Research Review: The effect of school‐based suicide prevention on suicidal ideation and suicide attempts and the role of intervention and contextual factors among adolescents: a meta‐analysis and meta‐regression

Abstract

Background Globally, suicide is the fourth highest cause of adolescent mortality (Suicide: https://www.who.int/news-room/fact-sheets/detail/suicide). The effects of post‐primary school‐based suicide prevention (PSSP) on adolescent suicidal thoughts and behaviours (STBs) have not been comprehensively synthesised. We aim to estimate the population effect for PSSP interventions on adolescent STBs and explore how intervention effects vary based on intervention and contextual moderators. Methods Searches of PsycINFO, Medline, Education Source, ERIC, Web of Science, and the Cochrane Central Register of Controlled Trials identified cluster randomised trials examining the effectiveness of PSSP on adolescent STBs. The Cochrane Risk of Bias tool assessed bias. Crude and adjusted back‐transformed odds ratios (ORs) were calculated. Multilevel random‐effects models accounted for dependencies of effects. Univariate meta‐regression explored variability of intervention and contextual moderators on pooled effects. Results There were 19 and 12 effects for suicidal ideation (SI) and suicide attempts (SA). Compared with controls, interventions were associated with 13% (OR = 0.87, 95%CI [0.78, 0.96]) and 34% (OR = 0.66, 95%CI [0.47, 0.91]) lower crude odds reductions for SI and SA, respectively. Effects were similar for adjusted SI (OR = 0.85, 95%CI [0.75, 0.95]) and SA (OR = 0.72, 95%CI [0.59, 0.87]) models. Within‐study (0.20–9.10%) and between‐study (0–51.20%) heterogeneity ranged for crude and adjusted SA models and SI heterogeneity was 0%. Moderator analyses did not vary SA effects (ps > .05). Conclusions This meta‐analysis contributes to the PSSP evidence‐base by demonstrating that PSSP targeting STBs as both primary intervention outcomes and with other health and well‐being outcomes reduced SI and SA among 33,155 adolescents attending 329 schools, compared to controls. The number needed to treat estimates suggests the potential of reducing the incidence of SA and SI in one adolescent by implementing PSSP in 1–2 classrooms, supporting PSSP as a clinically relevant suicide prevention strategy. Although moderator analyses were nonsignificant and contained a small number of trials, larger SA effect sizes support particular effectiveness for interventions of a duration of ≤1 week, involving multiple stakeholders and with a 12‐month follow‐up.

Editorial: Schools on the frontline of suicide prevention

“…The review and meta‐analyses by Walsh et al. (2022) provide a refreshing focus on alternative and innovative forms of intervention – namely the implementation of suicide prevention strategies in school. While the findings shed light and give hope to the efficacy of such programs, it also highlights the nascency of the field and potential lack of representation of youth in our diverse school systems.…”

“…Even more promising, the authors found that such interventions targeting suicidal thoughts and behaviors were effective in reducing suicide risk when implemented as both primary, and secondary/adjunctive interventions. The authors included 12 studies spanning across close to 30 years (1991–2020), that resulted in the examination of 33,155 youth in 329 schools between the ages of 11 and 18 years (Walsh et al., 2022). Overall findings suggest that PSSR in schools can reduce suicidal ideation and suicide attempts by 13% and 34%, respectively (Walsh et al., 2022).…”

“…The authors included 12 studies spanning across close to 30 years (1991–2020), that resulted in the examination of 33,155 youth in 329 schools between the ages of 11 and 18 years (Walsh et al., 2022). Overall findings suggest that PSSR in schools can reduce suicidal ideation and suicide attempts by 13% and 34%, respectively (Walsh et al., 2022).…”

“…The authors tackle a crucial topic in their manuscript that has the potential to significantly impact the current needs of our field. Namely, they identify that the research base to date suggests that implementing these school‐based programs actually does have a positive effect in reducing suicide risk (Walsh et al., 2022). In a time of overflowing pediatric emergency departments, lack of hospital beds and resources, and an overburdened behavioral health system (Radfar, Ferreira, Sosa, & Filip, 2021), this is quite promising.…”

“…The authors make the important point that, appropriately so, their meta‐regressions were not completed when there was limited heterogeneity in the samples, and as a result, no individual school characteristics were examined (Walsh et al., 2022). The authors include the fact that this was because of the 12 studies included, 11 of them were in public schools.…”