The Saving and Empowering Young Lives in Europe (SEYLE) randomized controlled trial (RCT) was originally established to evaluate the efficacy of three school-based interventions on preventing suicide in 11,000 adolescents.1 The three interventions included the Youth Aware of Mental Health Program (YAM);2 Question, Persuade, and Refer (QPR); 3 and Professional Screening of at-risk pupils (ProfScreen).4
At 12-months follow-up, YAM was found to significantly reduce the number of new cases of suicide attempt (SA) and severe suicide ideation (SI) compared to controls who received educational posters on mental health resources. 5 Now, Shira Barzilay and colleagues have taken the SEYLE study further by, (i) testing two psychological models of suicide within the context of this RCT — the interpersonal theory of suicide (IPTS)6 and a two-pathway model7 — and (ii) evaluating the moderating effects of interventions on the pathways to SI and SA.
Barzilay et al. found that IPTS showed a better fit than the two-pathway model, whereby low parental belongingness, but not peer belongingness or burdensomeness, predicted a greater likelihood of SI. In terms of the moderating effects of the SEYLE interventions, YAM, QPR, and ProfScreen all reduced the association between repeated SA (vs. no SA) and the interaction between SI and self-injury at baseline compared to the control intervention. The YAM intervention also diminished the direct association between risk behaviours at baseline and the likelihood of repeated SA (vs. no SA). The researchers thus conclude that universal suicide prevention can effectively attenuate the risk of SA by impeding the different facets of self-harm from leading to SA. Because perceived interpersonal difficulties with parents primarily mediated SI, they suggest that interventions with high parental involvement might be most effective.
Barzilay, S. et al. (2019), A longitudinal examination of the interpersonal theory of suicide and effects of school-based suicide prevention interventions in a multinational study of adolescents. J. Child Psychol. Psychiatr. doi:10.1111/jcpp.13119
1Wasserman, D., Carli, V., Wasserman, C., Apter, A., Balazs, J., Bobes, J., et al. (2010), Saving and empowering young lives in Europe (SEYLE): a randomized controlled trial. BMC Public Health, 10: 192. doi: 10.1186/1471-2458-10-192.
2Wasserman, C., Postuvan, V., Herta, D., Iosue, M., Värnik, P., and Carli, V. (2018), Interactions between youth and mental health professionals: The Youth Aware of Mental health (YAM) program experience. PLoS One, 13: e0191843. doi: 10.1371/journal.pone.0191843.
3Tompkins, T. L., Witt, J., & Abraibesh, N. (2010), Does a gatekeeper suicide prevention program work in a school setting? Evaluating training outcome and moderators of effectiveness. Suicide Life Threat Behav, 40: 506-515. doi: 10.1521/suli.2010.40.5.506.
4Kaess, M., Brunner, R., Parzer, P., Carli, V., Apter, A., Balazs, J. A., et al. (2014). Risk-behaviour screening for identifying adolescents with mental health problems in Europe. European child & adolescent psychiatry, 23(7), 611-620.
5Wasserman, D., Hoven, C. W., Wasserman, C., Wall, M., Eisenberg, R., Hadlaczky, G., et al. (2015), School-based suicide prevention programmes: the SEYLE cluster-randomised, controlled trial. Lancet, 385: 1536-1544. doi: 10.1016/S0140-6736(14)61213-7.
6Joiner, T. E., Jr. (2005), Why people die by suicide: Cambridge, MA, US: Harvard University Press.
7Apter, A., Gothelf, D., Orbach, I., Weizman, R., Ratzoni, G., Har-Even, D. and Tyano, S. (1995), Correlation of suicidal and violent behavior in different diagnostic categories in hospitalized adolescent patients. J Am Acad Child Adolesc Psychiatry, 34: 912-918.
Youth Aware of Mental Health Program (YAM): a manual, universal intervention school-based program that targets all pupils through a focused workshop to raise mental health awareness and enhance coping skills when dealing with adverse life events, stress and suicidal behaviours. YAM is typically delivered in three sessions, totalling 5 hours of training.
Question, Persuade, and Refer (QPR): a manual gatekeeper training program for suicide prevention. In this case, the gatekeepers are schoolteachers, who are trained to learn how to recognize the warning signs of a suicide crisis and how to question, persuade and refer someone to help.
Professional screening of at-risk pupils (ProfScreen): a program that screens baseline questionnaire answers for pre-established cut-off points of psychopathology symptoms and risk behaviours. Young people identified as at risk of suicide are then recommended for clinical referral.
Interpersonal theory of suicide (IPTS): IPTS proposes that an interaction between two interpersonal constructs — “thwarted belongingness” (experience of loneliness/isolation) and “perceived burdensomeness” (perception of being a burden on others) — increases a desire to commit suicide. The theory proposes that this interaction will lead to SA only in the presence of “acquired capability for suicide”, through exposure and thus habituation to painful or fearsome experiences such as prior self-injury or risk behaviours.
Two-pathway model of suicide: this model conceptualizes two separate mechanisms leading to SA among adolescents. One pathway is driven via reactive self-directed aggression and impulsivity, which may have underlying dysregulated serotonin metabolism or non-conventionality with social norms. The other independent pathway is driven by an internalizing process based on anxiety and depression that might be related to interpersonal distress.
This paper forms part of JCPP Special issue 2019 – Suicide and self-harm: Pathways for Minimizing Suicide & Premature Deaths and Maximizing Hope and Wellbeing.
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