Schools are important for preventing suicide, but more needs to be done

The COVID‐19 pandemic has revealed that social connection and social factors are critical for the mental health of young people

Adolescence is a critical period of emotional, social, and physical development, during which young people are vulnerable to a variety of stressors, as they have not yet fully developed effective coping mechanisms.1 It is during this period that rates of intentional self‐harm and suicidal ideation peak; in Australia, the age‐specific rate of hospital presentations linked with self‐harm is highest for those aged 15–19years.2 During the first 15 months of the coronavirus disease 2019 (COVID‐19) pandemic (March 2020 – June 2021), the number of hospital presentations by New South Wales girls and women aged 10–24years related to self‐harm and suicidal ideation increased by 31.7% per year (compared with 7.6% per year during 2015–2019), but was unchanged for males.3 On the other hand, the overall suicide rate did not increase in Australia during the pandemic, except among men under the age of 25years.4 In a school‐based survey in four New South Wales regions, nearly one‐third of year 9 adolescents (aged 13–16years) reported that they had experienced active suicidal thoughts during the preceding two weeks.5

Adolescence is undoubtedly a critical period for preventive action. As it is estimated that only 29% of adolescents who experience suicidal thoughts seek help from mental health services,6 schools have become important settings for implementing effective, multi‐tiered preventive strategies that build mental health literacy in the entire school community.

Nevertheless, as in other settings, certain challenges make effective school‐based suicide prevention difficult. Although the evidence base regarding school‐based programs is growing, it remains limited. In 2022, a meta‐analysis found only eleven well designed trials of school‐based interventions that assessed suicide‐related outcomes.7 Most evidence for the efficacy of such programs concerns universal prevention and promotion programs.7,8

At the practical level, few effective interventions are available to schools outside research trials. Evidence regarding which strategies effectively support prevention programs in schools is limited, despite awareness of the many attitudinal and structural barriers to their implementation.9 As schools are often individually responsible for choosing which programs they offer, it is critical to involve education departments in planning and decision making, to acquire high quality evidence of what works, and to make this information accessible to schools.

In this issue of the MJA, Grummitt and colleagues report their post hoc analysis of three‐year follow‐up data on suicidal ideation from a randomised trial that included a brief selective, school‐based prevention program, Preventure.10 Preventure, consisting of two 90‐minute small group sessions, is delivered to students with personality profiles that make them vulnerable to emotional and behavioural problems. The odds of suicidal ideation among the 881 private school year 8 students who received the Preventure intervention were lower than for the 755 who did not (per year: adjusted odds ratio [aOR], 0.80; 95% confidence interval [CI], 0.66–0.97).10

As one of the few studies to assess suicidal ideation more than twelve months after the intervention, the findings of Grummitt and colleagues will interest those working in and with education systems, as they suggest that a very brief, selective intervention can provide sustained protection. Although the main intervention effect was not statistically significant after adjusting for sex (aOR, 0.82; 95% CI, 0.68–1.00), Preventure could be part of an effective, staged suicide prevention program if delivered alongside an effective universal program such as Youth Aware of Mental Health,11 building the capacity of schools to provide evidence‐based approaches that target the entire student population.

The COVID‐19 pandemic not only exacerbated mental ill‐health and self‐harm among young people in Australia, it has exposed the critical roles of social connection and social factors for their wellbeing. This may suggest new targets for preventive approaches that were not taken into account by programs evaluated before the pandemic. Interventions such as Preventure — for which randomised controlled trial assessment of mental health outcomes was undertaken in 2015 — should be further evaluated and undergo quality assurance to determine whether they still meet the needs of children and adolescents.

Standalone interventions can be useful, but implementing multi‐tiered or staged suicide prevention programs is difficult for schools. Not only are their choices of evidence‐based approaches limited; many programs require suicide literacy training, digital interventions, and workforce capacity initiatives that are themselves unavailable. Co‐designing school‐based strategies could improve their relevance and acceptability, and thereby increase their effectiveness. A multi‐tiered approach is likely to be most effective for improving the mental health of young people.