For this reason, identification of risk
factors should not be the main focus of any program. It is
widely accepted that within the school setting there should
be a focus on building resilience in young people to enable
them to cope with the various challenges they encounter
School Mental Health (2016) 8:413–424 421
123
during adolescence (Seligman, Ernst, Gillham, Reivich, &
Linkins, 2009; White & Waters, 2015).
A number of the reviewed programs reported success in
reducing risk factors and increasing protective factors
(Hooven et al., 2010, 2012; Jegannathan et al., 2014;
Landgrave & Gomez-Maqueo, 2011; Schmidt et al., 2015;
Strunk et al., 2014; Wasserman et al., 2015; Wyman et al.,
2010). Future program design, then, should integrate this
evidence-based, resilience-building approach alongside
multi-level and recovery-focused training. Multi-compo-
nent prevention and promotion programs that focus
simultaneously on different levels, such as changing the
school environment, improving students’ individual skills,
and involving parents, are more effective than those that
intervene on only one level (WHO, 2014).
R9: Delivery should be varied, interactive, and engag-
ing Suicide prevention programs should avoid the pitfall
of ‘death by PowerPoint’ (Kerr, 2001). Delivery methods
shown to be effective include interactive workshops, dis-
cussions, group activities/exercises, booklets, posters,
cards, home assignments, and video vignettes, while the
development and dissemination and accessible takeaway
resources have also been suggested as a means of pro-
moting conversations between students and their parents
(Freedenthal, 2010; Schmidt et al., 2015; Wasserman et al.,
2012, 2015).
While the Internet has been successfully used to address
other mental health issues (Calear & Christensen, 2010), its
use in suicide prevention programs has been limited. When
used, it has been demonstrated as effective in managing
suicidal ideation and detecting and challenging problematic
thinking (Hetrick et al., 2014), suggesting the potential for
development as an accessible and familiar resource.
Role-play is an effective technique in assisting with
suicide prevention (Cross et al., 2011; Petrova et al., 2015;
Strunk et al., 2014; Wasserman et al., 2015), as it allows
for the practicing of help-seeking behavior and the revision
of procedural knowledge (Ornelas, 2012) in a nonjudge-
mental space. In addition to the interactive nature, it also
has the potential to promote empathy, instigate discussion,
and build confidence by experimenting with ways and
words to ask for help and refer those who need help
(Petrova et al., 2015).
R10: Re-evaluate program outcomes regularly The con-
clusion of a training program does not signify a conclusion
of learning on suicide-related issues. While practical time
and resource constraints may prevent continuous, year-
long, or back-to-back programs, there is benefit in regularly
revisiting and re-evaluating the strategies, skills, and out-
comes of previous programs. Cross et al. (2011) suggest
several strategies for teachers involved in a gatekeeper
training program to support maintenance of skills over time
including reminders via video applications for phones,
Web-based interactive practice opportunities, and provid-
ing feedback as part of a debriefing process.
Discussion and Conclusions
This scoping review sought to clarify existing research in
the implementation of school-based suicide prevention
programs in order to develop recommendations that would
inform the development of effective school-based pro-
grams for students aged 12–18 years old. This was the first
study to employ a scoping methodology to explore suicide
prevention in schools. Studies were reviewed based on the
five operational definitions of program types laid out by
Katz et al. (2013), education or awareness, gatekeeper, peer
leadership, skills training, and screening or assessment
programs. Issues and considerations relating to the imple-
mentation of programs and gaps in the existing evidence
provided the basis for ten recommendations for the design
and delivery of a school-based, adolescent suicide pre-
vention program.
This review should be considered as a stepping stone for
alternative forms of enquiry into suicide prevention in
schools. Future research should explore the implementation
of other school-based mental health programs and the
relationship between these and suicide prevention pro-
grams. Since most programs reviewed are from high
income countries, there is a research gap on the outcome of
school-based interventions among young people in low-
and middle-income countries/areas. Given the global
impact of suicide and its prevalence in all societies, there is
an urgent need to evaluate the effects of suicide prevention
programs in the context of different cultures and countries.
Better understanding of factors that predict and protect
against suicidal behaviors among racial/ethnic groups of
adolescents is needed to identify modifiable factors and
develop culturally responsive prevention and intervention
strategies (Borowsky et al., 2001).
Strengths, Limitations, and Opportunities
The key strength of this study was the use of an under-used
but very effective methodology to summarize a large vol-
ume of information. The comprehensive, international
review of school-based programs for 11–18-year-old stu-
dents identified research gaps and examples of best prac-
tices that enabled the generation of ten evidence-based
recommendations for more effective suicide prevention
programs for schools.
