Children and Youth Services Review 121 (2021) 105826

Contents lists available at ScienceDirect

Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

A meta-analysis of suicide prevention programs for school-aged youth

Kristy L. Brann a, *, Derek Baker a, Mills K. Smith-Millman b, Sarah J. Watt a, Courtney DiOrio a
a
Miami University, United States
b
McLean Hospital, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Suicide is an increasingly prevalent cause of death among adolescents across all demographics. Schools can be
School effective settings for identification and prevention of suicide due to the amount of time that students spend in
Suicide prevention school. This study presents a meta-analysis of school-based suicide prevention programs for students and school
Meta-analysis
staff on the following outcomes: suicide awareness, helping skill, suicide behavior, psychological wellness, and
Youth
psychological distress outcomes. A total of 27 studies were identified via 5 databases. Results suggest that suicide
prevention programs have the largest impact on suicide awareness (k = 18, g = 0.72) and helping skill (k = 15, g
= 0.43) compared to suicide behavior (k = 8, g = 0.17), psychological wellness (k = 7, g = 0.16), and psy­
chological distress (k = 9, g = 0.16). However, results are limited by the availability of previous research. We
conclude with a discussion of limitations, implications for practice, and directions for future research.

1. Introduction
Suicide is the second leading cause of death among 10 to 24-year-
olds in the United States (Center for Disease Control, 2015). Further,
almost eighteen percent of American high school students report having
seriously considered suicide in the past year (Kann et al., 2016). Suicide
is associated with major economic and emotional costs to society.
Economically, it is estimated that the sum total of direct and indirect
costs of total completed suicides in the United States per year converts to
$16.83 billion in 2005 United States dollars, while that of suicide at­
tempts approximates to $4.72 billion in 2005 United States dollars
(Yang & Lester, 2007). The emotional consequences of suicide can
manifest in the suicide contagion effect, or the elevated risk of suicide
among individuals exposed to suicide and/or suicide behavior, to which
adolescent populations are particularly vulnerable (Center for Disease
Control, 2015; Gould et al., 1989). The high prevalence rate of suicidal
ideation coupled with the high social and economic costs of suicide
demonstrate a clear need for improved youth suicide prevention. Suicide
prevention programs are particularly important because they seek to
provide all students with knowledge about suicide and resources for how
to help themselves and/or friends who are contemplating suicide
(Kalafat, 2003).
Schools allow for unparalleled access to most of the nation’s youth,
and as such, are an ideal setting to provide suicide prevention services
(Cooper et al., 2011; Hayden & Lauer, 2000; Stein et al., 2010). As such,
most states require high schools to provide suicide prevention training
to school staff and/or education about suicide to all students (American
Foundation for Suicide Prevention, 2017). Thus, school-based suicide
prevention programs have proliferated in high schools in an attempt to
prevent both the onset of suicidality in youth and to train youth in how
to obtain help for suicidal peers (Kalafat & Elias, 1994). To take a more
preventative and upstream approach, Wyman (2014) recommends that
childhood school-based suicide prevention programs can target
improving psychological wellness (e.g., strengthen self-regulation of
behavior and emotions) to impact risk and protective factors before
suicide behavior occurs. In addition to kindergarten through 12th grade
settings, institutions of higher education provide another potential
avenue for school-based suicide prevention programs (Jodoin & Rob­
ertson, 2013). For instance, colleges can provide psychoeducation to
students and train residential advisors and staff to recognize warning
signs and intervene (Coleman et al., 2019; Shannonhouse, Lin, Shaw,
Wanna, & Porter, 2017). Therefore, school-based suicide prevention
programs can be implemented across a range of developmental settings.
1.1. Types of suicide prevention programs
School-based suicide prevention programs typically involve one or
more of the following three components: gatekeeper training for school
staff, curriculum-based education for students, or screening for early
identification of students’ suicide risk (Cooper et al., 2011; Singer et al.,

* Corresponding author at: 210 E. Spring Street, 201 McGuffey Hall, Miami University, Oxford, OH 45056, United States.
E-mail address: brannk@miamioh.edu (K.L. Brann).

