DEPRESSION AND ANXIETY 30:10301045 (2013)

Prevention and Treatment

A SYSTEMATIC REVIEW OF SCHOOL-BASED SUICIDE
PREVENTION PROGRAMS
Cara Katz, B.Sc.,1 Shay-Lee Bolton, M.Sc. (Ph.D. Candidate),2 Laurence Y. Katz, M.D., F.R.C.P.C.,1
Corinne Isaak, M.Sc.,1 Toni Tilston-Jones, B.A., M.S.W.,3 Jitender Sareen, M.D., F.R.C.P.C.,4 and Swampy
Cree Suicide Prevention Team5

Objective: Suicide is one of the leading causes of death among youth today.
Schools are a cost-effective way to reach youth, yet there is no conclusive evidence
regarding the most effective prevention strategy. We conducted a systematic re-
view of the empirical literature on school-based suicide prevention programs.
Method: Studies were identified through MEDLINE and Scopus searches, using
keywords such as suicide, education, prevention and program evaluation. Ad-
ditional studies were identified with a manual search of relevant reference lists.
Individual studies were rated for level of evidence, and the programs were given
a grade of recommendation. Five reviewers rated all studies independently and
disagreements were resolved through discussion. Results: Sixteen programs were
identified. Few programs have been evaluated for their effectiveness in reducing
suicide attempts. Most studies evaluated the programs abilities to improve stu-
dents and school staffs knowledge and attitudes toward suicide. Signs of Suicide
and the Good Behavior Game were the only programs found to reduce suicide
attempts. Several other programs were found to reduce suicidal ideation, im-
prove general life skills, and change gatekeeper behaviors. Conclusions: There
are few evidence-based, school-based suicide prevention programs, a combination
of which may be effective. It would be useful to evaluate the effectiveness of gen-
eral mental health promotion programs on the outcome of suicide. The grades
assigned in this review are reflective of the available literature, demonstrating
a lack of randomized controlled trials. Further evaluation of programs exam-
ining suicidal behavior outcomes in randomized controlled trials is warranted.
Depression and Anxiety 30:10301045, 2013. 
C 2013 Wiley Periodicals, Inc.

Key words: child/adolescent; suicide/self-harm; dissemination/implementation;

empirical supported treatments; depression

INTRODUCTION suicide is still a serious public health concern. Challenges

S uicide is one of the leading causes of death among
youth today.[1] Although the rates of suicide among ado-
lescents have been stagnant over the past 10 years, youth
currently exist in the understanding of the contribut-
ing factors to suicide and little evidence exists on ef-
fective psychosocial and pharmacological treatment.[2]

Contract grant sponsor: Canadian Institutes of Health Research

1 Department of Psychiatry, University of Manitoba, Winnipeg, (CIHR); Contract grant numbers: 184490 and 152348.
Manitoba, Canada
Correspondence to: Jitender Sareen, PZ430771 Bannatyne Ave
2 Departments of Community Health Sciences and Psychiatry,

University of Manitoba, Winnipeg, Manitoba, Canada Winnipeg, MB, Canada R3E 3N4.
3 Department of Social Work, University of Manitoba, Winnipeg, Email: sareen@cc.umanitoba.ca
Received for publication 02 July 2012; Revised 17 January 2013;
Manitoba, Canada
4 Departments of Psychiatry, Psychology, and Community Accepted 09 March 2013
Health Sciences, University of Manitoba, Winnipeg, Manitoba, DOI 10.1002/da.22114
Canada Published online 3 May 2013 in Wiley Online Library
5 University of Manitoba, Winnipeg, Manitoba, Canada (wileyonlinelibrary.com).


