Effectiveness of a school-based multimodal suicide and depression prevention program: cluster-randomized pragmatic trial

BackgroundSuicide is one of the leading causes of death among adolescents. Suicidal thoughts and behaviors are significant risk factors for suicide, whilst depressive symptoms are significant risk factors for suicidal thoughts and behaviors. Multimodal school-based interventions that address these risk factors are considered the appropriate approach to suicide prevention. Method1,593 adolescents (aged 11-15 years) from 15 high schools in the Netherlands took part in the study, which was designed as a pragmatic cluster-randomized trial. The experimental condition consisted of (1) screening for depressive symptoms and suicidal thoughts and behaviors, followed by referral of those who scored positive; (2) gatekeeper training for school mentors; (3) a serious game to reduce stigma, promote health literacy and improve help seeking behavior; and (4) eight CBT-based sessions for adolescents with elevated depressive symptoms. The control group consisted of screening and the gatekeeper training. Both suicidal thoughts and behaviors and depressive symptoms were assessed at baseline, after 6 months and after 12-months follow-up. ResultsMultilevel mixed-model analysis revealed that, over the entire 12-month follow-up period, both suicidal thoughts and behaviors and depressive symptoms increased significantly in the experimental group, but not in the control group. No clinically relevant change was observed in either group. ConclusionsThe multimodal stepped-prevention program tested in the present study did not lead to a reduction in suicidal thoughts and behaviors or depressive symptoms. However, it is likely that the adverse impact of COVID-19-related school closures overwhelmed the programs effectiveness. Furthermore, few high-risk adolescents participated in the CBT-based sessions. Key Practitioner MessagesO_ST_ABSWhat is known?C_ST_ABSO_LISchool-based prevention programs aim to reduce suicidal thoughts, behaviors, and depressive symptoms among adolescents. C_LIO_LIMulti-modal interventions are increasingly promoted, but evidence of their effectiveness is limited under real-world conditions. C_LI What is new?O_LIThe multimodal stepped STORM program did not reduce STBs or depressive symptoms at 12-month follow-up; a small group-level increase was observed in the experimental group. C_LIO_LIParticipation in the indicated CBT-based module was low, revealing critical implementation gaps school programs. C_LI What is significant for clinical practice?O_LISchool-based programs should prioritize early identification with active referral, gatekeeper training. C_LIO_LIActive referral to a brief CBT-based intervention for high-risk students need to be implemented in close collaboration with both students and teachers to better assure its uptake C_LI