Best practices in prevention

Evaluation and research, together with lived experiences and service provider insight, all help in generating evidence to show what’s effective in reducing rates of youth suicide. One challenge in suicide prevention research is conducting studies with enough statistical power, because death by suicide and suicidal behaviours are generally low-frequency events. That makes it hard for us to know how well our prevention strategies are actually working. One of the key things you can do to enrich the evidence base is evaluate your own suicide prevention efforts and then share that knowledge to inform future work. That way, as the field evolves, new knowledge is bound to emerge.

While we certainly don’t have answers for everything yet, it’s important we put the knowledge we do have to work. The following youth suicide prevention strategies are ones you can implement in your community. You can use the strategic planning tool to prioritize them, based on your specific circumstances and capacity. Your approach might also differ based on the groups of youth you’re working with - refer to the special partnerships section to familiarize yourself with the unique characteristics and realities of FNIM, LGBTQ, rural and newcomer youth.

Keep in mind that policy is an important tool in youth suicide prevention. Many, if not all of these strategies may require that you create new or modify existing policies to effect change and make it last – whether it be on a small scale (e.g. policies in a single primary care office), or across the larger community (e.g. information sharing policy amongst service agencies). For more information on policy, refer to our policies and protocols section.

One last thing before you dive in: whatever the strategy being implemented, it’s crucial you remember why you do this work. Suicide prevention isn’t just about preventing death by suicide. It’s about promoting life in its most wholesome, meaningful form. Make sure this approach is foundational to your work.

 

Level of prevention effort: Universal preventionUniversalSelective preventionSelectiveIndicated preventionIndicated

What is it? Public awareness campaigns aim to improve recognition of suicide risk and help-seeking behaviour by educating the general public about causes and risk factors of suicide. They also seek to reduce stigmatization of mental illness and suicide by challenging certain misconceptions, such as the acceptance of suicide as an inevitable outcome of mental illness. Campaign formats can vary from short (single exposure) to long (multiple exposures), be conducted on a local, provincial or national scale, and involve various means (e.g. educational materials, television ads, etc.).

Why is it important? Education and awareness-raising activities are a way to help change the negative conversations and attitudes around suicide, making it easier for people struggling with suicidal thoughts and behaviours to come forward and seek help. In addition, they have the ability  to reach entire populations at once, so they’re an efficient way to put suicide warning signs on many people’s radar while also bringing attention to support resources such as helplines.

What does the research tell us? While some research suggests that public awareness campaigns can improve knowledge, awareness and attitudes around mental illness and suicide in the population, research results seem mixed on how effective they may be in promoting help-seeking behaviours 1. Overall, these campaigns seem to be more effective when they’re paired with other strategies (e.g. gatekeeper training) and when they target one or two specific issues at once (e.g. depression and suicide) as opposed to mental illness in general1.

Cautionary note: The wide-ranging influence of public awareness campaigns can be a double-edged sword. As important as their benefits may be and despite being well-intentioned, they can have the effect of normalizing suicidal behaviours under certain contexts (e.g. when suicide is wrongly presented as a common event) or exposing people to conflicting messages about it. Before launching any campaign, it’s important you do your research.

Helpful resource: The Government of Manitoba developed a set of helpful Guidelines for Public Awareness and Education Activities to help you create effective and safe public campaigns.

What is it? Mental health promotion is a general term to define community-wide approaches that aim to better the emotional and behavioural well-being of children and youth. This can include (but isn’t limited to) general mental health awareness and stigma reduction campaigns, positive youth development programs, mental health policies, school-wide social and emotional learning programs for young children, youth engagement initiatives and skills training programs.

Why is it important? Mental illness is a root cause of suicidality, so mental health promotion and suicide prevention go hand in hand. To help all children and youth flourish and rise above challenges in life, it’s crucial we give them the right tools to develop self-efficacy, positive relationships and a positive identity early on. At a community-level, mental health promotion helps break down systemic barriers by promoting diversity, inclusivity and strength-based education, which ultimately helps promote population-wide health.

What does the research tell us? Though researchers agree mental health promotion is a priority, little research has actually examined how it impacts the wellbeing of young people, much less how it might affect suicidality 2. That’s because measuring population-wide mental health outcomes is a tall order for researchers – it requires lots of time (years!) and money, not to mention communities are quite complex environments to study. One study found that when youth were engaged in meaningful extracurricular activities, suicidal thoughts decreased 3. Research also suggests that school-based programs that focus on mental health promotion and strength-based approaches, rather than illness prevention, are most effective in promoting young people’s mental health, especially among Aboriginal youth 4.

What is it? Suicide awareness curricula are delivered to students in schools to educate them about the causes and signs of suicide and ways to address it. Ideally, these programs incorporate the components of mental health education, suicide awareness and gatekeeper training.

Why is it important? Suicide is a reality that’s too often tied with taboos and stigma. To encourage young people struggling with suicidality to talk to someone about it, it’s important to debunk misinformation and help everyone understand more about suicide and why it happens. And when they do feel comfortable opening up, young people are more likely to turn to their peers than adults for support, which is why it’s also important for students to know what to do about suicide risk.

What does the research tell us? There is some empirical support for suicide awareness curricula. One study suggests that the Signs of Suicide (SOS) program, which also includes a brief screening component, helped decrease suicide attempts in young people5. Other studies show that similar programs may help improve students’ knowledge and attitudes about suicide, increase protective factors in their lives and encourage them to seek help5.