C 2013 Wiley Periodicals, Inc.
 Prevention and Treatment: School-Based Suicide Prevention Review
In the United States, it is estimated that up to 16%
of high school students seriously consider suicide over
a 12-month period.[3] Further, 13% of students had a
plan for their suicide attempt over a year. Many pro-
grams exist on the Best Practices Registry, and while
schools are selecting programs to implement from what
is thought to be best practice, few programs are
evidence-based.[4] There is controversy surrounding the
best practice guidelines for suicide prevention. With
the current shortage of clinicians with the expertise to
manage suicide in adolescents, effective prevention tech-
niques are an integral part of the solution.
A comprehensive plan to combat youth suicide in-
cludes health promotion, prevention, intervention, and
postvention.[5] The goals of suicide prevention programs
are to reduce the prevalence of suicidal thoughts, at-
tempts, and deaths.[6] Prevention programs have been
implemented in schools, communities, and health care
systems, and are designed to either reduce risk factors, or
to identify those at risk and provide treatment.[5] Vari-
ous prevention programs include suicide awareness cur-
ricula, screening, general skills training, gatekeeper, and
peer leadership training. Three classes of programs exist,
all serving different roles. Universal programs typically
focus on curricula that are implemented schoolwide,
whereas selected and indicated programs target those
who are considered or are established as "at-risk."[7]
Since youth spend most of their time in school, school-
based programs may be the most effective way to reach
youth.[7]
Many school-based suicide prevention programs exist;
however, there are no denitive, evidence-based, best-
practice guidelines. Due to the large number of programs
available, policy makers are in need of an evidence-based
review to inform practice. This report reviews the sup-
porting evidence of existing programs and gives a rec-
ommendation of the best-practice programs.
METHOD
A literature search was conducted using MEDLINE (19662012)
and Scopus (19602012). Search terms included suicide, educa-
tion, prevention and program evaluation. The MEDLINE search
produced 1,208 relevant articles for the initial suicide and educa-
tion search. With the inclusion of prevention, the search was re-
stricted to 565 articles. Of these, 48 articles pertained specically
to program evaluation. The search was restricted to English arti-
cles within the 018 age category. The identical Scopus search pro-
duced 112 relevant articles, which was nally restricted to 25 rel-
evant articles. Subtracting duplications, the combined search pro-
duced 60 abstracts. Reference lists of relevant articles were reviewed
and key articles were searched. Specic programs were identied and
hand-searched. Inclusion criteria were an evaluation of a suicide pre-
vention program in a school context measuring outcomes such as
attitudes toward and knowledge about suicide (e.g., understanding of
suicide and depression), general skills training (e.g., increasing protec-
tive factors, such as coping and decision-making skills, and decreas-
ing risk factors such as depression, hopelessness, and poor academic
achievement), gatekeeper behavior change, help-seeking, and suicide
behavior change. In particular, the general skills training category,
while broad, encompasses programs that teach students life skills, such
1031
as mood management, problem solving, and coping skills, which they
can turn to in difcult situations rather than turning to suicide. Out-
come categories were chosen based on broad groupings of outcomes
consistently measured in the literature. The specic skills training pro-
grams that are reviewed in this paper were selected due to existing
evidence for their effect on suicide-related outcomes. Many other pro-
grams may exist that also aim to reduce risk factors; however, they have
not been evaluated specically for suicide-related outcomes. The gen-
eral skills training category is further described below in the discussion
of skills training programs. Studies that focused on mental health more
broadly, such as programs designed to reduce suicide risk factors (e.g.,
a substance abuse prevention program), but not specically evaluated
for any suicide-related outcomes, and studies that were individual-
based rather than a schoolwide program or did not take place in a
school setting, were beyond the scope of this review and were excluded.
Indicated programs are not discussed in this review. Two reviewers
(C. Katz, Bolton) collaborated in selecting appropriate studies. Six-
teen programs were identied. Outcome measures included improve-
ment in attitudes, knowledge and help-seeking, suicidal behavior, and
general skills enhancement. Five reviewers (C. Katz, Bolton, L. Katz,
Isaak, Sareen) independently evaluated the studies and rated the evi-
dence following the Oxford Centre for Evidence-Based Medicine.[8]
Levels of evidence outlined in Table 1 are dened based on the quality
of the studies with the highest level being rated 1a and lowest rating
5. Grades of recommendation, listed in Table 2, reect the level of
supporting evidence for the program. If there was discrepancy in the
ratings, a consensus was achieved through debate; however, most inde-
pendent ratings were concordant, with an inter-rater agreement rate
of 0.80.
TABLE 1. Oxford Centre for Evidence-Based Medicine:
levels of evidence
Levels of evidence
1a Systematic review of RCTs
1b Individual RCT with narrow condence interval
1c All or none (case series)
2a Systematic review of cohort studies
2b Individual cohort studies (and low-quality RCT)
2c Outcomes research
3a Systematic review of case-control studies
3b Individual case-control study
4 Case series (and low-quality cohort and case-control studies)
5 Expert opinion without critical appraisal
RCT, randomized controlled trial.
TABLE 2. Grades of recommendation for programs
based on Oxford Centre for Evidence-Based Medicine
Grades of recommendation
A Consistent level 1 studies
B Consistent level 2 or 3 studies or extrapolations from
level 1 studies
C Level 4 studies or extrapolations from level 2 or 3 studies
D Level 5 evidence of troublingly or inconclusive studies of
any level
Adding a minus sign () denotes inconclusive answer due to: single
result with wide condence interval or systematic review with trouble-
some heterogeneity. Inconclusive results can only generate a grade of
D recommendations.
Depression and Anxiety
1032 Katz et al.

RESULTS designed to stigmatize suicide and destigmatize the use of

Table 3 summarizes recommendations for best-
practice programs. Programs that were evaluated on
multiple outcomes received a separate grade for each
outcome. High-grade programs will be described in de-
tail below. All programs, including those that remain
inconclusive are listed in Tables A1 and 3. Table A1 also
explicitly states whether each program is universal or
selected, as the two different classes should not be com-
pared against one another. The majority of programs
discussed are universal, school-based suicide prevention
programs.
Five broad types of suicide prevention programs
exist: awareness/education curricula, screening, gate-
keeper, peer leadership, and skills training. Each of
these broad categories will be discussed, as well as the
higher grade, evidence-based programs of each program
type.
AWARENESS/EDUCATION CURRICULA
The goal of these programs is to make students more
familiar with signs and symptoms of suicide so they can
recognize them in themselves and in others. These pro-
grams are designed to facilitate self-disclosure, especially
to other peers.[9] Suicide awareness and education is typ-
ically incorporated into the regular school curriculum.
Past programs of this nature have produced mixed results
in terms of changing attitudes, knowledge, and behavior,
demonstrating some improvement, but also some detri-
mental effects.[5] Currently, the design of these programs
reects a hybrid model that includes both screening
and gatekeeper components, increasing the likelihood
of identifying at-risk students. However, these programs
have potential limitations. Although the programs are
mental health services, knowledge and attitude changes
are not necessarily correlated with changes in behavior.
As well, students who are suicidal often lack a broad peer
network, limiting the scope of these programs.[5] Signs
of Suicide (SOS) is a promising evidence-based aware-
ness/education curricula program.
SOS. SOS is a universal program that promotes the
idea of suicide being directly related to mental illness,
rather than a normal reaction to stress or emotional dis-
tress. The program includes suicide awareness, educa-
tion, and screening strategies. Through video and guided
classroom discussions, students learn to acknowledge the
SOS displayed by others and to take them seriously, to
let their peers know that they care, and to tell an adult.
Secondary to the awareness education is the screening
component of the program using the Brief Screen for
Adolescent Depression (BSAD). Students identied as
at-risk are encouraged to seek further help.[10]
Due to the high quality of the conducted trials, on the
suicide attempt outcomes, SOS received a grade of B; but
failed to show statistically signicant results for decreas-
ing suicidal ideation, eliciting a grade of D on this out-
come. Two randomized controlled trials (RCTs) have
evaluated the effectiveness of this program in reducing
suicide attempts, increasing suicide knowledge and im-
proving attitudes toward suicide, depression, and help-
seeking behaviors.[11, 12] Two thousand, one-hundred
students from ve high schools in grades nine through
12 were randomized to receive the SOS program either
in the rst or second semester.[11] This study demon-
strated signicant short-term effects of the program. At
the 3-month follow-up, signicant reductions were seen
in the number of self-reported suicide attempts as well
as signicant increases in knowledge about suicide. No