422 School Mental Health (2016) 8:413–424
123
There are several limitations with the current study.
Firstly, due to the nature of scoping reviews, programs and
studies were not graded in terms of their effectiveness and
there was a lack of consensus in specific goals which made
direct comparisons challenging. Similarly, identifying gaps
in the literature is impeded by the absence of a quality
marker in relation to program design or to the research
itself, since quality assessment does not form part of the
scoping review remit. Secondly, while programs aimed at
promoting general mental health may hold promise for
suicide prevention, they were not included in this review.
Finally, the exclusive focus on the literature published
within the previous 5 years may have excluded older but
beneficial studies. Future research in this area could be
extended to ascertain the extent of such omissions.
This review highlights the need for future programs to
have an inbuilt flexibility that accommodates issues arising
throughout delivery. Future research should reflect this
flexibility accordingly by expanding the range of method-
ologies currently pursued and in the shift from the tradi-
tional focus on predicting risk to strengthening resilience
and protective factors.
Funding This study was conducted without funding.
Compliance with Ethical Standards
Conflict of interest Paul Surgenor, Paul Quinn, and Catherine
Hughes declare that they have no conflict of interest.
Ethical Approval This article does not contain any studies with
human participants or animals performed by any of the authors.
Informed Consent For this type of study formal consent is not
required.
References
Anderson, L. W., Krathwohl, D. R., Airasian, P. W., Cruikshank, K.
A., Mayer, R. E., Pintrich, P. R., et al. (2001). A taxonomy for
learning, teaching, and assessing: A revision of Bloom’s
taxonomy of educational objectives. New York: Longma.
Arksey, H., & O’Malley, L. (2005). Scoping studies: Towards a
methodological framework. International Journal of Social
Research Methodology, 8(1), 19–32.
Balaguru, V., Sharma, J., & Waheed, W. (2013). Understanding the
effectiveness of school-based interventions to prevent suicide: A
realist review. Child and Adolescent Mental Health, 18(3), 131–139.
Biggs, J., & Tang, C. (2011). Teaching for quality learning at
University. Maidenhead: McGraw-Hill and Open University
Press.
Bloom, B. S., Engelhart, M. D., Furst, E. J., Hill, W. H., & Krathwohl,
D. R. (1956). Taxonomy of educational objectives: The classi-
fication of educational goals. Handbook I: Cognitive domain.
New York: David McKay Company.
Borowsky, I. W., Ireland, M., & Resnick, M. D. (2001). Adolescent
suicide attempts: Risks and protectors. Pediatrics, 107(3), 485–493.
Brausch, A. M., & Gutierrez, P. M. (2009). The role of body image
and disordered eating as risk factors for depression and suicidal
ideation in adolescents. Suicide and Life-Threatening Behavior,
39(1), 58–71.
Calear, A. L., & Christensen, H. (2010). Systematic review of school-
based prevention and early intervention programs for depression.
Journal of Adolescence, 33(3), 429–438.
Cooper, G. D., Clements, P. T., & Holt, K. (2011). A review and
application of suicide prevention programs in high school
settings. Issues in Mental Health Nursing, 32(11), 696–702.
Cross, W. F., Seaburn, D., Gibbs, D., Schmeelk-Cone, K., White, A.
M., & Caine, E. D. (2011). Does practice make perfect? A
randomized control trial of behavioral rehearsal on suicide
prevention gatekeeper skills. Journal of Primary Prevention, 32,
195–211.
Cusimano, M. D., & Sameem, M. (2011). The effectiveness of middle
and high school-based suicide prevention programmes for
adolescents: A systematic review. Injury Prevention, 17,
43–49. doi:10.1136/ip.2009.025502.
Davidson, L., & Linnoila, M. (Eds.). (2013). Risk factors for youth
suicide. London: Taylor & Francis.
Erbacher, T. A., Singer, J. B., & Poland, S. (2014). Suicide in schools:
A Practitioner’s guide to multi-level prevention, assessment,
intervention, and postvention. London: Routledge.
Fountoulakis, K. N., Gonda, X., & Rihmer, Z. (2011). Suicide
prevention programs through community intervention. Journal
of Affective Disorders, 130(1), 10–16.
Freedenthal, S. (2010). Adolescent help-seeking and the yellow
ribbon suicide prevention program: An evaluation. Suicide and
Life-Threatening Behavior, 40(6), 628–639.
Gould, M. S., Greenberg, T. E. D., Velting, D. M., & Shaffer, D.