https://doi.org/10.1016/j.childyouth.2020.105826
Received 20 May 2020; Received in revised form 4 December 2020; Accepted 4 December 2020
Available online 14 December 2020
0190-7409/© 2020 Elsevier Ltd. All rights reserved.
K.L. Brann et al.
2019). Gatekeeper training involves teaching school staff members how
to recognize signs of suicide in students and connect at-risk students to
the appropriate resources. Student education typically involves a suicide
curriculum that is taught to all students in a school to increase both their
knowledge about suicide and their capacity to effectively help suicidal
peers. Finally, screening programs strive to increase the identification of
students experiencing suicidal thoughts by having students complete a
brief suicide assessment. Additional components may include campaigns
to change social norms (Silk et al., 2017) or postvention (Hazell &
Lewin, 1993) after a suicide occurs in efforts to prevent future suicidal
behavior.
Several standardized suicide prevention programs have been devel­
oped for implementation in school settings, yet the extant empirical
evidence regarding the effectiveness of these programs in promoting
protective factors and attenuating suicidality varies (Cooper et al.,
2011). Katz et al. (2013) identifies Question, Persuade, Refer (Quinnett,
1995; QPR) as the most widely-used gatekeeper training program in
school settings. QPR is a universal program designed to equip teachers
and peers to identify the warning signs of suicide, communicate their
support of suicidal individuals, and refer suicidal individuals for pro­
fessional care (Wasserman et al., 2015). A systematic review by Rob­
inson et al. (2013) suggested QPR programming increases the
confidence of school staff in dealing with suicide-related behavior and
mental health issues among students. However, a systematic review of
school-based suicide interventions (Katz et al., 2013) suggested that
although QPR demonstrated effectiveness in improving attitudes and
knowledge about suicide, QPR failed to demonstrate positive behavioral
changes in gatekeepers (e.g., asking students about suicide).
A second gatekeeper training program, Sources of Strength, is a
universal program that involves nominating and training “peer leaders”
as gatekeepers in schools (Cooper et al., 2011). Peer leaders, in coop­
eration with adult mentors, design and implement suicide-prevention
messaging activities meant to specify and change peer-group percep­
tions regarding typical behavior (i.e., descriptive norms) and the bene­
fits of positive coping behavior (i.e., injunctive norms; Wyman et al.,
2010). Thus, Sources of Strength aims not only to empower peer leaders
to promote positive help-seeking and coping behaviors in fellow stu­
dents (e.g., engaging a trusted adult), but also to change broader school
social norms and increases the overall acceptability of help-seeking
(Wyman et al., 2010). The success of this strategy is supported by Katz
et al (2013), whose review indicated Sources of Strength as effective for
increasing peer leaders’ knowledge and awareness about suicide, while
also increasing peer leaders’ gatekeeping behavior (i.e., confiding in
trusted adults about suicidal peers).
Cooper et al. (2011) identified Signs of Suicide (SOS) as a favorable
curriculum-based suicide prevention program. SOS is a multi-
component program that combines curriculum-based prevention with
student screening. SOS combats the notion of suicide-related behavior as
a normal response to stress by directly linking suicide with diagnosable
mental illness (Katz et al., 2013). SOS programming educates students
on the warning signs of suicide, presents depression as a treatable con­
dition, and imparts the importance of help-seeking for themselves and
their peers (Schilling et al., 2016). SOS curricula involve filmed vi­
gnettes that model appropriate responses to suicidal individuals, vid­
eotaped testimonials by individuals affected by suicide, and guided class
discussion. Additionally, SOS incorporates a brief, self-report screening
measure to identify students at risk for suicide. SOS is not only associ­
ated with positive changes in knowledge and attitudes about suicide, but
also reduced suicide attempts (Cooper et al., 2011; Katz et al., 2013;
Schilling et al., 2016).
1.2. Previous reviews of suicide prevention programs
Despite the proliferation of programming, only a small body of
research has been conducted on the effectiveness of school-based suicide
prevention programs (Cooper et al., 2011; Gould et al., 2003). Brown
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Children and Youth Services Review 121 (2021) 105826
et al. (2007) lament the scarcity of randomized control trials investi­
gating the success of school-based suicide prevention programs, as
controlled investigation into suicide prevention programs may safe­
guard against unsubstantiated conclusions, particularly if the number of
suicides in the targeted school is relatively small. The authors specif­
ically advocate for systematic investigation into the effectiveness of
school-based prevention programs, as high rates of participation may
enable such programs to protect both individuals with existing risk of
suicide and individuals whose risk of suicide may change after pro­
gramming is complete (Brown et al., 2007).
Systematic reviews of suicide prevention programs reveal that while
these programs often increase knowledge about suicide and decrease
stigmatizing attitudes toward suicide, very few demonstrate positive
effects on suicidal behavior (Cooper et al., 2011; Gould et al., 2003;
Robinson et al., 2013; Singer et al., 2019). However, improvements in
suicide awareness may connect to suicide behavior as Zalsman et al.
(2016) found that school-based awareness programs were shown to
reduce suicidal ideation and suicide attempts. Yet documented im­
provements are still lacking; Kutcher et al. (2016) conducted an in-depth
review of two commonly used suicide prevention programs in Canada,
SafeTALK and Applied Suicide Intervention Skills Training (ASIST), and
found that neither program demonstrated effectiveness. Robinson et al.
(2013) similarly found limited evidence for the efficacy of school-based
suicide prevention programs in their systematic review. Katz et al.
(2013) graded the strength of evidence regarding efficacy of programs,
however, the outcomes reviewed uncontrolled studies as well as pro­
vided a limited scope regarding confounding variables that impact the
programs. Previous reviews were also limited by focusing on a narrow
range of suicide-focused outcomes and not evaluating how school-based
prevention programs may impact psychological wellness and distress. In
light of recommendations to implement comprehensive school-based
suicide prevention programs across developmental settings that target
a range of outcomes (Wyman, 2014) and the lack of conclusive evidence
for suicide prevention programs, additional research is needed to better
understand school-based suicide prevention program effectiveness.
Further, as effect sizes of universal prevention programs are highly
variable across prevention outcome variables, Tanner-Smith, Durlak,
and Marx (2018) emphasize the need to examine various outcome areas,
rather than merely the aggregate effects of the prevention program.
1.2.1. Moderator analyses
Though it is crucial to understand the conditions under which suicide
prevention programs are most effective, moderators in suicide preven­
tion literature are often unexplored (Musci et al., 2018). This study seeks
to address this gap in literature by examining whether the effects of
suicide prevention programs vary as a function of the conditions and
settings of program implementation. Specifically, the modality of pre­
vention (i.e., Gatekeeper, Screening, Curriculum-Based, and Multi-
Component) was expected to moderate effects. Multi-component sui­
cide prevention programs were expected to yield greater effects on
suicide-related and mental health outcomes compared to other types of
programs, as multi-component programs were expected to combine the
identified benefits of more specific types of prevention programs (e.g.,
Gatekeeper, Curriculum-Based), while also addressing the recognized
shortcomings of such programs.
For example, while previous research suggests gatekeeper programs
are associated with improved self-efficacy, gatekeeper skills, and
knowledge, there is mixed evidence on the effect of gatekeeper programs
on participants’ behavior in response to student suicidality (e.g., asking
students about suicide) and their attitudes toward student suicide (Mo
et al., 2018). Similarly, curriculum-based programs are often effective in
increasing knowledge and awareness about suicide; yet, limited research
demonstrates curriculum-based programs foster change in suicide
behavior and insufficient support exists to link change in suicide
knowledge with change in suicide behavior (Gould et al., 2003). Addi­
tionally, traditional curriculum-based programs typically are delivered
K.L. Brann et al.
at a universal level and are not designed to identify at-risk students
(Cooper et al., 2011). While screening programs aim to identify students
at-risk for suicide in order to implement early intervention, Cooper et al.
(2011) suggest screening programs are most effective when screening
initiatives operate synchronously with gatekeeper programming, such
that students who are identified as at-risk can be efficiently referred to
trained gatekeepers for help. Ultimately, Cooper et al.’s (2011)
comprehensive review of suicide prevention programs suggests hybrid
programs that integrate prevention curricula, effective and feasible
screening, and streamlined gatekeeper training may be most effective
for promoting positive outcomes and protective factors with regard to