TABLE 3. Grades of recommendation of school-based suicide prevention programs. Ratings are based on a modification
of the Oxford Centre for Evidence-Based Medicine Criteria (2009). For full names of programs, see Table A1

General skills training

Attitude/ (decreased risk/ Gatekeeper Help-seeking Suicide behavior
Program Knowledge increased protective factors) behavior behavior Ideation Attempts

ASAP C C D - - -
CAST/CARE B B - - D D
CD-ROM (team up to save lives) D - - - - -
Psychoeducational program C- - - - - -
QPR B - D - - -
RAPP C - - - - -
Reconnecting youth B B - - - -
SEHS C - - - - -
SOAR C - C - - -
SOS B - D D B
Sources of Strength B - B - - -
TeenScreen (Columbia Suicide Screen) B - - - - -
The Good Behavior Game - - - - B B
Yellow Ribbon Suicide Prevention Program - - - D - -
Youth Suicide Prevention Program (YSPP) C - - - - -
Zuni/American Indian Life Skills Development - C - - C -

Depression and Anxiety

 Prevention and Treatment: School-Based Suicide Prevention Review
differences between the treatment and control groups
were observed for suicidal ideation or help-seeking be-
haviors. In a replication study,[12] 4,133 students from
nine high schools were included. At the 1-year mark,
similar results to the previous study were found. It should
be noted that this study may be biased by the self-report
design of the study, possibly leading to an inated effect
of this study. This time, students also exhibited more
adaptive attitudes toward suicide and depression. This
program is graded B on the attitudes and knowledge out-
comes. On the outcome of help-seeking behaviors, the
program received a grade of D, because it was unable
to demonstrate a statistically signicant improvement.
This study speculates that although there was no impact
on help-seeking behaviors, the improvement in attitudes
and understanding about suicide and depression led to
a reduction in self-reported suicide attempts; however,
this hypothesis has not been evaluated.
SCREENING
Screening is a case-nding technique of suicide pre-
vention. The method involves screening either all stu-
dents or at-risk students only, noting those at increased
risk and recommending further treatment. Pivotal to
screening programs, is the availability of referral sites
before screening occurs. This may be a problem in and
of itself, as there is a lack of conclusive evidence on how
to best treat suicidal adolescents, in addition to a shortage
of clinicians with such expertise. Screening tools look for
risk factors such as depression, drug and alcohol abuse,
and past suicidal behavior to identify at-risk students who
are otherwise underidentied. However, the possibility
of false positives and false negatives exists. Some op-
ponents of the screening techniques are worried about
their potential iatrogenic effects.[5] In a large RCT,[13]
screening did not cause an increase in distress or suici-
dal ideation. Rather, suicidal youth who were not asked
about suicide, tended to be more distressed. TeenScreen
is the primary screening program, in addition to SOS, as
discussed above.
TeenScreen. The TeenScreen tool is a universal
self-report tool that assesses risk factors for suicide. Since
its development, the tool has evolved for use in schools,
primary care, and other settings. Although some of the
forms of this screening tool are broader, the Columbia
TeenScreen is focused on school-based screening. A
nonrandomized cohort study was conducted, demon-
strating its validity and reliability in identifying at-risk
students. All students who had obtained parental consent
were given this screening tool plus the Beck Depression
Inventory. Students who endorsed key risk factors were
interviewed further. The tool has sensitivity of 75100%
in a student population.[14, 15] A convenience sample was
used, and found that many students identied through
this method were not identied by any other method.[15]
However, the benet of the tool is time-dependent, and
can fail to identify students who are not actively at risk.
Its success is also dependent on subsequent referral. Re-
1033
cent data indicate that students who were screened were
more likely than those who were not to get mental health
service referrals, with a high proportion of those in-
dividuals accessing school-based services, and a lesser,
but signicant proportion, accessing community-based
services.[16] As a suicide prevention tool, this program
was given a grade of B on the knowledge and attitudes,
based on the ability of this tool to increase knowledge
of those who are at risk; however, this program was not
an RCT, therefore the results must be interpreted in the
context of nonrandomized data.
GATEKEEPER TRAINING
Gatekeeper training takes those considered to be nat-
ural helpers and teaches them skills to recognize signs
and symptoms of suicide. The underlying principle is
that suicidal youth are underidentied and by training
school staff to recognize the warning signs, identica-
tion can be enhanced.[5] In addition, adults are taught
how to respond effectively. The effectiveness of this type
of program is also dependent on the subsequent service
use of those identied at risk. Question, Persuade, Refer
(QPR) is the primary gatekeeper program in schools.
QPR. The QPR gatekeeper program is a universal
program that trains students and school staff to recognize
suicide risk factors in fellow classmates or students, re-
spectively. The program is based on four steps: (1) to rec-
ognize suicide warning signs, (2) training all school staff
in QPR, (3) training school counselors to properly assess
at-risk students, and (4) organizing access to professional
assessment and treatment.[17] The expected outcomes of
this program include increasing school personnel aware-
ness of suicide and their abilities to intervene by recog-
nizing the warning signs and responding appropriately.
In an RCT of 249 school staff, QPR demon-
strated benecial effects on suicide knowledge, skills,
and attitudes.[18] Positive effects were shown on gen-
eral knowledge, perceived preparedness, self-evaluated
knowledge, and efcacy outcomes. School staff partic-
ipated in one of two contrasting gatekeeper-training
models. Outcomes included increased self-reported
knowledge about suicide, appraisals of efcacy, and
access to services. Unfortunately, although gatekeepers
could learn how to identify those at risk, only the gate-
keepers who typically approached students to seek help
felt comfortable doing so. This program did not show an
effect on subsequent mental health service use, an impor-
tant follow-up to any gatekeeper program. In a second
study, Tompkins et al.[19] evaluated the effectiveness of
training 78 school staff in QPR with a 24-person control
group. As above, QPR resulted in increased knowledge
about and more positive attitudes toward suicide. As a
result, due to the high-quality RCT, QPR was given a
grade of B for the knowledge and attitudes outcome.
However, on gatekeeper behavioral outcomes, such as
asking students about suicide, increased number of re-
ferrals, and better connections with students, the study
Depression and Anxiety
1034 Katz et al.

