Outcomes of School Based Suicide Intervention Programs

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As reported by the Centers for Disease Control and Prevention (2017), “suicide is the third leading cause of death among youth between the ages of 10 and 24, resulting in approximately 4600 lives lost each year” (“Suicide in Youth”, 2017, p.1). The CDC also reports a concerning prevalence of suicide attempts in youth as shown in the results of the National Youth Risk Behavior Survey (YRBS) indicating that in 2017, 17. 2% of high school students had seriously considered attempting suicide in the past year. The percentage of students who had seriously considered attempting suicide in the past year increased significantly from 2007 through 2017. Out of these considering attempting suicide 13. 6% of high school students had made a suicide plan and 7.4% of high school students had attempted suicide one or more times in the past year (Centers for Disease Control and Prevention, 2017). Statistics such as these put a strong emphasis on the importance of early detection, prevention and intervention. Lieberman, Poland, and Cowan (2006), place “responsibility on school systems under the mandates of educating and protecting students, to assign them as key for suicide intervention and prevention”. Additionally, they discuss the importance of school suicide prevention programs being designed to provide these key elements, “awareness education and screenings, crisis and mental health team coordination, collaboration with community services, reliance on evidence based practices, as well as clear intervention and “postvention” protocols” (2006).

The purpose of this study is to determine the effectiveness of the Question, Persuade, Refer (QPR) Gatekeeper Training for Suicide Prevention program on the detection of suicidal behaviors, knowledge of appropriate steps to take if factors are present, and attitudes and willingness to offer help. This gatekeeper method is designed for use by all school personnel and aims to teach school personnel, who may have routine contact with students potentially at risk for suicide, how to recognize and respond to these youths and then refer them to appropriate resources once the need is identified.

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Literature Review

Deep emotional pain and isolation are feelings experienced by most suicidal adolescents. Hopelessness, anger, sadness, feelings of misunderstanding and worthlessness often times encourage them to keep their feelings private. Warning signs may be detected by those close to the youth and when, or if, a cry for help does arise it is usually confided to another peer or someone indirectly close to them, such as school personnel. Three domains are commonly recognized when strategizing youth suicide prevention: community, health care systems and school based interventions (Gould, Greenberg, Velting, and Shaffer, 2003). The QPR Gatekeeper Training for Suicide Prevention Program is an evidence based practice that is used in many school based programs across the world. Other prevention programs at the school level include suicide awareness curricula, skills training, and postvention/ crisis intervention.

Suicide, the leading cause of preventable death in adolescents, spearheaded the development of numerous prevention and intervention programs over the span of several years. As a cost effective yet efficient means, school based programs have been introduced in hopes of creating a network of education professionals, students and the greater school community, working alongside mental health professionals to combat the epidemic (Joshi, Hartley, Kessler, & Barstead, 2015).

There is evidence to show that the potential for suicide, of adolescents who complete suicide is rarely recognized by professionals and consequently these young people fail to receive the assistance that may prevent their death. Only one third of suicide completers have had contact with a mental health practitioner and only 7 to 8% of suicide victims are in active treatment at the time of their death (Ashkenassy, Clark, Zinn, & Richtsmeiser, 1992; Pirkis & Burgess, 1998). Researchers have recently considered that there may be more than one physiological profile to describe self-harming adolescents (Stanford, Jones, & Hudson, 2017). Self-harm can be defined as self-inflicted, intentional, injury and can occur with or without suicidal ideations or completions. An Australian study of high school students indicated that in fact multiple psychological profiles exist and five distant profiles were identified; 1) Psychologically “normal”; 2) Anxiety; 3) Impulsiveness; 4) Pathological; and 5) Pathological-Impulsive (Stanford, et el, 2016). Given these various profiles screening may be a valuable asset in detecting adolescents with risky behavior potential.

Gatekeeper trainings are aimed at arming adults with the skills and knowledge to recognize the warning signs and to know how to react if they are detected. Much like the lifesaving technique CPR, QPR, involves three simple steps that could also make the difference between life and death. Knowledge is key to success, knowledge not only helps with the recognition of signs and symptoms but also removes the stigma associated with suicide. With knowledge comes understanding and with understanding comes comfortability of working with potentially suicidal youths. Built on the principle that in general, suicidal youths may be grossly under identified; the training of “natural helpers”, such as school personnel or peers, to detect warning signs can enhance identification of suicidal youth.

The QPR program is based on 4 steps with the expected outcome to include awareness, and increased ability to intervene and respond appropriately: (1) training and education to recognize signs, (2) training all school staff in QPR, (3) training school counselors to properly assess at risk students, (4) organize access to professional assessment and treatment (Joshi, Hartley, Kessler, & Barstead, 2015). Gatekeepers can be identified as anyone who is strategically placed to recognize and refer for help those at risk for suicide. Parents, friends, coaches, teachers, peers may all be trained as gatekeepers. The Suicide Prevention Resource Center designated the QPR program as a “program with evidence of effectiveness” based on its inclusion in the Substance Abuse and Mental Health Association’s National Registry of Evidence-Based Programs and Practices (Suicide Prevention Resource Center, 2012).