suicide-related behavior and mental health. Thus, we hypothesize that
multicomponent prevention programs may be the most effective.
Additionally, prevention setting for the intervention target (univer­
sal “whole class/staff”, selected “small group”, indicated “individual”)
was expected to moderate effects of suicide prevention programs. Sui­
cide prevention literature (Cooper et al., 2011) suggests the effective­
ness of suicide prevention programs may vary as a function of the setting
and level of reach. For example, at the one-year follow-up of universal
QPR gatekeeper training, Wyman et al. (2008) found students who
report a previous suicide attempt were less likely to seek help from adult
gatekeepers in school as well as less likely to report that friends would
want them to seek help from an adult at school. In a systematic review of
gatekeeper training programs, Mo et al. (2018) found such programs
had limited impact on gatekeeper behavior as measured by asking stu­
dents about suicide or increase in the number of referrals. Thus, uni­
versal gatekeeper training programs that simply focus on the gatekeeper
roles of school personnel, rather than overall school help-seeking norms
(e.g., Wyman et al., 2010), may be inadequate in preventing student
suicide among distressed and suicidal students (Mo et al., 2018; Wyman
et al., 2008). Therefore, it is important to examine how effects differ by
prevention setting.
Further, in relation to prevention setting, effect sizes in universal
prevention programs are expected to be lower relative to the effect other
prevention settings. In their review of meta-analyses of universal pre­
vention programs for behavior and emotional problems in youth, Tan­
ner-Smith and colleagues (2018) mean effect size distributions that
warrant new interpretative benchmarks for effect sizes of universal
prevention programs. Researchers found that the median average effect
of such programs on various prevention outcomes typically fell within
0.17 and 0.16 standard deviations, which suggests common standards of
effect size interpretation as small/medium/large should be discarded as
inappropriate within the context of universal prevention (Tanner-Smith
et al., 2018). Thus, in addition to feasibility and fidelity considerations
in evaluating cost-effectiveness of universal prevention programs, Tan­
ner-Smith et al., 2018) implore researchers, practitioners, and policy-
makers to interpret the magnitude of effect sizes within the setting of
prevention, so as not to discard or underestimate the effectiveness of
successful universal prevention programs. Other prevention settings (i.
e., selected, targeted) may be expected to yield larger effect sizes, as
participants’ initial levels of symptomatology have greater improvement
for improvement across prevention outcomes with the implementation
of prevention programming (Tanner-Smith et al., 2018). Based on this
review of research, we expect effect sizes to be lower for universal
prevention programs.
Relatedly, with regard to intervention target, Singer and colleagues
(2019) examined the empirical support of universal, selected, and tar­
geted school-based suicide prevention programs within a multi-tiered
systems of support (MTSS) framework. Indeed, authors found school-
based suicide prevention programs varied with regard to empirical
support, as well as program type, and the content of screening proced­
ures, staff education and training, and student education. To further
understand favorable conditions for suicide prevention programming,
prevention target (students, parents, teachers/staff), duration, partici­
pant age-level, prevention agent, and content of prevention were
included in an exploratory analysis of moderating factors that impact
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Children and Youth Services Review 121 (2021) 105826
program effectiveness.
1.3. The current study
Given the importance of preventing youth suicide, schools are
encouraged to implement school-based suicide prevention programs.
Such programs can be costly in terms of time and resources; yet,
conclusive evidence on the effectiveness of school-based suicide pre­
vention programs is lacking. Despite the mixed results and various sys­
tematic reviews (Cooper et al., 2011; Gould et al., 2003; Katz et al.,
2013; Robinson et al., 2013; Singer et al., 2019), there is a paucity of
meta-analyses assessing the impact of school-based suicide prevention
programs. Further, no meta-analysis has included the wider criteria of
ages and incorporated both positive and negative outcome measures.
The current study aims to fill this gap in the literature by exploring the
overall effectiveness of suicide prevention programs for school-aged
youth on suicide-related and mental health outcomes as well as
exploratory analyses of moderating factors that impact program
effectiveness.
2. Method
2.1. Eligibility criteria and search strategy
To examine the impact of school-based suicide prevention programs,
we used the following inclusion criteria: (1) targeted youth populations,
which included K-12 students or college students in the school or college
setting, (2) written in English, published in or after 1980, (3) included a
treatment group with a suicide prevention focus, (4) included a control
group, (5) targeting suicide through prevention/intervention or
outcome measure, and (6) included sufficient treatment and control
group data to calculate effect sizes post intervention. Given the difficulty
of conducting randomized controlled trials with school-based universal
prevention studies (National Research Council, 2002), randomized-
controlled trials, clustered-randomized trials, and quasi-experimental
studies were all eligible for inclusion
A comprehensive search of the literature was conducted using five
search methods to identify potential studies for inclusion. Relevant
studies were located through a computer search of Education Research
Complete, ERIC, PSYCArticles, PsycINFO, and Psychology and Behav­
ioral Sciences. The full texts were searched under the following term
groupings: Suicide (all text) AND (prevention OR training OR curriculum
OR intervention [abstract]) AND (school OR college OR adolescent [all
text]). The initial search was limited to articles written in English,
published between 1980 and 2019, and published in peer-reviewed
journals. In order to include potential grey literature, we also searched
the first 600 dissertation results on ProQuest, completed reference
checks, and contacted authors to locate potential unpublished studies.
The initial search was limited to peer-reviewed articles as van Driel et al.
(2009) found that grey literature is often of a lower methodical quality
and that high-quality unpublished trials are eventually published. The
authors recommend that meta-analyses focus on published trials but
suggest a need for regularly updating meta-analyses. Further,
Schmucker et al. (2017) recently completed a systematic review and
found that excluding grey literature did not overestimate effect sizes in
meta-analyses.
Duplicate articles were first removed and then the 13,731 articles
were screened for inclusion; an article was determined acceptable to
continue to the next phase contingent on having a relevant title, abstract
that mentioned a prevention program related to suicide, and meeting the
publication cutoff of 1980. After the initial phase, there were 171 arti­
cles included for full-text review for inclusionary determination. Next,
articles were evaluated for inclusion dependent on the inclusion criteria.
Fig. 1 presents a diagram of the search procedure and decisions with
the number of articles for each step. Following this inclusionary deter­
mination, 28 articles remained. During the final review, articles were
K.L. Brann et al.
Fig. 1. PRISMA Inclusion Diagram.
included dependent on having treatment and control data to derive ef­
fect sizes for post-test results, which excluded five studies. We contacted
authors to request additional detail to calculate effect sizes but did not
receive a response. The search yielded 23 articles that met criteria for
inclusion in the review. Following a reference check of included articles
(14 potential new relevant articles located), an additional two articles
met all of the inclusion criteria totaling 25 articles. The corresponding
authors of the 25 articles were contacted to identify potentially missed
articles that may be in press, unpublished, or missed during the article
search, which resulted in considering five additional articles but none
met inclusion criteria. Two articles contained multiple studies with
different samples, which resulted in a total of 27 included studies.
Agreement for inclusion was determined through group discussion and
collective decision based on majority when a deviation of coding was
flagged.
2.2. Outcome measures
Studies on suicide prevention programs often study a wide range of
outcomes because many prevention programs targeting suicide are also
broad in nature and hope to improve psychological well-being as well as
reduce psychological distress (Cooper et al., 2011). It is theorized that
improving psychological well-being and reducing psychological distress
will reduce risk factors and increase protective factors, resulting in
decreased risk of suicide (Meerwijk et al., 2016; Wyman, 2014). Further,
it is difficult to observe direct suicide outcome measures, such as idea­
tion, attempts, and completions, due to the low base rate and difficulty
accurately measuring ideation and attempts (Wasserman et al., 2015).
Therefore, the present study included a wide range of potential outcome
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Children and Youth Services Review 121 (2021) 105826
measures that focused on three broad domains: suicide-related out­