found no positive effects and the program was given a crease protective factors. Programs teach general life
grade of D on this measure. skills, such as coping, problem solving, decision mak-
ing, and cognitive skills. Although these programs do
PEER LEADERSHIP TRAINING not directly target suicide, by targeting risk factors and
giving youth important skills, the goal of the program is
It has been shown that youth are more likely to talk to
to prevent the development of suicidal behavior.
peers than adults about suicidal thoughts.[9] Peer lead-
American Indian Life Skills Development
ership training puts students in a position to help sui-
(AILSD). The AILSD program is a culturally adapted
cidal peers by training them to respond appropriately
universal prevention program designed to reduce
and associate with a trusted adult, in addition to help-
suicide risk factors and improve protective factors.
ing establish positive coping norms within the school
Students are taught general life skills, such as building
environment.[5] Sources of Strength is the rst program
self-esteem, identifying emotions and stress, increasing
of this kind.
communication and problem-solving skills, eliminating
Sources of Strength. The Sources of Strength sui-
self-destructive behavior, and setting personal and
cide prevention program is a universal program designed
community goals. Lessons are interactive and involve
to increase eight protective factors in the student pop-
experiences more likely relevant to an American Indian
ulation and decrease risk factors such as social isolation
adolescent life.[10] The program has been adapted for
and ineffective coping skills, by creating positive cop-
20 different Aboriginal tribes.[22] Expected outcomes
ing norms and building in protective inuences within
of this program are a decrease in hopelessness and
the school.[20] This model enables positive peer sup-
increased levels of suicide intervention skills.
ports in the school environment. Peer leaders, selected
In a quasiexperimental design, LaFromboise and
by school staff, are trained to encourage their friends to
Howard-Pitney[23] evaluated this program in the Zuni
identify and engage with a trusted adult and to use formal
Pueblo reservation. Sixty-nine students received the in-
and informal coping resources. The program aims to in-
tervention and 59 students were assigned to the no-
crease the likelihood that students will receive help, and
intervention group. A subsample of these students was
thereby reduces the likelihood of suicidal ideation and
also selected to participate in a behavioral assessment.
attempts.[21] This program is therefore similar to a skills
Students who received the intervention scored better
training program, but utilizes peer leaders to deliver the
on measures of hopelessness and on the probability of
program.
suicide, based on a self-report, 36-item scale measuring
This program has been evaluated in one RCT.[21]
hopelessness, hostility, negative self-evaluation, and
Eighteen high schools were randomly assigned to re-
suicidal ideation. However, there was no difference
ceive training immediately or after being waitlisted. Sur-
in levels of depression or self-efcacy ratings be-
veys were given to 453 peer leaders and 2,675 students
tween the control and intervention groups. On the
at baseline and after 4 months. Trained peer leaders
behavioral assessment scores, the intervention group
demonstrated an increase in adaptive norms regarding
demonstrated better problem-solving skills and suicide
suicide, including increased willingness to engage an
intervention skills than the control group. This program
adult in cases of suicidal friends despite requests for se-
may reduce suicide risk factors and increase protective
crecy. Compared with the control group, trained peer
factors, and has proven that it can be culturally tailored
leaders were four times more likely to engage an adult in
to numerous Aboriginal communities.[22] Because this
cases of suicidal friends, likely due to their perception of
program has not been evaluated with an RCT, this pro-
increased adult support and acceptability of help seeking.
gram received a grade of C on outcomes of general skills
Because this program had positive effects on attitude and
enhancement and on suicide ideation.
knowledge outcomes, and increased students likelihood
CARE (Care, Assess, Respond, Empower)/CAST
to approach an adult, and the conducted evaluation was
(Coping and Support Training). The CARE pro-
of high quality, this program was graded B on both at-
gram is a selected program that identies high-risk youth
titudes and knowledge and gatekeeper behaviors. This
through an in-depth, computer-assisted suicide assess-
program has not yet evaluated suicidal ideation or at-
ment interview and a subsequent motivational counsel-
tempts as outcomes; however, an RCT measuring these
ing intervention. The counseling component provides
outcomes is currently taking place. This program is the
students with empathy and support, a safe environment
rst of its kind to involve peer leaders in order to increase
for sharing, and encourages positive coping and help-
protective factors and reduce risk factors associated with
seeking behavior. The program also includes a follow-
youth suicide. Overall, the program provided students
up booster session and reassessment of suicide risk and
the opportunity to positively inuence at-risk school-
protective factors. The goals of the CARE program are
mates and increased the perception among students that
to decrease suicidal behaviors and related risk factors and
adults can help.
increase personal and social capital.[10] The CARE pro-
gram has been culturally adapted.[22]
SKILLS TRAINING CAST is also a selected prevention program that aims
The skills-training approach uses a risk-reduction to increase life skills and social support of students in
strategy for suicide prevention and is designed to in- a small-group format. At-risk students are identied

