Multimodal stepped-prevention program fails to reduce suicidal thoughts in adolescents
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Key Takeaway
Consider that this multimodal stepped-prevention program did not reduce suicidal thoughts or depressive symptoms in adolescents during COVID-19.
This cluster randomized controlled trial evaluated a multimodal stepped-prevention program for depression and suicidal ideation in 1593 adolescents aged 11-15 years across 15 high schools in the Netherlands. The intervention included screening for depressive symptoms and suicidal thoughts, gatekeeper training for school mentors, a serious game to reduce stigma, and eight CBT-based sessions for those with elevated symptoms. The comparator was screening and gatekeeper training only.
At 12 months follow-up, suicidal thoughts and behaviors increased significantly in the experimental group but not in the control group; however, neither group showed a clinically relevant change. Similarly, depressive symptoms increased significantly in the experimental group but not in the control group, again without clinically relevant change. Exact effect sizes, absolute numbers, and p-values were not reported.
Safety outcomes, including adverse events and discontinuations, were not reported. Key limitations include the adverse impact of COVID-19-related school closures, which likely overwhelmed the program's effectiveness, and the fact that few high-risk adolescents participated in the CBT-based sessions.
Clinicians should note that this multimodal stepped-prevention program did not reduce suicidal thoughts or depressive symptoms in adolescents during the pandemic. The observed increases may be due to external factors such as COVID-19, and results should not be generalized to non-pandemic settings.
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View Original Abstract ↓
Background: Suicide 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. Method: 1,593 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. Results: Multilevel 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. Conclusions: The 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 program's effectiveness. Furthermore, few high-risk adolescents participated in the CBT-based sessions.
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