comes, psychological well-being, and psychological distress.
To determine specific outcome measures, we considered the avail­
able outcome measures from studies in addition to theory. First, previ­
ous literature and theory were considered in order to develop broad
categories of suicide-related behavior, psychological well-being, and
psychological distress. Next, included articles were reviewed, and each
specific dependent variable provided in the respective articles were
recorded. Following this, the dependent variables were collaboratively
coded into thematic categories (e.g., suicide attitude and knowledge)
and then groups were combined when applicable. For example, suicide
attitude and knowledge were combined into the thematic category of
suicide awareness. Next, each thematic category was given a definition
and examples based on both the dependent variable articles’ definitions
as well as a collaborative understanding of the outcome category
(available in electronic supplemental materials). Each category was
assigned a specific code and each dependent variable from included
studies were assigned to an outcome code. Finally, each dependent
variable was checked for accuracy by the first author. The final outcome
groups were suicide behavior/intention, suicide awareness, helping
skill, psychological wellness, and psychological distress. When there
were multiple effects per outcome category in a study with the same
participants, effects were aggregated within the study to produce one
effect, as recommended by Borenstein et al. (2009) where the correla­
tion between outcome measures was set at 0.50.
2.3. Statistical procedures effect sizes
Data were analyzed with Comprehensive Meta-Analysis Version
K.L. Brann et al.
Three (CMA; Borenstein et al., 2009). A random effects model was
selected due to the variability in the studies (e.g., population and sample
size, type of intervention, duration of the intervention, calculation of
effect sizes) rendering a fixed effects model inappropriate. A maximum
likelihood estimation procedure was used for analyses (Lipsey & Wilson,
2001). When available, post-test means and standard deviations were
used for the control and treatment groups in each study to calculate
effect sizes. When means and standard deviations were unavailable, the
sample sizes for means and standard deviations and the p-value an
estimation of effect size was created. Effect sizes were calculated with
standardized mean difference (Hedges’ g) and effect sizes were inter­
preted as a small effect = 0.2, a medium effect = 0.5, and a large effect =
0.8 (Cohen, 1988). One calculated effect size per study for each outcome
variable was calculated. If there were multiple outcome variables for
each category, we aggregated effects in CMA. To determine the overall
effect size, the variance for each study was calculated to weigh each
effect size by its inverse variance, where larger weights suggest better
precision, and then we calculated the mean of the weighted effects
(Lipsey & Wilson, 2001). Due to several studies including multiple
outcome categories for each sample, analyses were completed sepa­
rately for each outcome category. Therefore, independence was main­
tained (Borenstein et al., 2009). A grand mean effect was estimated by
aggregating effects within each study to calculate one overall effect for
each sample.
Effect size outliers were identified by calculating the mean and
standard deviation of all effects, determining which effects were more
than three standard deviations away from the mean, and resetting out­
liers to three standard deviations away from the mean, which resulted in
an adjusted effect of 3.96 (Cooper, 2017; Lipsey & Wilson, 2001). Three
outliers were adjusted.
2.3.1. Moderator analyses
To examine homogeneity and determine if moderator analyses were
appropriate, we calculated the Q statistic and considered the between-
study heterogeneity with the I2 and T2 values (Borenstein et al., 2017;
Raudenbush, 2009). Moderator analyses were completed by evaluating
Qbetween to determine if the moderator was significant for the outcome
effect size. To evaluate group differences when appropriate, we
computed effect sizes for each category with a mixed effect analysis
(Borenstein et al., 2009) and compared effect sizes and examined the
overlap of confidence intervals and interpreted that non-overlapping
confidence intervals differed significantly (Cumming & Finch, 2005)
for mixed effect analyses.
We examined moderators of suicide prevention programs to under­
stand conditions and settings of effective programs as moderators in
suicide prevention studies are critical but often unexplored (Musci et al.,
2018). Due to the wide variety of included studies, we examined several
program implementation moderators. Specifically, we evaluated mod­
erators for the type of preventions and how it was implemented which
included modality of prevention (Gatekeeper, Screening, Curriculum-
Based, and Multicomponent), prevention setting for the intervention
target (universal, selected, and indicated), prevention target (students,
parents, teachers/staff, peers) as determined based on the outcome, and
duration of prevention (less than 1 week, 1–4 weeks, 5 weeks or more).
We also explored how effects differed by the population by examining
participant age level (high school, college, multiple age levels). Other
moderators (i.e., duration, prevention agent, content of prevention)
were considered but there was minimal variability and thus the vari­
ables were excluded from analyses.
To examine how effects differed by methodological quality, we
examined moderators of established baseline equivalency (yes, no),
design (randomized-control trial, quasi-experimental study), small
sample size as indicated by less than 35 participants in one condition
(yes, no), length of follow-up time greater than 1 week (yes, no), fidelity
(yes, no), collected follow-up data (yes, no), indication of reliable
measure (yes, no), and indication of valid measure (yes, no) to
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Children and Youth Services Review 121 (2021) 105826
determine how effects differed by study quality as an indication of the
impact of methodological features on effect sizes. Due to the large
number of comparisons for moderator analyses, we determined that
statistical significance was p < .01 to correct for multiple tests.
2.4. Reliability
2.4.1. Training
A team of graduate students completed article searches to review
articles for inclusion. All coders were first trained by the second author.
The second author reviewed the process for coding and modeled the
process. A codebook was created that defined each variable and cate­
gories (available in electronic supplemental materials). The team coded
the first article collaboratively to practice coding and review questions.
Then, team members each independently coded the second article and
met to discuss similarities, resolve inconsistencies, and answer questions
to clarify coding. The coding team reviewed articles for inclusion and
coded the studies.
2.4.2. Selection process agreement
Interobserver agreement (IOA) was also conducted for eligibility and
inclusion decisions for 25% of screened articles and resulted in 86%
agreement.
2.4.3. Intercoder agreement
The coding team completed coding independently and the first
author conducted IOA and reviewed the coding as well as flagged any
coding disagreements between authors. A total of 14 articles were coded
for interobserver agreement out of the possible 27 which resulted in 52%
of total articles. The number of potential codings was divided by the
total number of possible codings and multiplied by 100, which resulted
in 86% agreement. Disagreements were resolved by discussion among
coders and the first author until a consensus was reached. After
reviewing coding procedures and reaching consensus as a team, coders
then reviewed previously coded articles to check for accuracy in coding.
2.5. Publication bias
Funnel plots were examined to address the possibility of publication
bias for each outcome (Sutton et al., 2000). Funnel plots present the
effect size and standard error for each study. If there is no publication
bias, the plot will display a symmetrical distribution on both sides. The
“trim and fill” method was used as a means of creating funnel plot
symmetry due to the removal of smaller studies that may skew the
overall result (Card, 2012; Duvall, 2005; Duval & Tweedie, 2000).
Following the removal of the smaller studies, a true center was esti­
mated. Finally, the removed studies were replaced around the center as
a way to “fill” the funnel plot. The adjusted effect was performed by
including the filled studies to the left of the mean (Borenstein, 2005).
3. Results
Table 1 presents descriptive information and prevention program
features for each study. A total of 27 studies and aggregated effects from
25 articles (2 articles included multiple studies) were included that
resulted in 27,249 total participants for the grand mean outcome;
12,258 participants for the awareness outcome (28 effects); 18,081
participants for the suicide behavior outcome (8 effects); 4,556 partic­
ipants for the helping skill outcome (15 effects); 3,401 participants for
the psychological wellness outcome (7 effects); and 4,740 participants
for the psychological distress outcome (9 effects). Many studies evalu­
ated suicide awareness (46 outcomes from 18 studies aggregated into 18
effects), while few evaluated suicide behavior/intention (24 outcomes
from 8 studies aggregated into 8 effects). A large number of studies
evaluated helping skills (61 outcomes from 15 studies aggregated into
15 effects), with fewer evaluating psychological wellness (28 outcomes
K.L. Brann et al. Children and Youth Services Review 121 (2021) 105826