Depression and Anxiety

 Prevention and Treatment: School-Based Suicide Prevention Review
through CARE and participate in CAST. The goals
of the program are to improve mood management and
school performance and decrease drug use. Group ses-
sions teach skills such as goal setting, decision-making,
self-esteem, academic ability, and control of drug use.
These skills help at-risk youth to increase their family
and adult support. Every session concludes with a life-
work assignment, where the youth are called upon to
practice their skills in daily life.[10]
Four studies have examined the efcacy of the CARE
program in youth suicide prevention, three of which also
evaluate the CAST program. Participants were random-
ized to receive C-CARE only, C-CARE plus CAST,
or treatment as usual.[2426] All trials found C-CARE
only and C-CARE plus CAST to be effective in decreas-
ing depressive symptoms and enhancing self-esteem. All
groups had a decrease in suicide risk behaviors, anger
control issues, and family distress. Increases in skills like
problem solving and self-control were only seen in the
combination group. The combination of C-CARE plus
CAST was effective in reducing depression and hope-
lessness, and among females, was effective in reducing
anxiety and anger. An increase in perceived family sup-
port was observed among those who received C-CARE
and CAST. In a follow-up study,[26] at-risk youth who
received the intervention had lower levels of depression.
Hooven et al.[27] looked solely at the CARE program.
Six hundred and fteen youth were randomly assigned
to a parent intervention (P-CARE), C-CARE, a com-
bination and P- and C-CARE, or a minimal interven-
tion group. Overall, the CARE program was effective
at reducing suicide risk factors and increasing protective
factors. The P-CARE program, together with C-CARE,
showed improvement in positive behavior and reduction
in negative behavior. In the long-term follow-up, CARE
showed the greatest reduction in suicide risk behavior,
depression, and anger. P-CARE alone showed no signif-
icant results. Due to the improvement in attitudes and
knowledge with CAST and CARE, the program received
a grade of B. The evaluations found no signicant effects
of the programs on the suicidal behavior outcomes and
as such, the program is given a grade of D.
Reconnecting Youth (RY). RY is a selected
school-based suicide prevention program that targets
students who have poor academic achievement and are at
risk for dropping out of school. Such students often show
symptoms such as substance abuse, depression, aggres-
sion, and suicidal ideation. These students are taught to
build resiliency and to control early signs of substance
abuse and emotional distress. The program also pro-
vides social support through school bonding activities
and parental involvement.[10] The program is designed
to weaken deviant peer relationships and strengthen con-
nections to school; however, in grouping at-risk youth
together to participate in the program, it may actually
strengthen deviant peer connections, possibly leading to
iatrogenic effects.[28]
Several studies have evaluated this program, three
of which are available to the authors. Eggert and
1035
Herting[29] found the program may decrease drug use
and increase students GPAs. The program had no
effect on school attendance. There was no change
among males; however, fewer females had deviant peer
connections.[28] RY may also reduce risk factors for sui-
cide, like anger, depression and hopelessness, and in-
crease self-esteem and social support.[30] Thompson et
al.[31] showed personal control to be the mediator be-
tween resources of support and reduction in depression
and suicide risk behaviors. Although no RCTs were con-
ducted, there have been multiple trials evaluating RY
with consistent ndings. Based on available evidence,
RY was given a grade of B on outcomes of attitudes and
knowledge and skills training.
The Good Behavior Game (GBG). The GBG is
a universal program for students in early elementary
school. It is a classroom-based, teamwork, behavior man-
agement approach to help children develop intrinsic self-
regulation by rewarding teams that meet the behavior
standards set by each teacher. The goal of the program
is to create a positive classroom environment where chil-
dren are supported by other students, and can learn in an
environment without aggressive or disruptive behavior.
Students are grouped into teams with equal distribution
of those with disruptive and aggressive behavior histo-
ries. The teacher posts the rules of the game regarding
student behavior, and all teams who accumulate four or
fewer infractions of acceptable student behavior are re-
warded.
The GBG has previously been shown to positively im-
pact key risk factors, such as tobacco use and drug and
alcohol abuse in adolescence and early adulthood.[3234]
The GBG targets early aggressive, disruptive behavior,
a shared risk factor for later maladaptive behavioral out-
comes. A reduction in these risk factors may impact sui-
cide rates. A more recent study evaluated the programs
effect on youth suicide. Prior literature has shown poor
academic achievement to be associated with suicidality
and depression.[35] By reducing aggressive and disruptive
behaviors, the GBG helps reduce risk factors associated
with suicidality, as well as other behavioral outcomes,
such as impulse control problems, alcohol and drug use
disorders, and antisocial personality disorder.[36] Wilcox
et al.[36] evaluated this program using an RCT. First
grade students in 41 different classrooms in 19 elemen-
tary schools participated in this trial over 2 years. Class-
rooms and teachers were randomly assigned to the inter-
vention group or the standard school program. Over 15
years, 1,918 of the participants (83%) completed follow-
up interviews. The primary outcome measure was suici-
dal ideation and attempts. Individuals who received the
intervention were half as likely to experience suicidal
ideation compared to the control group. Those assigned
to the GBG group were also less likely to experience
suicide attempts as compared to the control group, af-
ter adjusting for covariates, such as gender and baseline
depressive and anxious symptoms. The GBG program
resulted in a delayed onset of suicide attempts in females
and a reduction in relative risk estimates by 30% for
Depression and Anxiety
1036 Katz et al.
suicide attempts. Based on the high-level 1B evidence of
this program, the GBG received a grade of B on suicidal
ideation and attempts.
DISCUSSION
Upon review, it became clear that it is difcult to se-
lect one program as the best school-based suicide pre-
vention program. Many programs exist, however few
of them are evidence-based. Each program has dif-
ferent strengths and limitations. Below, we have dis-
cussed the ndings from the present review in two
sections, based on whether the programs garnered