(2003). Youth suicide risk and preventive interventions: a review
of the past 10 years. Journal of the American Academy of Child
and Adolescent Psychiatry, 42(4), 386–405.
Harrison, L., & Harrington, R. (2001). Adolescents’ bereavement
experiences. Prevalence, association with depressive symptoms,
and use of services. Journal of Adolescence, 24(2), 159–169.
Hetrick, S., Yuen, H. P., Cox, G., Bendall, S., Yung, A., Pirkis, J., &
Robinson, J. (2014). Does cognitive behavioural therapy have a
role in improving problem solving and coping in adolescents
with suicidal ideation? The Cognitive Behaviour Therapist, 7,
13.
Hooven, C., Herting, J. R., & Snedker, K. A. (2010). Long-term
outcomes for the promoting CARE suicide prevention program.
American Journal of Health Behavior, 34(6), 721.
Hooven, C., Walsh, E., Pike, K. C., & Herting, J. R. (2012).
Promoting CARE: Including parents in youth suicide prevention.
Family and Community Health, 35(3), 225.
Jacob, S. (2009). Putting it all together: Implications for schoolpsychology. School Psychology Review, 38(2), 239.
Jegannathan, B., Dahlblom, K., & Kullgren, G. (2014). Outcome of a
school-based intervention to promote life-skills among young
people in Cambodia. Asian Journal of Psychiatry, 9, 78–84.
Johnson, L. A., & Parsons, M. E. (2012). Adolescent suicide
prevention in a school setting use of a gatekeeper program.
NASN School Nurse, 27(6), 312–317.
Katz, C., Bolton, S., Katz, L. Y., Isaak, C., Tilston-Jones, T., &
Sareen, J. (2013). A systematic review of school-based suicide
prevention programs. Depression and Anxiety, 30(10),
1030–1045.
Kerr, C. (2001). Death by PowerPoint: how to avoid killing your
presentation and sucking the life out of your audience. Santa
Ana: ExecuProv Press.
Klomek, A. B., Kleinman, M., Altschuler, E., Marrocco, F.,
Amakawa, L., & Gould, M. S. (2011). High school bullying as
School Mental Health (2016) 8:413–424 423
123
a risk for later depression and suicidality. Suicide and Life-
Threatening Behavior, 41(5), 501–516.
Lake, A. M., & Gould, M. S. (2011). School-based strategies for
youth suicide prevention. In R. C. O’Connor, S. Platt, & J.
Gordon (Eds.), International handbook of suicide prevention:
Research, policy, and practice (pp. 507–529). New York: Wiley.
Landgrave, P. A., & Gomez-Maqueo, E. L. (2011). A school-based
program for adolescents at risk of suicide (p. 37). Stress and
Anxiety: Application to Education and Health.
Levac, D., Colquhoun, H., & O’Brien, K. K. (2010). Scoping studies:
Advancing the methodology. Implement Science, 5(1), 1–9.
Lonka, K., & Ahola, K. (1995). Activating instruction: How to foster
study and thinking skills in Higher Education. European Journal
of Psychology of Education, 10, 351–368.
Miller, D. N. (2014). Levels of responsibility in school-based suicide
prevention: Legal requirements, ethical duties, and best prac-
tices. Editorial Staff, 9(3), 15.
Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & The PRISMA
Group. (2009). Preferred reporting items for systematic reviews
and meta-analyses: The PRISMA statement. PLoS Medicine,
6(6), e1000097. doi:10.1371/journal.pmed1000097.
Mustanski, B., & Liu, R. (2013). A longitudinal study of predictors of
suicide attempts among lesbian, gay, bisexual, and transgender
youth. Archives of Sexual Behavior, 42(3), 437–448.
Nadeem, E., Kataoka, S. H., Chang, V. Y., Vona, P., Wong, M., &
Stein, B. D. (2011). The role of teachers in school-based suicide
prevention: A qualitative study of school staff perspectives.
School Mental Health, 3(4), 209–221. doi:10.1007/s12310-011-
9056-7.
Ornelas, A. (2012). Differentiation of knowledge types and Behavior
change in youth in a school based suicide prevention program.
Outstanding Honors Theses. Paper 94. University of South
Florida.
Patton, G. C., Coffey, C., Cappa, C., Currie, D., Riley, L., Gore, F.,
et al. (2012). Health of the world’s adolescents: A synthesis of
internationally comparable data. The Lancet, 379(9826),
1665–1675.
Petrova, M., Wyman, P. A., Schmeelk-Cone, K., & Pisani, A. R.