Table 1 Table 1 (continued )

Features of Studies and Interventions. Study Participants Name of Program School
Study Participants Name of Program School Intervention Length level
Intervention Length level (Type of
(Type of Prevention)
Prevention)
School Students Public Schools
Abbey et al. Total n (% male): Short-Term 2 weeks College Grade: 11th (Curriculum-
(1989) 73 (NR) Suicide Grade based)
Target: Awareness Orbach and Total n (% male): Introspective 7 weeks High
Undergraduate Curriculum Barjoseph 393 (45) Suicide School
Students (Curriculum- (1993) Target: High Prevention
Ages: 18–22 based) School Students Program
years Grade: 11th (Curriculum-
Angerstein et al., Total n (% male): Project SOAR NR K-12 Grade based)
1991 172 (NR) (Multi- Grade Petrova et al. Total n (% male): Peer leader < 1 day High
Target: K-12 component) (2015) 462 (51) modeling after School
School Intervention 1 Target: High Sources of
Counselors School Students Strength
Ages: NR Grades: 9th-12th presentation
Aseltine & Total n (% male): Signs of Suicide 2 days High Grade (Multi-
Demartino, 2100 (NR) (Multi- School component)
2004 Target: High component) Petrova et al. Total n (% male): Sources of < 1 day High
school Students (2015) 454 (53) Strength School
Grades: 9th-12th Intervention 2 Target: High (Multi-
Aseltine et al., Total n (% male): Signs of Suicide 2 days High School Students component)
2007 4133 (51) (Multi- School Grades: 9th-12th
Target: High component) Grade
school Students Portzky and van Total n (% male): Psycho- < 1 day High
Grades: 9th-12th Heeringen 166 (37) educational School
grade (2006) Target: High prevention
Ciffone (2007) Total n (% male): South Elgin 3 days High School Students program
“A” 271 (48) Suicide School Grades: 10th- (Multi-
Target: High Prevention 11th grade Ages: component)
School Students Program 14–16, M = 15.6
Grade: 10th (Multi- Schilling et al. Total n (% male): Signs of Suicide 1 day High
grade component) (2016) 1575 (58) (Multi- School
Ciffone (2007) Total n (% male): South Elgin 3 days High Target: Technical component)
“B” 150 (45) Suicide School High School
Target: High Prevention Students
School Students Program Grade: 9th grade
Grade: 10th (Multi- Shannonhouse, Total n (% male): Applied 2 days K-12
grade component) Lin, Shaw, & 149 (28) Suicide Grade
Coleman et al., Total n (% male): Kognito Online NR, “brief College Porter, 2017 Target: K-12 Intervention
2019 117 (26) Gatekeeper training” School Personnel Skills Training
Target: Training Ages: Mtreatment = (Gatekeeper)
Undergraduate (Gatekeeper) 43.7, SD = 10.4;
Students Mcontrol = 46.1,
Ages: M = 20.5, SD = 12.3
SD = 7.3 Shannonhouse, Total n (% male): Applied 2 days College
Hazell & Lewin, Total n (% male): Postvention 90 min High Lin, Shaw, 77 (30) Suicide
1993 806 (NR) Counseling School Wanna, & Target: College Intervention
Target: High (Multi- Porter, 2017 Staff Skills Training
School Students component) Ages: Mtreatment = (Gatekeeper)
Age: M = 14.75, 42.2, SD = 13.0;
SD = NR Mcontrol = 42.7,
Jodoin (2014) Total n (% male): Kognito Online < 1 day College SD = 17.0
123 (24.6) Gatekeeper Silk et al., 2017 Total n (% male): Suicide 4 weeks College
Target: College Training 391 (39) Prevention
Student Support (Gatekeeper) Target: Campus
Professionals Undergraduate Campaign
Ages: 25–50+ Students (Other)
Kalafat & Elias, Total n (% male): Lifelines 3 days, 3 High Ages: 18–28, M
1994 253 (57) (Curriculum- 40–45 min School = 19.01, SD =
Target: High based) lessons 1.07
School Students Spirito et al. Total n (% male): Barrett’s 6 weeks High
Grade: 10th (1988) 473 (NR) program School
Grade Target: High (Curriculum
LaFromboise Total n (% male): The Zuni 30 weeks; High School Students based)
and Howard- 128 (36) Lifeskills approx. 3 School Grades: 9th
Pitney (1995) Target: High Development times per grade
School Students Program week Strunk et al., Total n (% male): Surviving the four 50 min High
Grade: 9th Grade (Curriculum- 2014 1547 (44) Teens sessions School
and11th Grade based) Target: High (Curriculum-
Murray (1991) Total n (% male): Suicide 3 days High School Students based)
66 (0) Prevention School Grades: 9th-12th
Target: High Program Ages: 13–18
California years
1h College
(continued on next page)