support through RCT data or through uncontrolled
data.
RANDOMIZED CONTROLLED DATA
Although suicide attempts are relatively rare, and are
thus hard to measure as an outcome, the gold stan-
dard of suicide prevention programs is to reduce sui-
cide ideation, attempts, and deaths. Only three programs
were evaluated for their ability to reduce suicidal be-
haviors: SOS, GBG, and CARE/CAST. The SOS and
GBG programs are the only evidence-based programs
that have demonstrated a reduction in suicide attempts.
SOS, however, has not been shown to reduce suicidal
ideation. This may be because the program is not de-
signed to address the underlying causes of suicide at-
tempts and that suicidal ideation is common in a larger
proportion of students than are suicide attempts. Addi-
tionally, ideation may take longer to treat. Further in-
vestigation is required into this occurrence, as well its
effectiveness in diverse populations. When comparing
the two programs, it is important to note that while the
SOS program was effective in reducing suicide attempts
in two trials, the mechanism is entirely unclear and the
evaluation only included a 3-month follow-up, whereas
the GBG study included a more rigorous trial design
with a 15-year follow-up.
GBG is a highly recommended suicide prevention
program and is currently supported by SAMHSA in the
United States, and in several provinces in Canada. This
program has demonstrated its ability to decrease sui-
cidal ideation, even in younger age groups. This pro-
gram also exhibited a reduction in the number of sui-
cide attempts and showed delayed onset of attempts.
As mentioned above, this program has also been evalu-
ated and results replicated multiple times for other out-
comes. It differs from the SOS program, as the goal is
to impact a student before the initiation of any suicidal
thoughts, producing a more signicant reduction in sui-
cidal ideation, and preventing students from getting to
the attempt stage. In fact, the reduction of suicidal be-
haviors is not the primary goal of the GBG, but rather
a benecial outcome of the program. It is for this rea-
son, that the effect of the program on suicidal behaviors
has not been more rigorously studied to date. As this
program has only been evaluated once, further investi-
Depression and Anxiety
gation is required to assess its effect on suicidal behavior
outcomes.
Although the CAST/CARE program is supported
by good evidence and has been adapted for diverse
populations, it is not recommended due to its docu-
mented repeated failure to decrease suicidal ideation or
attempts.
Sources of Strength is another promising program
that has demonstrated its ability to improve gatekeeper
behavior, attitudes, and knowledge about suicide. No
other program with a high level of evidence was able to
accomplish this. Perhaps, this is due to the peer lead-
ership training approach. Unfortunately, there are cur-
rently no evaluations of this program testing suicidal be-
havior as an outcome; therefore we do not yet know the
impact of the program on suicidal behavior. However, a
National Institute of Health funded RCT with approx-
imately 14,000 students, measuring both self-reported
and medically serious suicide attempts is currently tak-
ing place, and upon completion of this study, can further
elucidate the value of this program.
Conversely, the RCT evaluating the QPR program
has not demonstrated an improvement in gatekeeper be-
haviors. Therefore, even though this program is effective
in changing attitudes and behaviors toward suicide, it is
not recommended.
UNCONTROLLED STUDIES
There are other programs that may decrease suicidal
ideation, and improve attitudes, knowledge, and general
skills toward suicide prevention among youth and school
personnel. The AILSD program has demonstrated pre-
liminary data for its ability to enhance life skills to reduce
suicidal ideation; however, no RCT has been conducted
to date, therefore these results must be interpreted in the
context of an uncontrolled study. No evaluations have
tested this programs effectiveness in reducing suicide
attempts. More rigorous evaluation with a randomized
controlled design, as well as inclusion of suicide attempts
as an outcome, would help gain insight into this pro-
grams value.
LIMITATIONS
This review is limited in several ways. First, there exists
some heterogeneity in the grading of programs due to
the large variation in the specic programs. Not all pro-
grams were designed with similar goals, and outcomes
were measured in a variety of ways. This study attempted
to report the efcacy of programs based on common out-
comes; however, due to the nature of the variation, we
must be careful in comparing programs against one an-
other. Second, for the remaining programs we cannot
conclude whether they impact suicide attempts. Fur-
ther evaluations of these programs are required, test-
ing the outcomes of suicidal ideation and attempts in
a school population. Third, the recommendations that
were made reect the evidence available. For example, a
grade of D is not necessarily indicative of an ineffective
 Prevention and Treatment: School-Based Suicide Prevention Review
program, but rather a lack of conclusive evidence or a
poorly designed study. Further investigation into these
programs could yield more conclusive results and higher
program grades. Fourth, studies aimed at mental health
promotion not designed to specically prevent suicide
behavior, but rather to reduce causal factors, were be-
yond the scope of this review. Such programs, however,
may hold promise as suicide prevention programs. As
mentioned above, mental health promotion is the rst
part of a comprehensive suicide prevention strategy.
CONCLUSIONS
We hypothesize that one program may not be suf-
cient on its own to cover the breadth of suicide pre-
vention required in schools, and that a combination of
programs may be most effective. We encourage further
investigation into the combination of programs, such as
SOS and GBG, where the two may compliment each
other, reducing suicidal ideation and attempts.
With the limited evaluation data on the programs dis-
cussed, we cannot recommend any specic program as
a "best-practice" for school-based suicide prevention.
However, some programs have more evidence to sup-
port their implementation than others. Future research
should focus on more rigorous evaluation of these pro-
grams, alone and in combination, with a focus on suicidal
behaviors as an outcome.
Acknowledgments. Preparation of this article was
supported by a Canadian Institutes of Health Research
(CIHR) operating grant (#184490), New Investigator
Award (#152348), a Manitoba Health Research Council
Chair award, and a Manitoba government grant to Dr.
Sareen, and Healthy Child Manitoba Operating Grant.
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 TABLE A1. Summary of evidence-based, school-based suicide prevention programs

