Prevention of suicide in university and other post-secondary educational settings

Review question

We reviewed evidence about the effect of suicide prevention programs on post-secondary students who are not known to be suicidal. We examined the effects of these programs on suicide, suicidal behavior, and knowledge and attitudes about suicide.

Background

Worldwide, suicide is a leading cause of death among post-secondary students. Suicidal thoughts and planning are common among such students. However, fewer than half of students who report suicidal thoughts or other serious mental illness have received professional treatment. There is a need for suicide prevention programs that target students who are not already known to be suicidal ("primary prevention").

Study characteristics

We identified eight studies that were eligible for this Cochrane Review. All studies had both primary and secondary prevention components. That is, they targeted students known to be suicidal as well as those not known to be suicidal. We separately analysed the effects of classroom instruction, institutional policies, and gatekeeper training programs. Gatekeeper training programs train people to recognize and respond to warning signs of emotional crises or suicide risk in students they encounter. The evidence is current to June 2011.

Key results

Three studies, including 312 students, evaluated classroom instruction. Classroom instruction increases short-term knowledge of suicide and suicide prevention. It may slightly enhance short-term confidence in ability to prevent suicide. However, long-term effects have not been studied. Effects of classroom instruction on suicidal behavior have also not been studied. One study evaluated an institutional policy. The policy restricted access to laboratory cyanide and required professional assessment for students who threatened or attempted suicide. The policy significantly reduced student suicides. These findings have not been tested in other post-secondary institutions. Four studies, ranging from 53 to 146 participants, evaluated the effect of gatekeeper training programs. Gatekeeper training may lead to small-to-medium improvements in short-term suicide-related knowledge and confidence about being able to prevent suicide. We found no evidence that gatekeeper training improved short-term attitudes toward suicide or long-term knowledge or behaviors about suicide. The effect of gatekeeper training on suicide or suicidal behavior has not been evaluated.

Quality of evidence

The quality of evidence for short-term knowledge of suicide and suicide prevention was moderate. For suicide prevention self-efficacy, the quality of evidence was low. The quality of evidence was reduced because results were not similar across studies and there were not enough data.

Authors' conclusions: 

We found insufficient evidence to support widespread implementation of any programs or policies for primary suicide prevention in post-secondary educational settings. As all evaluated interventions combined primary and secondary prevention components, we were unable to determine the independent effects of primary preventive interventions. Classroom instruction and gatekeeper training increased short-term suicide-related knowledge. We found no studies that tested the effects of classroom instruction on suicidal behavior or long-term outcomes. Limited evidence suggested minimal longer-term effects of gatekeeper training on suicide-related knowledge, while no evidence was found evaluating its effect on suicidal behavior. A policy-based suicide intervention reduced student suicide, but findings have not been replicated. Our findings are limited by the overall low quality of the evidence and the lack of studies from middle- and low-income countries. Rigorously designed studies should test the effects of preventive interventions on important health outcomes, including suicidal ideation and behavior, in varying post-secondary settings.

Read the full abstract...
Background: 

Suicide is a leading cause of death among post-secondary students worldwide. Suicidal thoughts and planning are common among post-secondary students. Previous reviews have examined the effectiveness of interventions for symptomatic individuals; however, many students at high risk of suicide are undiagnosed and untreated.

Objectives: 

We evaluated the effect on suicide and suicide-related outcomes of primary suicide prevention interventions that targeted students within the post-secondary setting.

Search strategy: 

We searched the following sources up to June 2011: Specialised Registers of two Cochrane Groups, Cochrane Central Register of Controlled Trials, and nine other databases, trial registers, conference proceedings, and websites of national and international organizations. We screened reference lists and contacted authors of included studies to identify additional studies. We updated the search in November 2013; we will include these results in the review's next update.

Selection criteria: 

We included studies that tested an intervention for the primary prevention of suicide using a randomized controlled trial (RCT), controlled before-and-after (CBA), controlled interrupted time series (CITS), or interrupted time series (ITS) study design. Interventions targeted students within the post-secondary setting (i.e. college, university, academy, vocational, or any other post-secondary educational institution) without known mental illness, previous suicide attempt or self-harm, or suicidal ideation. Outcomes included suicides, suicide attempts, suicidal ideation, changes in suicide-related knowledge, attitudes and behavior, and availability of means of suicide.

Data collection and analysis: 

We used standardized electronic forms for data extraction, risk of bias and quality of evidence determination, and analysis. We estimated standardised mean differences (SMD) with 95% confidence intervals (CIs). We analysed studies by intervention type and study design. We summarized RCT effect sizes using random-effects models meta-analyses; and analysed statistical heterogeneity using the Chi2 test and I2 statistic. We described narratively the results from studies that used other study designs.

Main results: 

Eight studies met inclusion criteria. They were heterogeneous in terms of participants, study designs, and interventions. Five of eight studies had high risk of bias. In 3 RCTs (312 participants), classroom-based didactic and experiential programs increased short-term knowledge of suicide (SMD = 1.51, 95% CI 0.57 to 2.45; moderate quality evidence) and knowledge of suicide prevention (SMD = 0.72, 95% CI 0.36 to 1.07; moderate quality evidence). The effect on suicide prevention self-efficacy in one RCT (152 participants) was uncertain (SMD = 0.20, 95% CI -0.13 to 0.54; low quality evidence). One CBA analysed the effects of an institutional policy that restricted student access to laboratory cyanide and mandated professional assessment for suicidal students. The incidence of student suicide decreased significantly at one university with the policy relative to 11 control universities, 2.00 vs. 8.68 per 100,000 (Z = 5.90; P < 0.05). Four CBAs explored effects of training 'gatekeepers' to recognize and respond to warning signs of emotional crises and suicide risk in students they encountered. The magnitude of effect sizes varied between studies. Gatekeeper training enhanced short-term suicide knowledge in students, peer advisors residing in student accommodation, and faculty and staff, and suicide prevention self-efficacy among peer advisors. There was no evidence of an effect on participants' suicide-related attitudes or behaviors. One CBA found no evidence of effects of gatekeeper training of peer advisors on suicide-related knowledge, self-efficacy, or gatekeeper behaviors measured four to six months after intervention.

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