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K.L. Brann et al. Children and Youth Services Review 121 (2021) 105826

Table 1 (continued ) Notes: H = High school, K = Kindergarten through 12th grade; CO = College;
MH = Middle school and High school; NR = Not reported.
Study Participants Name of Program School
Intervention Length level
(Type of from 7 studies aggregated into 7 effects), and evaluating psychological
Prevention) distress (28 outcomes from 10 studies aggregated into 9 effects). A
Tompkins and Total n (% male): Question, majority of the studies implemented multi-component preventions
Witt (2009) 240 (41) Persuade, Refer (44%), while some implemented a gatekeeper program alone (33%). A
Target: College (Gatekeeper)
majority of the studies (n = 17) evaluated programs targeted at high-
Residence
Advisors school students (63%), while the remaining evaluated grades K-12 (n
Ages: M = 20 = 2; 7%), middle and high school (n = 3; 11%), and college aged (n = 5;
years, SD = 1.02 19%). Studies typically researched outcomes among students (n = 16;
Tompkins et al. Total n (% male): Question, 1h High 59%) and peers (n = 5; 19%), while the remaining researched outcomes
(2010) 102 (22) Persuade, Refer School
Target: (Gatekeeper)
among school staff (n = 6; 22%). The majority of prevention programs
Secondary were delivered within the whole class (n = 25; 93%) as universal pre­
School Personnel vention, while a few programs were delivered to smaller groups (n = 2;
Ages: Mtreatment = 7%).
42.10, SD =
11.34; Mcontrol =
47.09, SD = 3.1. Effects on outcomes
10.94
Wasserman et al. Total n (% male): Question, 1h High Fig. 2 visually displays effects sizes and confidence intervals for each
(2015) 4568 (37) Persuade, Refer School study by outcome. The grand study-level mean for the 27 studies was g
Intervention 1 Target: Target: (Gatekeeper)
European High
= 0.50, 95% CI [0.36-0.64], p < .01). In terms of the Q statistic, results
School Students were significant (Q = 216.55, df = 26, p < .01, I2 = 87.99%, T2 = 0.10),
Ages: 14–16 which indicates heterogeneous effect size distribution for the grand
years old mean (Lipsey & Wilson, 2001).
(Mintervention =
Effect sizes for specific outcomes are presented in forest plots in
14.80, SD =
0.82; Mcontrol = Fig. 2 that presents standardized mean differences with 95% confidence
14.78, SD = intervals (CI) and pooled results calculated with random effects weights.
0.89) Prediction intervals are represented for each overall outcome effect with
Wasserman et al. Total n (% male): Youth Aware of 3 weeks High a dashed line. Effects ranged from g = 0.16 for psychological distress and
(2015) 4537 (40) Mental Health School
Intervention 2 Target: High Programme
wellness to g = 0.72 for suicide awareness. Results were significant for
School Students (Gatekeeper) all outcomes. Suicide prevention programs were associated with large
Ages: 14–16 improvements for suicide awareness (g = 0.72, 95% CI [0.52-0.91], p <
years old .01), small to moderate effects for helping skill (g = 0.43, 95% CI
(Mintervention =
[0.33–0.54], p < .01), and small effects for suicide behavior (g = 0.17,
14.80, SD =
0.85; Mcontrol = 95% CI [0.07-0.26], p < .01), psychological wellness (g = 0.16, 95% CI
14.78, SD = [0.06-0.26], p = .002), and psychological distress (g = 0.16, 95% CI
0.89) [0.10-0.23], p < .01).
Wasserman et al. Total n (% male): Screening by 1h High
(2015) 4730 (42) professionals screening, School
Intervention 3 Target: High (Screening) occurred
3.2. Moderator analyses
School Students over 4
Ages: 14–16 weeks Moderator analyses were conducted to evaluate features of the pre­
years old vention programs, study design, and sample that were associated with
(Mintervention =
effect sizes. Homogeneity analyses indicated significant variability for
14.81, SD =
0.80; Mcontrol = the suicide awareness (Q = 285.83, df = 17, p < .01, I2 = 94.05%, T2 =
14.78, SD = 0.14) and helping skill (Q = 35.14, df = 14, p = .001, I2 = 60.16%, T2 =
0.89) 0.021), which signified appropriateness to proceed with moderator an­
Wyman et al. Total n (% male): Question, 1 day High alyses for the two outcomes (Lipsey & Wilson, 2001). The Q statistic was
(2008) 252 (18) Persuade, Refer School
Target: School (Gatekeeper)
also significant for the grand mean, which suggests heterogeneity in the
Staff effects for the overall analysis; however, we proceeded with moderator
Ages: 22–75 analyses at the specific outcome level due to the variety in types of
years, M = 44.5 outcomes. Table 2 displays effect size moderators and 95% confidence
years
intervals for outcomes with significant variability.
Wyman et al., Total n (% male): Sources of 1 day High
2010 453 (24) Strength School Type of prevention was the only significant moderator for suicide
Target: High (Multi- awareness (Qbetween = 24.48, df = 3 p < .01). However, one study (Silk
School Students component) et al., 2017) is an outlier in terms of type of prevention and effect size.
Grade: 9th-12 When that study and the Other category is removed, type of prevention
grade
Mintervention =
is no longer significant (Qbetween = 1.84, df = 2 p = .40). Effects for
15.7, SD = 1.17; Gatekeeper, Curriculum-Based, and Multicomponent prevention pro­
Mcontrol = 16.1, grams were all moderate to large with overlapping confidence intervals,
SD = 1.12 suggesting that type of prevention is not significantly accounting for
Wyman et al., Total n (% male): Sources of 1 day High
variance in effects. No other moderators related to program imple­
2010 “School” 16,961 (NR) Strength School
Target: High (Multi- mentation or methodological quality were found to be statistically sig­
school Students component) nificant (p < .01) for suicide awareness. Therefore, the significant levels
Grade: 9th-12th of heterogeneity for suicide awareness are unaccounted for in the cur­
grade rent meta-analysis.