The Journal of Adolescent Health published a study in 2015 examining the relative contributions of perceptions of social support from parents, close friends, and their school on current suicidal ideation and attempts in a clinical sample of adolescents (Miller, Esposito-Smythers, and Leichweis, 2015). The analysis revealed that perceptions of lower school support independently predicted a greater chance of suicidal ideations with the strongest probability being seen where lower school support was combined with low parental support. This particular study addressed a significant gap by linking the contributions of parents, school, and peers’ significance in suicidal behaviors. It is suggested that support across all three areas a predominately important in understanding these behaviors (Miller, Esposito-Smythers, and Leichweis, 2015). The relative contributions of the combined support from family, peers and schools have been less studied and often times linked as independent entities when given consideration for increased suicidal ideation reports and risks. Providing knowledgeable, understanding, compassionate, people in positions to assist in these areas could make the difference in the adolescent seeking help prior to attempts or ideations.


Dependent Variable:

Despite the introduction of gatekeeper programs in many settings, evidence is lacking as to its effectiveness on increasing the participant’s knowledge, skills, attitudes, and behaviors for suicide detection and prevention. This study aims to conduct a systematic review on the effectiveness of school based gatekeeper training in increasing the skills needed to assist with the decrease of suicidal ideations and attempts in adolescents.


Prior studies related to school based gate keeper trainings were identified from several sources pulled from peer reviewed articles and databases obtained from the University of Kentucky Libraries, the Center for Disease Control and Prevention, the World Health Organization, and the Suicide Prevention Resource Center, to name a few. A broad search strategy was used and key terms categorized as the following: adolescent suicide, school based interventions, gate keeper programs, and suicide risks and factors. The searches deemed several articles and studies, as well as dissertations that gave insight into the topic.

Inclusion and Exclusion Criteria

Studies that were included for this review contained 1) a control trial or quasi experiment design; 2) adolescent suicide prevention and detection; 3) gatekeeper training approach; 4) participants were of middle or high school status, 5) produced outcomes to prevention; and 6) contained a comparison group. Exclusions were made when 1) they were not school based; 2) lacked the gatekeeper approach, 3) were not directed to adolescents; 4) used a single group design and; 5) were nonintervention designed.


This research will include school personnel at the middle and high school level that is interested in becoming a “gatekeeper”. There are a total of 250 middle and high school personnel and to that number a survey will be administered by a trained QPR professional to determine participation. The research will exclude substitute employees, and non-regular staff due to limitations of availability and accessibility to students.


A pre and posttest will be administered to the participants using a Likert scale regarding their knowledge, likelihood of recognizing risks, attitudes of offering help, and level of comfort in approaching students that show risks, and resources to refer for help. A scale will also be included to determine how likely they would be to acknowledge and react if needed and if they would be comfortable following protocol based on their current knowledge. These assessments will be administered to participants over a course of two days breaking them into 4 groups, surveying 2 groups each day. Following comparisons of the pre and post intervention responses, interviews will be conducted to determine what was deemed beneficial and what was not and why. Interviews will be conducted over a two-day period broken into assessment of beneficial findings and non-beneficial findings.


The 5 point Likert scale will be used as the data collection instrument. This sale is marketed for its versatility and ability to obtain information on a more informative level. Consumers can gain a deeper level of detail and a stronger measure of sentiment through this scale. To ensure validity, literature reviews and the use of questions similar to those posed by prior researchers, whom investigated similar studies, were used. The Likert survey (Appendix 1) designed for this study was adapted from previous suicide program studies. Some questions taken from Asetine and Demartino (2004) measuring knowledge of depression and suicide risks were adapted to determine the knowledge of participants before versus after the training was administered.

Each survey response earns a certain number of points as indicated on the sample survey; these points did not show up on the actual surveys. A response could have a value of 1-5 with a higher degree of knowledge and understanding as well as those with a higher level of positive or adaptive attitudes garnering a higher score. The scale will be reversed if disagreement with the statement reflected greater knowledge, adaptability or engagement. These scores will be compared in pre and post interventions to determine which factors provided the most help and the least.

The open ended questions in this survey pertained to how gatekeepers would react should they be confronted with risky behaviors or help seeking individuals. They responses will be scored from 0-3 based on the action steps taught by QPR 1) Question, 2) Persuade, 3) Refer and how the elements were incorporated into the responses.


The expectations of this study are results yielding a statistically significant increase in school personnel’s knowledge, understanding, and attitudes towards adolescent suicide risk behaviors, ideation and attempts and their efficacy in providing assistance and resources. By providing the student body more access to trained gatekeepers, the likelihood of a student with a potential suicidal ideation getting help would increase therefore aiding in the prevention of attempts and/or completions. The limitations and weaknesses that could accompany this study could potentially by lack of interested staff and faculty, drop out or staff/faculty turnover rates, and pre conceived attitudes and bias from school personnel.