Expected Level of
Program Type of program Description of program outcomes Evidence evidencea
Training
Duration and Cost per child or requirements
frequency Who is involved Age level program (and cost)

Adolescent Universal; 2 hr educator Trained school Grade 910 N/A Educator 1. Increased 1. Kalafat, 4
Suicide gatekeeper seminar; 1/22 personnel; seminar; likelihood that Ryerson[37]
Awareness hr parent parents parent brieng youth in
Program workshop contact with
(ASAP) suicidal peers
will respond
appropriately
and seek adult
help
2. Troubled 2. Kalafat,
youth more Elias[9]
likely to seek
adult help
3. Adults in
school more
prepared to
help and
respond
appropriately
4. Communities
and schools
collaborate to
establish
guidelines for
proper
management
of distressed
youth
Prevention and Treatment: School-Based Suicide Prevention Review

California Youth Universal; suicide Student 4-hr Parents; school Grade 912 N/A 4-hr youth 1. Improvement 1. Nelson[38] 2C
Suicide awareness training staff training; in students
Prevention course; parent 90-min parent knowledge of
Program and school staff and school staff suicide
(YSPP) 90-min youth training 2. Increased
suicide ability to
awareness respond
seminar effectively to
suicidal crisis

Depression and Anxiety

1039
 1040

TABLE A1. Continued

Depression and Anxiety

Expected Level of
Program Type of program Description of program outcomes Evidence evidencea
Training
Duration and Cost per child or requirements
frequency Who is involved Age level program (and cost)

Coping and Selected; skills 12 55 min High school 1319 $26.50/notebook $699/curriculum 1. Increased 1. Randell 1B
Support training group sessions teachers, or $190.80 for + 4-day on- or mood et al.[24]
Training over 6 weeks counselors, or 8 off-site management 2. Thompson
(CAST) nurses with training for 2. Improved et al.[25]
school-based leaders school 3. Eggert et al.[26]
experience ($1,000/each) performance
Additional 3. Decreased
training drug
available at involvement
cost
Care, Assess, Selected; 2-hr, one-on-one High-risk youth; 1325 Cost for licensing Training 1. Decreased 1. Randell 1B
Respond, screening computer- school-based to use registration suicidal et al.[24]
Katz et al.

Empower assisted suicide case worker; computer- and follow-up behaviors 2. Thompson
(CARE) assessment school nurses, based CARE certication 2. Decreased et al.[25]
interview; 2-hr counselors, program processing, related risk 3. Eggert et al.[26]
motivational psychologists, required, at factors 4. Hooven
counseling and or social cost 3. Increased et al.[27]
social support worker who personal and
intervention; has completed social assets
booster session training
9 weeks after
initial
counseling
CD-ROM Universal; suicide Educators of Grade 712 $1.10/CD-ROM N/A 1. Increase ability 1. Fendrich et 4
mail-out awareness grade 7 and + $3.90 S+H to recognize al.[39]
(Team up to upwards suicidal risk
save lives) factors and
warning signs
 TABLE A1. Continued

Expected Level of
Program Type of program Description of program outcomes Evidence evidencea
Training
Duration and Cost per child or requirements
frequency Who is involved Age level program (and cost)

2. Increase ability
to respond to
crises
3. Increase ability
to restrict
youth access to
rearms
Columbia Suicide Screen Universal; 10-min Parents; 1319 Costs for staff, FREE training 1. Identies those 1. Shaffer 2B
(TeenScreen) screening computerized teenagers; supplies, and online at risk for et al.[14]
questionnaire. mental health equipment mental health 2. Scott et al.[15]
Positive professional problems and
screens for positive suicide
participate in screens
clinical
interview
Psychoeducational program Universal; 1, 2-hr meeting Psychologist 1418 N/A N/A 1. Increase 1.Portzky, van 4
education knowledge Heeringen[40]
2. Increase
adaptive
attitude
3. Decrease levels
of hopelessness
Question, Persuade, Refer Universal; 12 hr for Certied N/A N/A QPR instructor 1. Increased 1. Wyman 1B
(QPR) gatekeeper gatekeeper instructors; training suicide- et al.[18]
training; 2-hr school teachers session $495; relevant 2. Tompkins
instructor QPR knowledge and et al.[19]
training gatekeeper attitudes
Prevention and Treatment: School-Based Suicide Prevention Review

training
session $2 per
booklet
Raising Awareness of Universal; N/A Peer counselors; N/A N/A N/A 1. Raising student 1. Cigularov 4
personal power (RAPP) gatekeeper trained awareness of et al.[41]
volunteers their own
power to make
difference in
peoples lives

Depression and Anxiety

1041
 1042

TABLE A1. Continued

Expected Level of
Program Type of program Description of program outcomes Evidence evidencea