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K.L. Brann et al. Children and Youth Services Review 121 (2021) 105826

Fig. 2. Forest Plot for Outcomes. Note. The dashed line represents the prediction interval. Shannonhouse a = Shannonhouse, Lin, Shaw, & Porter, 2017; Shan­
nonhouse b = Shannonhouse, Lin, Shaw, Wanna, & Porter, 2017.

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K.L. Brann et al. Children and Youth Services Review 121 (2021) 105826

Table 2
Moderator Results by Outcome.
Moderator Suicide Awareness Helping

k g (95% CI) Qbetween k g (95% CI) Qbetween

Type of prevention 24.48* 6.70

Gatekeeper 6 0.66 (− 0.04–1.36) 7 0.54* (0.33–0.75)
Screening tool 0 – 0 –
Curriculum-based 4 0.62* (0.18–1.06) 4 0.49* (0.23–.0.74)
Multi-component 7 0.96* (0.66–1.26) 3 0.40* (0.21–0.59)
Other 1 0.0 (− 0.25–0.25) 1 0.15 (− 0.08–0.38)
School level 0.28 1.67
High school 9 0.63* (0.42–0.84) 6 0.38* (0.28–0.50)
College 5 0.94 (− 0.23–2.11) 6 0.58* (0.24–0.92)
Multiple 4 0.66* (0.48–0.84) 3 0.50* (0.28–0.72)
Intervention target 0.02 2.18
Students 11 0.71* (0.49–0.93) 7 0.43* (0.27–0.59)
School staff 7 0.67 (0.06–1.27) 6 0.54* (0.31–0.78)
Peers 0 – 2 0.32* (0.13–0.51)
Prevention setting 1.27 1.82
Group 3 0.98* (0.45–1.51) 5 0.51* (0.37–0.65)
Individual 0 – 0 –
Whole class/staff 15 0.67* (0.45–0.86) 10 0.38* (0.24–0.51)
Small sample size 4.71 13.72*
Yes 5 1.36* (0.61–2.11) 7 0.69* (0.51–0.87)
No 13 0.50* (0.31–0.70) 8 0.32* (0.25–0.39)
Fidelity 2.66 1.38
Yes 2 0.30 (− 0.23–0.84) 3 0.51* (0.42–0.61)
No 16 0.78* (0.57–1.0) 12 41* (0.28–0.55)
Valid measures 0.85 0.32
Yes 10 65* (0.37–0.93) 4 0.52* (0.18–0.87)
No 8 0.86* (0.52–0.1.19) 11 0.42* (0.31–0.53)
Reliable measures 4.98 0.04
Yes 10 1.17* (0.56–1.77) 6 0.42* (0.17–0.67)
No 8 0.46* (0.38–0.59) 9 0.45* (0.34–0.57)
Follow-up 1.97 0.01
Yes 3 0.03 (− 1.06–1.12) 6 0.45* (0.33–0.57)
No 15 0.83* (0.62–1.03) 9 0.45* (0.29–0.62)

Note. g = Hedges’ g; k = number of studies; Qbetween = between-group goodness-of fit. *p < 0.01.

For the helping skill moderator analysis, there were no significant
moderators related to program implementation. When we examined
moderators related to methodological quality, we found that small
sample size was a significant moderator for helping skill, (Qbetween =
13.72, df = 1 p < .01) with a moderate effect found with studies that
included a sample size (less than 35 for a condition), g = 0.69 (CI
0.51–0.87), and a small-to-moderate effect found for studies with
adequate sample sizes for each condition, g = 0.32 (CI 0.25–0.39).
Moderator findings may be limited due to the small number of studies
for some moderator categories, which resulted in large effect size con­
fidence intervals.
3.3. Publication bias
Publication bias was initially assessed by reviewing the funnel plots
of each outcome via standard error as well as standard difference in
means. The funnel plot for the grand mean was asymmetrical but no
studies were trimmed to the left of the mean. Results for suicide
awareness were also asymmetrical to the right with no studies trimmed
to the left. Publication bias test results for suicide behavior and psy­
chological wellness were found to be symmetrical on the funnel plot and
no studies were trimmed. Helping skill publication bias test yielded
asymmetry on the funnel plot with five studies trimmed to the left of the
mean but the difference in effects was small with a score change of g =
− 0.07 (adjusted g 95% CI [0.24–0.47]). The funnel plot for psycholog­
ical distress was asymmetrical with no studies trimmed to the left of the
mean.
4. Discussion
Given the widespread call for suicide prevention programming
(Robinson et al., 2018; Wasserman et al., 2015; Wyman et al., 2010) and
cost of programs (Vasiliadis et al., 2015), it is important to evaluate
outcomes from suicide prevention programs. The current results suggest
that suicide prevention programs have variable impacts on outcomes of
interest. We found large effects for suicide awareness, small to moderate
effects for helping skill, and small effects for suicide behavior, psycho­
logical wellness, and psychological distress. Results indicate that suicide
prevention programs have the largest impact on skills and outcomes
taught directly by the intervention (i.e., improving suicide knowledge
and awareness, teaching helping skills) rather than distal and more
valued outcomes of suicide behavior and psychological distress and
wellness. Study effect sizes can also be interpreted within the context of
Tanner-Smith et al. (2018) review of school-based prevention meta-
analyses that found that effect size distributions for universal preven­
tion programs for youth are expected to be lower compared to Cohen’s
(1988) guidelines. The current study’s effect sizes are consistent with
expected distributions for school-based internalizing prevention pro­
grams, which were found to have a distribution of 0.09–0.44 on mea­
sures of internalizing behavior (Tanner-Smith et al., 2018).
4.1. Suicide awareness
Suicide awareness was the most frequently evaluated outcome and
included suicide knowledge, attitude, stigma, and awareness. For
instance, Applied Suicide Intervention Skills Training was found to have
a large effect on attitudes about suicide and suicide knowledge for col­
lege staff gatekeepers (Shannonhouse, Lin, Shaw, Wanna, & Porter,
2017) and a moderate effect for K-12 staff gatekeepers (Shannonhouse,
Lin, Shaw, & Porter, 2017). Ciffone (2007) found the largest effect for
suicide awareness with the implementation of South Elgin High School
Suicide Prevention on suicide awareness, attitudes, and stigma in two