  1. Centers for Disease Control and Prevention. (2017, September 15). Suicide among youth. Retrieved November 10, 2018, from https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/SuicideYouth.html
  2. Feng, C., Waldner, C., Cushon, J., Davy, K., & Neudorf, C. (2016). Suicidal ideation in a community-based sample of elementary school children: A multilevel and spatial analysis. Canadian Journal of Public Health, 107(1), E100-E105.
  3. Gould, Greenberg, Velting, & Shaffer. (2003). Youth suicide risk and preventive interventions: A review of the past 10 years. Journal of the American Academy of Child & Adolescent Psychiatry, 42(4), 386-405.
  4. Joshi, Hartley, Kessler, & Barstead. (2015). School-based suicide prevention: Content, process, and the role of trusted adults and peers. Child and Adolescent Psychiatric Clinics of North America, 24(2), 353-370.
  5. Kutcher, S., Wei, Y., & Behzadi, P. (2017). School- and community-based youth suicide prevention interventions: Hot idea, hot air, or sham? The Canadian Journal of Psychiatry, 62(6), 381-387.
  6. Miller, Esposito-Smythers, & Leichtweis. (2015). Role of social support in adolescent suicidal ideation and suicide attempts. Journal of Adolescent Health, 56(3), 286-292.
  7. Mo, P., & Ko, T. (2018). School-based gatekeeper training programmes in enhancing gatekeepers’ cognitions and behaviours for adolescent suicide prevention: A systematic review. Child and Adolescent Psychiatry and Mental Health, 12(1), 1-24.
  8. Pisani, Anthony R., Schmeelk-Cone, Karen, Gunzler, Douglas, Petrova, Mariya, Goldston, David B., Tu, Xin, & Wyman, Peter A. (2012). Associations between suicidal high school students’ help-seeking and their attitudes and perceptions of social environment. Journal of Youth and Adolescence, 41(10), 1312-1324.
  9. Stanford, Jones, & Hudson. (2017). Rethinking pathology in adolescent self-harm: Towards a more complex understanding of risk factors. Journal of Adolescence, 54, 32-41.
  10. York, J., Lamis, D., Friedman, L., Berman, A., Joiner, T., Mcintosh, J., Pearson, J. (2013). A systematic review process to evaluate suicide prevention programs: A sample case of community??based programs. Journal of Community Psychology, 41(1), 35-51.

Appendix 1: Pre and Post Intervention QPR Training Survey

Please read each of the following scenarios and briefly describe what action you would take.

    1. A student is isolating them self from peers and seems sad all the time. Once active in sports and after school activities they have since stopped participating in everything. Attendance is becoming an issue and grades are dropping. Would you approach this student and if so how?
    2. A student confides in you that they have been actively “cutting” as a release from stress but has lately been considering suicide. What resources do you offer?
    3. A normally well-kept student is showing signs of depression and lack of interest in hygiene and personal appearance. Their attitude has changed from pleasant to condescending and rude. You have heard from community members that her parents are going through a terrible divorce and that she has been staying at a relative’s home. Do you confront her and if so what help do you offer?

Multiple Choice Items: Please read each statements and circle the answer that indicates your level of agreement with the statement.

    1. People who talk about suicide do not commit suicide.

Strongly AgreeDisagreeNeutralAgreeStrongly Agree

(5) (4) (3) (2) (1)

    1. School personnel cannot legally provide intervention to prevent suicide.

Strongly AgreeDisagreeNeutralAgreeStrongly Agree

(5) (4) (3) (2) (1)

    1. I can identify risks that a student may be depressed or feeling sad.

Strongly AgreeDisagreeNeutralAgreeStrongly Agree

(5) (4) (3) (2) (1)

    1. I know how to respond if I see risk factors of a suicidal adolescent.

Strongly AgreeDisagreeNeutralAgreeStrongly Agree

(5) (4) (3) (2) (1)

    1. It is important to get resources to a student that is having suicidal ideations.

Strongly AgreeDisagreeNeutralAgreeStrongly Agree

(5) (4) (3) (2) (1)

    1. If a student told me they were contemplating suicide I would respect their privacy and keep it quiet.

Strongly AgreeDisagreeNeutralAgreeStrongly Agree

(5) (4) (3) (2) (1)

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    1. School personnel at my workplace are equipped with a plan of action to help students that are contemplating suicide.

Strongly AgreeDisagreeNeutralAgreeStrongly Agree

(5) (4) (3) (2) (1)         “

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Outcomes of School Based Suicide Intervention Programs. (2019, Jan 01). Retrieved from https://papersowl.com/examples/outcomes-of-school-based-suicide-intervention-programs/