Depression and Anxiety

Training
Cost per child or requirements
Duration and frequency Who is involved Age level program (and cost)

2. Educates
students on
depression,
suicide, and
warning signs
3. Teaches
students how
to ask for help
for themselves
or their friends
Reconnecting Selected; 50-min daily session Parents; at-risk 1319 Student RY leader 1. Increased 1. Eggert and 2B
Youth (RY) gatekeeper during school hours youth; RY workbooks requires 4-day school Herting[29]
model; skills for 1 semester (80 leader $24.95 each or on/off-site performance 2. Eggert et al.[28]
training sessions) $211.95 for 10 training 2. Decreased 3. Eggert et al.[30]
$299.95 per ($1,000/each) drug 4. Thompson
curriculum Additional involvement et al.[31]
Katz et al.

training 3. Decreased
available at mental health
cost risk factors and
increased
protective
factors
4. Decreased
suicide risk
behaviors
South Elgin High Universal; suicide 50-min small group School social Grade 910 Costs include N/A 1. Learning 1. Ciffone[42] 2B
School (SEHS) awareness; presentation to all worker; health $65.49 for appropriate
Suicide screening ninth graders; 50-min teacher both videos. responses to
Prevention classroom take with
Program presentation over 2 at-risk peer
days (including
15-min video +
discussion, and
26-min video +
discussion) to all 10th
graders
 TABLE A1. Continued

Expected Level of
Program Type of program Description of program outcomes Evidence evidencea
Training
Duration and Cost per child or requirements
frequency Who is involved Age level program (and cost)

2. Become more 2. Ciffone[43]

willing to
inform adult
3. Increased
knowledge that
suicide is not
option
4. Increased
willingness to
make initial
connection
with adult if
having suicidal
thoughts
Suicide, Options, Universal; 18-hr primary School counselor; Grade K-12 N/A Training course 1. Increased 1. King, 4
Awareness and gatekeeper caregiver teachers; peers; for one school condence in Smith[44]
Relief (SOAR) course over 4 crisis team counselor identifying
months + 3-hr deemed students at risk
follow-up per primary for suicide and
year; 6-hr caregiver + offer support
general follow-up
instruction training;
course for instruction for
teachers all teachers
Signs of Suicide Universal; 2 days Mental health 1319 $300 per SOS kit Not required, but 1.Decreased 1. Aseltine, 1B
(SOS) awareness professionals available upon suicide DeMartino
education; or trained request, at cost attempts (2004)[11]
screening caregivers in 2. Increased 2. Aseltine
Prevention and Treatment: School-Based Suicide Prevention Review

school knowledge et al.[12]

about suicide
3. Develop
desirable
attitudes
toward suicide,
depression,
and
help-seeking
behaviors

Depression and Anxiety

1043
 1044

TABLE A1. Continued

Expected Level of

Depression and Anxiety

Program Type of program Description of program outcomes Evidence evidencea
Training
Duration and Cost per child or requirements
frequency Who is involved Age level program (and cost)

Sources of Universal; skills Peer leaders meet Youth Opinion 1319 N/A 46 hr training 1. Increased 1. Wyman 1B
Strength training; peer biweekly with Leaders; 2 for adult positive norms et al.[18]
leadership adult adult supervisors; regarding
training supervisors supervisors 34 hr peer suicide
over 34 leader training 2. Increased
months (1/21 (w/supervisors) social
hr each) connectedness,
number of
trusted adults
3. Increased
frequency of
engaging
adults to help
distressed
Katz et al.

students
4. Increased
student
perception that
adults can help
The Good Universal; skills Incorporated into Teacher; parents Grade K-6 $249 per PAX No additional 1. Reduced risk 1. Wilcox 1B
Behavior training classroom kit; $225 per training of suicidal et al.[36]
Game lesson plans on video. Extra (delivered by ideation and
daily basis resources teacher with 40 attempts
available at hr of training) during
cost adolescence
2. Reduced
aggressive and
disruptive
behavior
3. Increased
academic
achievement
 TABLE A1. Continued

Expected Level of
Program Type of program Description of program outcomes Evidence evidencea
Training
Duration and Cost per child or requirements
frequency Who is involved Age level program (and cost)

4. Reduced
depressive
symptoms
5. Delayed onset
or reduction of
risk of tobacco
smoking
Yellow Ribbon Universal; 60-min student 15 students Grade 912 N/A Student 1. Increase in 1. Freedenthal[45] 2C
Suicide awareness leadership selected by leadership and help-seeking
Prevention education training; 1.5-hr school staff training behavior
Program staff training; counselors; (slide
50-min school staff presentation)
schoolwide
assembly
Zuni/American Universal; skills 2856 lesson Teachers; 1319 Course manual Additional 1. Decreased 1. LaFromboise, 2B
Indian Life training plans, over 30 community $30/each. training not hopelessness Howard-
skills weeks in resource required, but 2. Increased Pitney[23]
development school year (3 leaders; available upon levels of 2. LaFromboise,
lessons/week) representatives request, at cost suicide Lewis[46]
of local social intervention
service skills
agencies
Prevention and Treatment: School-Based Suicide Prevention Review

a Levelof evidence-based on Oxford Centre for Evidence-Based Medicine Criteria. 1A, systematic review of RCTs; 1B, individual RCT; 2A, systematic review of cohort studies; 2B, individual
cohort study, low-quality RCT; 2C, ecological studies; 3A, systematic review of case-control studies; 3B, individual case control study; 4, case-series, poor quality cohort and case-control studies;
5, expert opinion without critical appraisal or based on physiology bench research.

Depression and Anxiety

1045
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