9
K.L. Brann et al.
different school buildings but did not present psychometric evidence to
support the use of their outcome measure.
The overall large effect for suicide awareness suggests that suicide
prevention programs have the largest impact on concepts directly taught
in prevention program trainings to increase suicide awareness, attitudes,
and knowledge. The large effect for suicide awareness outcomes is
promising given that school-based suicide awareness programs were
found to reduce suicide attempts and suicidal ideation in previous
research (Zalsman et al., 2016). In considering the large effect size for
suicide awareness, one should also consider the high level of heteroge­
neity and large confidence interval, which suggests a large amount of
variability in outcomes. Only one moderator, Type of Prevention Pro­
gram, was significant in the moderator analysis and the significant effect
was due to an outlier prevention program focused on a social norms
campaign (Silk et al., 2017). Thus, we were unable to account for the
variability in suicide awareness effects.
4.2. Suicide behavior
Few studies examined the impact of suicide prevention programs on
suicidal behavior (i.e., suicide attempts and ideation), which is con­
cerning given that the goal of suicide prevention programs is to prevent
suicide. However, there are known challenges with examining changes
in suicide behavior such as the low incidence of suicide attempts, time
needed to observe changes in suicidal behavior, internalized nature of
suicidality, and reliance on self-report measures (Katz et al., 2013;
Wasserman et al., 2015). Findings are consistent with previous research
indicating greater effects for knowledge compared to behavioral change
in school-based prevention research (Tanner-Smith et al., 2018). The
small effect on suicide behavior may also be due to analyzing immediate
post-test data rather than long-term follow-up results, which would
allow time to meaningfully examine impacts on suicide behavior.
However, not all studies included follow-up data. Signs of Suicide is the
most promising program focused on reducing suicidal behavior as the
outcome was examined in three studies (Aseltine et al., 2007; Aseltine &
Demartino, 2004; Schilling et al., 2016), with a small effect found in all
studies. Notably, Wasserman also examined suicide behavior for QPR;
Youth Aware of Mental Health Programme; and Screening by Pro­
fessionals, but program effects may be masked due to using the same
control group and needing to aggregate study effects.
4.3. Helping skills
Several studies examined the impact of suicide prevention programs
on helping skills, which refers to the behavior, intention, or confidence
related to receiving help or helping others (e.g., willingness to seek help,
likelihood of intervening, confidence in helping others). Results suggest
that after suicide awareness, suicide prevention programs have the
greatest impact on helping skills, with prevention programs yielding an
overall small-to-moderate effect. For instance, school personnel who
complete Question, Persuade, Refer (QPR) programming have demon­
strated significant gains in both their likelihood to intervene and their
self-efficacy to execute gatekeeper skills (Tompkins et al., 2010; Wyman
et al., 2008). Additionally, Applied Suicide Intervention Skills Training
(ASIST) has been shown to improve gatekeepers’ confidence and helping
skills for intervening with students at risk for suicide at both the
kindergarten through 12 grade (Shannonhouse, Lin, Shaw, & Porter,
2017) and college settings (Shannonhouse, Lin, Shaw, Wanna, & Porter,
2017).
Although these results suggest the utility of prevention programming
with streamlined student referral to trained gatekeepers, one should
consider the high level of heterogeneity when assessing the effectiveness
of suicide prevention programming. Indeed, Tompkins et al. (2010)
acknowledge increased self-efficacy and intent to help does not neces­
sarily generate increased or effective helping behaviors. For instance,
while QPR training has demonstrated effectiveness in increasing both
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Children and Youth Services Review 121 (2021) 105826
self-efficacy and helping behaviors among secondary school staff
(Wyman et al., 2008), improved self-efficacy and intent to intervene
with QPR training did not translate to measurable changes in helping
behavior among college resident assistants (Tompkins & Witt, 2009).
Only one moderator, sample size, emerged as significant in the analysis,
with a moderate effect found in studies with a small sample size and a
small effect found in studies with adequate sample sizes across study
conditions. No significant moderators emerged related to program
implementation.
4.4. Psychological wellness and psychological distress
Through improving psychological wellness and reducing psycho­
logical distress, suicide prevention programs can theoretically improve
outcomes to reduce suicidal behavior (Meerwijk et al., 2016; Wyman,
2014). However, we found that psychological wellness and distress were
evaluated less frequently in the included studies with only 26% of
studies evaluating impacts on psychological wellness and 30% of studies
evaluating psychological distress. The null to small effects for many
programs is also concerning. For instance, the curriculum-based pro­
gram, Surviving the Teens (Strunk et al., 2014) did not have a mean­
ingful impact on psychological wellness (i.e., self-esteem, confidence in
handling problems) or psychological distress (i.e., frequency in inef­
fectively handling problems). Alternatively, Wyman et al. (2010) found
a small effect for Sources of Strength on psychological wellness (i.e.,
sources of strength coping, school engagement, connection to trusted
adults, support to peers) and psychological distress (i.e., maladaptive
coping) for peer leaders but a null effect when evaluating the whole
school population psychological wellness for sources of strength coping.
Overall psychological wellness and distress findings suggest a need for a
greater emphasis on evaluating psychological wellness and distress
outcomes from suicide prevention programs, especially since results
may be more direct and immediate compared to impacts on suicide
behavior.
4.5. Features of included studies
Examining features of the included studies indicated that similar to
previous findings (Mo et al., 2018; Robinson et al., 2018; Singer et al.,
2019), most studies evaluated suicide awareness but few examined
suicide behavior. There was also a lack of research examining the impact
of suicide prevention programming on psychological wellness and
distress. The majority of studies implemented universal suicide pre­
vention strategies, suggesting a paucity of research on Tier 2 suicide
interventions in the literature. Further, no studies examined the effec­
tiveness of suicide screening alone using a treatment and control group.
Given that universal screeners are an effective method for identification
and treatment for students with suicidal thoughts/behaviors (Singer
et al., 2019), the lack of studies on universal suicide screening is sur­
prising. Notably, the suicide prevention programs implementing
screening also included curriculum programming and were thus coded
as multicomponent (Aseltine & Demartino, 2004; Aseltine et al., 2007;
Schilling et al., 2016; Wasserman et al., 2015). Further research is
needed to examine the impact of universal suicidal thoughts/behavior
screeners as well as Tier 2 interventions in order to gauge effectiveness
and assist in developing a plan for how to screen, as well as what to do in
the event of student identification.
Finally, most included studies focused primarily on high school and
college students. Only two studies (Angerstein et al., 1991; Shannon­
house, Lin, Shaw, & Porter, 2017) evaluated suicide prevention pro­
grams with younger students, and the two studies also included high
school students. Some research suggests that using upstream suicide
prevention, teaching students signs and symptoms of suicide prior to
these occurring, helps make students more sensitive and prepared to the
matter when it becomes a more likely occurrence (Cwik et al., 2019;
Wyman, 2014).
K.L. Brann et al.
4.6. Moderator analyses
Moderator analyses suggested significant variability for suicide
awareness and helping skill outcomes. We also found a significant level
of heterogeneity with the grand mean, suggesting variability for the
aggregated studies. At the specific outcome level, analyses showed a
significant moderator effect for suicide awareness for type of prevention
program. However, the result was impacted by an outlier (Silk et al.,
2017) that implemented a social norm intervention rather than the
standard types of suicide prevention programs (i.e., gatekeeper,
curriculum-based program, or screening). Once the outlier was
removed, type of prevention was no longer a significant moderator for
suicide awareness. However, we did find moderate to large effects for
gatekeeper, curriculum-based, and multicomponent programs, which
suggests that all can be beneficial for improving suicide awareness.
Similarly, Durlak et al. (2011) also did not find evidence to support their
hypothesis that effects would be higher for multi-component programs
compared to single-component programs. Regarding our hypothesis that
effect sizes would differ by prevention setting, we did not find a sig­
nificant difference for prevention setting. Although effect sizes were
lower for universal “whole class/staff” prevention programs, the confi­
dence interval overlapped with the confidence interval for selected
“small group” prevention programs.
We also examined if effects differed by methodological quality and
found that small sample size was a significant moderator for helping
skill, which suggests larger effects for studies that included small sample
size. There were no other significant moderators for methodological
quality, indicating that most results did not differ by methodological
quality. However, we also found an overall lack of methodological rigor
for included studies (see Table 3 in supplemental materials), which is
concerning but consistent with findings from previous reviews (Mo
et al., 2018; Robinson et al., 2013). For instance, there were few ran­
domized controlled designs, a lack of documentation for fidelity of
implementation, and minimal reporting of psychometric evidence for
measures.
4.7. Implications for practice
Taken in concert with previous research, these results suggest that
schools should use a portion of their resources to fund suicide prevention
programs that are evidence based (Robinson et al., 2018). Schools
should consider implementing gatekeeper, curriculum-based programs,
or multicomponent programs and balance both the fit and the evidence
for programs before selecting a program. In addition to considering the
evidence-base for programs, schools should also consider the costs, ca­
pacity to implement, goodness of fit for school needs, and usability
(Metz & Louison, 2018).
Schools should consider which suicide prevention program aligns
best with their outcomes of interest. As different suicide prevention
programs will have different foci and available research, schools looking
for increasing suicide knowledge and awareness need to determine
which evidence-based prevention programs have demonstrated knowl­
edge and awareness outcomes and choose from those options. Likewise,
if schools want to prevent or decrease suicidal thoughts or behaviors,
then schools need to look for evidence-based programs that have
demonstrated suicide thoughts and behavior outcomes such as Signs of
Suicide (SOS; Aseltine & Demartino, 2004; Schilling et al., 2016). Re­
sults of this study suggest that schools need to focus primarily on the
desired outcomes of the prevention program and choose an evidence-
based program that fits their needs and priorities.
Relatedly, schools should consider whether to implement programs
aimed at the prevention of prevalent cases, or those students who
currently exhibit suicidal ideation and/or suicide attempts, or directed
toward incident cases, or those students who may develop suicidal
ideation or suicide behavior in the future. Cooper et al. (2011)
acknowledge the overall objective of any type of suicide prevention
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Children and Youth Services Review 121 (2021) 105826
program, whether curriculum-based, gatekeeper, or multi-component, is
to decrease the incidence of student suicides to as close to zero as
possible. However, different prevention programs may vary in their
degree of focus on prevalent versus incident cases of student suicidal
ideation, plans, or attempts. For example, gatekeeper programming such
as QPR and ASIST centers on training gatekeepers such as school
personnel to effectively identify, intervene, and make referrals for stu­
dents at risk for suicide (Shannonhouse, Lin, Shaw, & Porter, 2017;
Shannonhouse, Lin, Shaw, Wanna, & Porter, 2017; Tompkins et al.,
2010). Thus, such programs are primarily directed at the prevention of
prevalent cases of suicidal ideation and suicide attempts among the
student population. Other programs emphasize the prevention of inci­
dent cases of suicide behavior. For instance, postvention programs (e.g.,
Hazell & Lewin, 1993) aim to prevent imitative suicide behavior among
students in the period of time following the incidence of a student sui­
cide. Still other programs, including universal curriculum-based or
multi-component programs, target both the prevention of incident and
prevalent cases of suicide behavior. For example, although Surviving the
Teens is a universal curriculum-based program, the emotion-regulation
strategies and self-efficacy beliefs taught to students within the curric­
ulum can be utilized by both students who currently experience
depression and suicidal ideation, as well as by students who may
develop depression or suicide behavior in the future (Strunk et al.,
2014).
Finally, results of this study also indicate that schools should
conceptualize suicide prevention programming as a method to raise
awareness via increasing knowledge and improving attitudes or increase
helping skills. Due to the finding that school-based prevention pro­
gramming has limited effects on suicide behavior, schools should
implement suicide intervention best practices for students with suicidal
thoughts/behavior to optimize student outcomes (Kalafat, 2003; Singer
et al., 2019) and be prepared with a comprehensive crisis prevention
plan and team (Substance Abuse and Mental Health Services Adminis­
tration, 2012). Thus, schools should take a comprehensive approach
when preparing suicide prevention efforts that ranges from prevention
to crisis response.
4.8. Limitations and directions for future research
While the current study advances the literature on school-based
suicide prevention, limitations must be addressed. First, there may be
relevant articles that were missed in the systematic search process. To
minimize this risk and allow the inclusion of grey material, we searched
reference lists, dissertations, and contacted authors of included studies
to identify potentially missed articles that may be in press, unpublished,
or missed during the article search (Siddaway et al., 2019). Results from
the publication bias analyses suggest funnel plots were either symmet­
rical or there were few studies trimmed to the left of the mean. However,
the presence of outliers may have impacted trim and fill results in the
random effects analysis (Shi & Lin, 2019).
There were also limitations with the research designs of the included
studies. Few studies used a randomized-controlled trial design, causing
the analysis to focus on quasi-randomized controlled studies that ran­
domized conditions by classroom or school, which in turn limits the
standard error or confidence interval in estimated program effect due to
student similarities within schools or school districts. The inclusion of
quasi-experimental studies may have also impacted the internal validity
of the meta-analytic findings. The authors decided to allow the inclusion
of quasi-experimental studies due to the difficulty of conducting ran­
domized controlled trials with school-based universal prevention studies
(National Research Council, 2002).
Further, of the 18 studies, 10 indicated an established baseline
equivalency for studies, while the remaining studies either did not
report baseline equivalence in the report or in the study. Also, we
combined data with two or more interventions and the same control
group, as recommended by Borenstein et al. (2009). However,
K.L. Brann et al.
combining the studies may mask effects from individual interventions.
For instance, Wasserman et al. (2015) compared three different in­
terventions to a control condition but effects were aggregated across
treatment conditions to maintain independence. Additionally, many of
the non-significant moderator analyses may be due to the low number of
studies, which can lead to a reduction in statistical power and large
confidence intervals (Card, 2012).
Future research should include studies addressing suicidal thoughts
and behaviors, as this outcome was limited in current research and is
often the goal of suicide prevention programs. Studies with suicidal
behavior as a specific outcome could determine effectiveness of suicide
prevention programs for at-risk students, which could, in turn, help
identify and decrease the number of students that may be or become
suicidal. Future research should also address psychological wellness and
psychological distress to determine if suicide prevention programs
improve protective factors and reduce risk factors for suicide. Further,
additional high-quality research is needed to examine outcomes of sui­
cide prevention programs. Research should report baseline equivalency
in outcomes as well as long-term follow-up results, as many studies
failed to report data. These could improve researcher understanding of
effective programs both immediately after intervention and long-term
outcomes. Additional randomized-controlled trials of school-based sui­
cide prevention programs are needed in order to establish experimental
control.
4.9. Conclusion
The present study conducted a meta-analysis on the effectiveness of
school-based suicide prevention programs. Findings suggest that suicide
prevention programs can improve knowledge and awareness of suicidal
signs and symptoms but also suggest a lack of high-quality studies that
attempt to address whether suicide prevention programs decrease sui­
cidal thoughts or behavior for at-risk students. The lack of high-quality
randomized-controlled trials makes it difficult to determine and
compare the overall effectiveness of these suicide prevention programs.
Given the importance of preventing youth suicide, more high-quality
studies are warranted to determine the benefit of investing resources
into implementing suicide prevention programs.
Funding
The current project was not financially funded.
Ethical Approval and Informed Consent
Ethical approval and informed consent are not applicable for the
meta-analysis.
CRediT authorship contribution statement
Kristy L. Brann: Conceptualization, Supervision, Writing - original
draft, Data curation, Software, Methodology, Project administration.
Derek Baker: Conceptualization, Writing - original draft, Data curation.
Mills K. Smith-Millman: Conceptualization, Writing - original draft,
Data curation. Sarah J. Watt: Supervision, Methodology. Courtney
DiOrio: Writing - original draft, Data curation.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
12
Children and Youth Services Review 121 (2021) 105826
org/10.1016/j.childyouth.2020.105826.
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