School-based suicide risk awareness programs

There is some evidence that school-based suicide risk awareness programs, also known as suicide prevention programs, increase suicide risk awareness among middle and high school students (Breet 2021, Brann 2021, Robinson 2013b, Cusimano 2011). More evidence is needed to determine if such programs reduce suicidal ideation, suicide attempts, or increase help-seeking behavior (Breet 2021, Brann 2021).

School-based suicide risk awareness programs such as Signs of Suicide, Sources of Strength, and Question, Persuade, Refer (QPR) can increase knowledge of suicide risk factors but have inconsistent effects on help-seeking behavior, suicidal ideation, and suicide attempts (Breet 2021, Brann 2021, Robinson 2013b). Such programs are often difficult to study and may not include suicide rates as an outcome (Singer 2019, Cusimano 2011).

Experts suggest that multicomponent prevention programs that combine gatekeeper training, screening, and curricula may be most effective (Brann 2021, Robinson-Link 2020). Suicide prevention can also include tailored interventions for students experiencing risk factors, known as indicated interventions (Breet 2021).

Suicide screening and education do not appear to increase risk of suicide in adolescents (Gould 2005, Bailey 2017). Youth suicide is complex and is associated with numerous risk factors, though these may not cause or predict a suicide attempt. Risk factors include mental disorders, previous suicide attempts, certain personality characteristics, family factors, stressful life events, exposure to suicide in media or local communities, and access to lethal means (Bilsen 2018).

The effectiveness of school-based suicide risk awareness programs to reduce youth suicide likely depends on accessible, affordable, and effective mental health services for students (Breet 2021). Schools that implement screening or gatekeeper training can help coordinate mental health care for students who are identified as being at risk of suicide (Granello 2018). Schools can also consider integrating suicide risk awareness and prevention efforts into existing structures, like multi-tiered systems of support (MTSS) (Singer 2019). Challenges to implementing school-based suicide risk awareness programs can include limited school resources, limited community mental health resources, and difficulty obtaining parental consent for participation (Breet 2021, Totura 2017).

Experts recommend that schools carefully consider what outcomes are of interest, as well as their capacity and resources, when determining what type of program to implement (Brann 2021). Experts emphasize gathering data, gaining administrative and stakeholder support, and building infrastructure to support mental health referral and coordination (Granello 2018).

It is unclear what impact universal school-based suicide risk awareness programs have on disparities in youth suicide across populations. Suicide rates are significantly higher among youth who are identified as American Indian or Alaska Native, Black, or Hispanic (CDC MMWR-Stone 2023). Youth who are female, LGBTQ+ youth, and youth who have any same-sex partners are more likely to attempt suicide than their peers (CDC-YRBS 2023). Suicide rates are also higher among youth who live in rural communities than those who live in urban communities (Fontanella 2015).

Experts recommend evaluating and shifting structural-level policies, such as public assistance, medical coverage, and law enforcement policy to address disparities in youth suicide rates (Alvarez 2022). Sovereignty, community autonomy, cultural identification, language, spirituality, healing ways, kinship models, and family connectedness are protective factors against suicide for Native youth (Zero Suicide). More research is needed on suicide prevention programs for youth experiencing the most risk factors for suicide (Singer 2019, Breet 2021).

Suicide is currently the second leading cause of death among youth ages 10 to 24 in the United States (CDC-Suicide disparities). Suicide rates for this age group increased 52% between 2000 and 2021, though the rate is lower than for other age groups (CDC-Suicide disparities). More broadly, suicide death rates vary substantially by state. Demographics, firearm availability, mental health status, and access to mental health services may influence suicide rate variation across states (KFF-Saunders 2023).

• Who in your school community experiences risk factors for suicide? How do existing policies at school, such as school discipline or attendance policies, contribute to this risk or discourage help-seeking? How do existing policies in the community, such as law enforcement policies, contribute?
• How can suicide prevention programs in your school connect students to mental health resources at school and in the community? How can school programs support students as they access these services?

There are many specific suicide risk awareness programs, particularly at the middle and high school level. The Substance Abuse and Mental Health Services Administration (SAMHSA) provides a toolkit to help high schools and districts around the country implement such programs (SAMHSA-High school toolkit). SAMHSA also awards grants in support of state and tribal youth suicide prevention efforts (GLS suicide prevention). The Suicide Prevention Resource Center outlines many approaches to suicide prevention programs, including school curriculums (SPRC).

CDC-Suicide prevention - Centers for Disease Control and Prevention (CDC). Suicide prevention resources for action.

SAMHSA TTAC-Suicide prevention resources - Substance Abuse and Mental Health Services Administration (SAMHSA), Tribal Training and Technical Assistance Center (TTAC). Suicide prevention resources.

SAMHSA-High school toolkit - Substance Abuse and Mental Health Services Administration (SAMHSA). Preventing suicide: A toolkit for high schools. HHS Publication No. SMA-12-4669. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; 2012.

