Elsevier

The Lancet

Volume 385, Issue 9977, 18–24 April 2015, Pages 1536-1544
The Lancet

Articles
School-based suicide prevention programmes: the SEYLE cluster-randomised, controlled trial

https://doi.org/10.1016/S0140-6736(14)61213-7Get rights and content

Summary

Background

Suicidal behaviours in adolescents are a major public health problem and evidence-based prevention programmes are greatly needed. We aimed to investigate the efficacy of school-based preventive interventions of suicidal behaviours.

Methods

The Saving and Empowering Young Lives in Europe (SEYLE) study is a multicentre, cluster-randomised controlled trial. The SEYLE sample consisted of 11 110 adolescent pupils, median age 15 years (IQR 14–15), recruited from 168 schools in ten European Union countries. We randomly assigned the schools to one of three interventions or a control group. The interventions were: (1) Question, Persuade, and Refer (QPR), a gatekeeper training module targeting teachers and other school personnel, (2) the Youth Aware of Mental Health Programme (YAM) targeting pupils, and (3) screening by professionals (ProfScreen) with referral of at-risk pupils. Each school was randomly assigned by random number generator to participate in one intervention (or control) group only and was unaware of the interventions undertaken in the other three trial groups. The primary outcome measure was the number of suicide attempt(s) made by 3 month and 12 month follow-up. Analysis included all pupils with data available at each timepoint, excluding those who had ever attempted suicide or who had shown severe suicidal ideation during the 2 weeks before baseline. This study is registered with the German Clinical Trials Registry, number DRKS00000214.

Findings

Between Nov 1, 2009, and Dec 14, 2010, 168 schools (11 110 pupils) were randomly assigned to interventions (40 schools [2692 pupils] to QPR, 45 [2721] YAM, 43 [2764] ProfScreen, and 40 [2933] control). No significant differences between intervention groups and the control group were recorded at the 3 month follow-up. At the 12 month follow-up, YAM was associated with a significant reduction of incident suicide attempts (odds ratios [OR] 0·45, 95% CI 0·24–0·85; p=0·014) and severe suicidal ideation (0·50, 0·27–0·92; p=0·025), compared with the control group. 14 pupils (0·70%) reported incident suicide attempts at the 12 month follow-up in the YAM versus 34 (1·51%) in the control group, and 15 pupils (0·75%) reported incident severe suicidal ideation in the YAM group versus 31 (1·37%) in the control group. No participants completed suicide during the study period.

Interpretation

YAM was effective in reducing the number of suicide attempts and severe suicidal ideation in school-based adolescents. These findings underline the benefit of this universal suicide preventive intervention in schools.

Funding

Coordination Theme 1 (Health) of the European Union Seventh Framework Programme.

Introduction

Worldwide, suicide is one of the three leading causes of death in young people.1, 2 Globally, in 2009, suicide accounted for 7·3% of all deaths in the age group 15–19 years, after road traffic accidents (11·6%), and preceding violence (6·2%), respiratory tract infections (5·4%), tuberculosis (4·8%), and HIV (2·3%).3 According to the latest data from WHO, figures are similar in 2014.4 The lifetime prevalence of suicide attempts in adolescents in the USA is 4·1%.5 In Europe, the lifetime self-reported prevalence for similar age groups is 4·2%.6

Suicide attempts and severe suicidal ideation have potentially serious consequences, including substantial psychological effects, increased risk of subsequent suicide attempt, and death.7, 8 Importantly, suicidal behaviour also has profound negative effects on relatives and other people in the person's life.9 The medical, financial, and emotional costs to communities affected by suicide are also substantial.10 Consequently, the prevention of suicidal behaviour should be a national health priority, with the development of existing11, 12, 13 and new evidence-based, suicide preventive interventions. Research lends support to the theory that the vast proportion of psychopathological changes has its onset in childhood and adolescence,14 and therefore young people are an especially important target.15, 16 Most children and adolescents attend school, which makes these an appropriate setting for reaching young people.17 The authors of two systematic reviews of school-based suicide preventive interventions18, 19 concluded that assessments of school-based intervention programmes tested in randomised controlled trials are needed. The theoretical framework of suicide prevention programmes generally acknowledges universal, selective, or indicated approaches.20, 21, 22 School-based universal programmes include all pupils, whereas selective and indicated efforts focus on those regarded at high risk or presenting suicidal behaviour. The few randomised trials based on a universal or a selective approach have focused almost exclusively on generating change in knowledge and attitudes.19 Very few trials, all from the USA and none from Europe, have investigated changes in the reduction of severe suicidal ideation or suicide attempts.23, 24, 25, 26 In this Article, we report the results of the Saving and Empowering Young Lives in Europe (SEYLE) study, the first large-scale, multicountry, European randomised controlled trial of school-based prevention of suicidal behaviour in adolescents.27 The main hypothesis is that preventive interventions are more effective than a control condition in reducing new cases of suicide attempt and severe suicidal ideation between baseline and follow-up assessments.

Section snippets

Trial design and participants

SEYLE was a multicentre, cluster-randomised trial designed to investigate the efficacy of school-based preventive interventions for suicidal behaviour. Pupils were recruited from 168 schools in ten European Union countries (Austria, Estonia, France, Germany, Hungary, Ireland, Italy, Romania, Slovenia, and Spain). Schools were deemed eligible if they were public, contained at least 40 pupils aged 15 years, had more than two teachers for pupils aged 15 years, and had no more than 60% of pupils of

Results

Of 232 schools that were approached and randomly assigned to one of four study groups, 168 schools (72%) accepted to participate. 27 099 pupils were approached: 14 267 were not enrolled because parental consent or pupils' assent were not given, and 1722 pupils were absent from school on the day of baseline assessment. We recruited 11 110 pupils (median age 15 years [IQR 14–15], mean age 14·8 years [SD 0·8]; 59% girls). Of the 11 110 pupils with baseline assessment, 9798 (88%) were available at

Discussion

This study represents the first European, multicountry, randomised controlled trial of the prevention of suicidal behaviour in adolescents (panel). The results show that the YAM, a universal, school-based intervention of short duration (5 h in 4 weeks),29 was significantly more effective in preventing new cases of suicide attempts and severe suicidal ideation, including planning, than no intervention (the control group). The reported reduction in incident suicide attempts was more than 50% with

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