(2015). Positive-themed suicide prevention messages delivered
by adolescent peer leaders: Proximal impact on classmates’
coping attitudes and perceptions of adult support. Suicide and
Life-Threatening Behavior. doi:10.1111/sltb.12156.
Pirruccello, L. M. (2010). Preventing adolescent suicide: A commu-
nity takes action. Journal of Psychosocial Nursing and Mental
Health Services, 48(5), 34–41.
Robinson, J., Hetrick, S., Cox, G., Bendall, S., Yuen, H. P., Yung, A.,
& Pirkis, J. (2014a). Can an internet-based intervention reduce
suicidal ideation, depression and hopelessness among secondary
school students: Results from a pilot study. Early Intervention in
Psychiatry. doi:10.1111/eip.12137.
Robinson, J., Hetrick, S., Cox, G., Bendall, S., Yung, A., Yuen, H. P.,
et al. (2014b). The development of a randomised controlled trial
testing the effects of an online intervention among school
students at risk of suicide. BMC Psychiatry, 14(1), 155.
Schilling, E. A., Lawless, M., Buchanan, L., & Aseltine, R. J. (2014).
‘Signs of Suicide’ shows promise as a middle school suicide
prevention program. Suicide and Life-Threatening Behavior,
44(6), 653–667.
Schmidt, R. C., Iachini, A. L., George, M., Koller, J., & Weist, M.
(2015). Integrating a suicide prevention program into a school
mental health system: A case example from a rural school
district. Children and Schools, 37(1), 18–26.
Seligman, M. E., Ernst, R. M., Gillham, J., Reivich, K., & Linkins, M.
(2009). Positive education: Positive psychology and classroominterventions. Oxford Review of Education, 35(3), 293–311.
Spokas, M., Wenzel, A., Brown, G. K., & Beck, A. T. (2012).
Characteristics of individuals who make impulsive suicide
attempts. Journal of Affective Disorders, 136(3), 1121–1125.
Stein, B. D., Kataoka, S. H., Hamilton, A. B., Schultz, D., Ryan, G.,
Vona, P., & Wong, M. (2010). School personnel perspectives on
their school’s implementation of a school-based suicide preven-
tion program. The Journal of Behavioral Health Services &
Research, 37(3), 338–349. doi:10.1007/s11414-009-9174-2.
Strunk, C. M., King, K. A., Vidourek, R. A., & Sorter, M. T. (2014).
Effectiveness of the surviving the teens� suicide prevention and
depression awareness program: An impact evaluation utilizing a
comparison group. Health Education and Behavior, 41(6),
605–613.
Tompkins, T. L., Witt, J., & Abraibesh, N. (2010). Does a gatekeeper
suicide prevention program work in a school setting? Evaluating
training outcome and moderators of effectiveness. Suicide and
Life-Threatening Behavior, 40(5), 506–515.
Wasserman, C., Hoven, C. W., Wasserman, D., Carli, V., Sarchi-
apone, M., Al-Halabı́, S., et al. (2012). Suicide prevention for
youth-a mental health awareness program: lessons learned from
the Saving and Empowering Young Lives in Europe (SEYLE)
intervention study. BMC Public Health, 12(1), 776.
Wasserman, D., Hoven, C. W., Wasserman, C., Wall, M., Eisenberg,
R., Hadlaczky, G., et al. (2015). School-based suicide prevention
programmes: The SEYLE cluster-randomised, controlled trial.
The Lancet, 385(9977), 1536–1544.
White, J., Morris, J., & Hinbest, J. (2012). Collaborative knowledge-
making in the everyday practice of youth suicide prevention
education. International Journal of Qualitative Studies in
Education, 25(3), 339–355.
White, M. A., & Waters, L. E. (2015). A case study of ‘The Good
School’: Examples of the use of Peterson’s strengths-based
approach with students. The Journal of Positive Psychology,
10(1), 69–76.
Wilbum, V. R., & Smith, D. E. (2005). Stress, self-esteem, and
suicidal ideation in late adolescents. Adolescence, 40(157),
33–45.
World Health Organization. (2008). The global burden of disease
2004 update. Geneva: World Health Organization.
World Health Organization. (2014). Preventing suicide: A global
imperative. Geneva: World Health Organization.
Wyman, P. A., Brown, C. H., LoMurray, M., Schmeelk-Cone, K.,
Petrova, M., Yu, Q., & Wang, W. (2010). An outcome
evaluation of the Sources of Strength suicide prevention program
delivered by adolescent peer leaders in high schools. American
Journal of Public Health, 100(9), 1653–1661.
424 School Mental Health (2016) 8:413–424
123