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

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