SPRC - Suicide Prevention Resource Center (SPRC). Effective suicide prevention requires multiple approaches.

TX-Steps for schools - Poland S, Poland D. Recommendations for Suicide Safer Schools Texas school district action steps. Texas Department of State Health Services, Texas Suicide Prevention Council, & Mental Health America of Texas; 2015.

YSP school guide - Lazear KJ, Roggenbaum S, Blasé K. Youth suicide prevention school-based guide (YSP school guide). Tampa, FL: University of South Florida, College of Behavioral & Community Sciences, Louis de la Parte Florida Mental Health Institute, Department of Child & Family Studies; 2012.

* Journal subscription may be required for access.

Alvarez 2022 - Alvarez K, Polanco-Roman L, Breslow AS, Molock S. Structural racism and suicide prevention for ethnoracially minoritized youth: A conceptual framework and illustration across systems. American Journal of Psychiatry. 2022;179(6):422-433.

Bailey 2017 - Bailey E, Spittal MJ, Pirkis J, Gould M, Robinson J. Universal suicide prevention in young people: An evaluation of the safeTALK program in Australian high schools. Crisis. 2017;38(5):300-308.

Bilsen 2018 - Bilsen J. Suicide and youth: Risk factors. Frontiers in Psychiatry. 2018;9:1-5.

Brann 2021* - Brann KL, Baker D, Smith-Millman MK, Watt SJ, DiOrio C. A meta-analysis of suicide prevention programs for school-aged youth. Children and Youth Services Review. 2021;121:105826.

Breet 2021 - Breet E, Matooane M, Tomlinson M, Bantjes J. Systematic review and narrative synthesis of suicide prevention in high-schools and universities: A research agenda for evidence-based practice. BMC Public Health. 2021;21(1):1-21.

CDC MMWR-Stone 2023 - Stone DM, Mack KA, Qualters J. Notes from the field: Recent changes in suicide rates, by race and ethnicity and age group — United States, 2021. Morbidity and Mortality Weekly Report (MMWR). 2023;72(6):160-162.

CDC-Suicide disparities - Centers for Disease Control and Prevention (CDC). Suicide prevention: Health disparities in suicide.

CDC-YRBS 2023 - Centers for Disease Control and Prevention (CDC). Youth Behavior Risk Survey: Data summary and trends report, 2011-2021. 2023.

Cusimano 2011* - Cusimano MD, Sameem M. The effectiveness of middle and high school-based suicide prevention programmes for adolescents: A systematic review. Injury Prevention. 2011;17(1):43-49.

Fontanella 2015 - Fontanella CA, Hiance-Steelesmith DL, Phillips GS, et al. Widening rural-urban disparities in youth suicides, United States, 1996-2010. JAMA Pediatrics. 2015;169(5):466-473.

GLS suicide prevention - Suicide Prevention Resource Center. Garrett Lee Smith (GLS) Suicide Prevention grantees.

Gould 2005 - Gould MS, Marrocco FA, Kleinman M. Evaluating iatrogenic risk of youth suicide screening programs: A randomized controlled trial. JAMA. 2005;293(13):1635-1643.

Granello 2018* - Granello PF, Zyromski B. Developing a comprehensive school suicide prevention program. Professional School Counseling. 2018;22(1).

KFF-Saunders 2023 - Saunders H, Panchal N. A look at the latest suicide data and change over the last decade. KFF; 2023.

PSW - Prevent Suicide Wisconsin (PSW). Partners saving lives in our state.

Robinson 2013b* - Robinson J, Cox G, Malone A, et al. A systematic review of school-based interventions aimed at preventing, treating, and responding to suicide-related behavior in young people. Crisis. 2013;34(3):164-182.

Robinson-Link 2020* - Robinson-Link N, Hoover S, Bernstein L, et al. Is gatekeeper training enough for suicide prevention? School Mental Health. 2020;12:239-249.

SAMHSA-High school toolkit - Substance Abuse and Mental Health Services Administration (SAMHSA). Preventing suicide: A toolkit for high schools. HHS Publication No. SMA-12-4669. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; 2012.

Singer 2019* - Singer JB, Erbacher TA, Rosen P. School-based suicide prevention: A framework for evidence-based practice. School Mental Health. 2019;11:54-71.

SPRC - Suicide Prevention Resource Center (SPRC). Effective suicide prevention requires multiple approaches.

Totura 2017* - Totura CMW, Kutash K, Labouliere CD, Karver MS. Evaluating active parental consent procedures for school programming: Addressing the sensitive topic of suicide prevention. Journal of School Health. 2017;87(2):114-120.

WI DHS-Prevent suicide - Wisconsin Department of Health Services (WI DHS). Suicide prevention.

WI DPI-Suicide curriculum - Wisconsin Department of Public Instruction (WI DPI). Classroom curriculum on youth suicide prevention.

Zero Suicide - Zero Suicide. Populations: Native American and Alaska Native. Resources for Native American and Alaska Native populations.