Cautionary note: Suicide awareness curricula aren’t quick-fixes and can’t be used as such. Simplistic programs or approaches – for example, where experts are invited to "talk at" groups of students about suicide for an hour and then leave without the right supports to address any emotions left running high – are simply not safe or effective. We actually know these kinds of approaches can worsen suicide-related attitudes and increase hopelessness and maladaptive coping6. For them to be safe and effective, suicide awareness curricula have to be implemented thoughtfully and sensitively, and as part of a broader mental health and suicide prevention curriculum.

What is it? Restricting access to means involves prohibiting, securing or eliminating methods that a young person could use to attempt suicide. This includes efforts at the population-level (e.g. safety fences on bridges and buildings), within hospitals or intensive care facilities (e.g. getting rid of sharp objects in patient rooms) and within families’ homes (e.g. locking away prescription medication).

Why is it important? In order to give ourselves the best possible chance at preventing suicide, we have to make youth’s environments as safe as possible. Restricting access to means is one of the first things we can do to lower the chances of youth hurting themselves. At a minimum, these restrictions can decrease some young people’s motivation to engage in suicidal behaviours.

What does the research tell us? Studies show that policies such as firearm control, restrictions on pesticides, detoxification of domestic gas, restrictions on the prescription and sale of barbiturates, and construction of barriers at jumping sites have been linked with reduced deaths by suicide in the general population6. The effectiveness of these strategies may differ based on which country they’ve been implemented in.

Cautionary note: Restricting access to means does not add up to safety. It’s merely groundwork for suicide prevention and it’s certainly not an infallible strategy, since restricting access to one method can lead to increased use of another 7. To avoid creating a false sense of safety, in any context, restricting access to means should always be one of several other suicide prevention strategies being implemented.

What is it? Media reporting guidelines aim to educate journalists and other media reporters about how to make suicide-related news stories safe, responsible and sensitive. Some of the main guidelines given to journalists are not to sensationalize suicide deaths or provide details on suicide methods.

Why is it important? Suicide is a painful and emotional topic. If that’s not taken into careful consideration, media stories about suicide can be triggering for some audiences and worse even, potentially lead to contagion. In fact, extensive research shows that irresponsible media coverage of suicide is linked with increased suicidal behaviours 8. Media is a powerful tool – we just have to use it right. And when we do, the benefits are significant. The media can be used to broadcast powerful messages of hope, reduce stigma and increase young people’s awareness of the resources available to them.

What does the research tell us? Most past research has focused on the negative effect that irresponsible media reporting can have (the Wherther effect) and much less on the protective effect that responsible media can have (the Papageno effect)8. Some studies do show that when we implement newspaper blackouts, keep media reporting to a minimum and improve on the quality of media reporting in the event of a death by suicide, suicide attempts and deaths tend to go down9.

Helpful resource: For more information on media reporting guidelines in youth suicide prevention, see our Working with the media page. It covers what terms, ideas and messages that should be avoided in media reporting, along with messages that may be helpful to convey.   

What is it? Skills training programs are mental health promotion programs designed to foster better coping, problem solving, decision making and other important life skills in young people. For convenience, these programs are delivered in schools, ideally starting as early as elementary school.

Why is it important? These programs don’t always focus explicitly on suicidality, but their potential impact on young people’s well-being makes them extremely relevant for suicide prevention. Youth who feel better equipped cognitively, emotionally and socially to face challenges in life are less likely to experience suicidal thoughts or engage in those behaviours.

What does the research tell us? There’s research to show that skills training programs can work. For example, one study showed that the Good Behaviour Game program can help reduce suicidal ideation and behaviours5. Another study suggests that the Zuni Life Skills program, which targets Aboriginal youth, was effective in reducing suicidal thoughts, behaviours and hopelessness, as well as in increasing problem-solving, although the program could have been improved by being more inclusive of traditional healers and parents10. The research remains mixed on the extent to which skills training programs are effective in motivating youth to seek help and increasing protective factors in their lives5.

What is it? Web-based suicide prevention strategies include any and all efforts aimed at making the internet safer and more helpful from a suicide prevention perspective. That includes giving support resources more visibility online and tracking worrisome messages on social media sites. In that same vein, online support services are programs, developed and delivered by mental health professionals, that use internet modalities such as chat, e-mail or discussion groups to help people who struggle with depression and suicidality.

Why is it important? The internet and social media have become a part of everyone’s average day and that has undeniable implications for suicide prevention. It’s more and more intuitive for young people to seek help online11,12. It’s also increasingly common for suicide attempts to be preceded by messages of distress on social media12. We have to keep up with the times. Web-based prevention and support services are necessary to respond to these new modern-day needs.

What does the research tell us?  Research in this emerging area of suicide prevention is still very limited, especially with young people11. In one study, at-risk college students who chatted anonymously with a therapist online were three times more likely to attend an in-person evaluation and enter treatment than those who didn’t engage in online discussions11. We need more research to better understand how these programs can work.

Cautionary note: The internet is a double edged sword. While incredibly convenient, it can also lead to things getting out of hand very fast, very easily. To ensure that conversations are safe and that no dangerous ideas (e.g. suicide methods) are left free to circulate, online discussion platforms have to be closely moderated by trained professionals.

Helpful resource: The website preventtheattempt.com was developed for organizations with an online presence (e.g. website, blog, Twitter, Facebook, YouTube) and who, by the same token, have the potential to encounter someone suicidal. The site provides best practices for responding to those in crisis online. It offers three levels of response for organization to choose from.

What is it? Suicide prevention training for primary care physicians involves teaching doctors how to screen for, recognize and address mood disorders (e.g., depression) and suicidality in their patients.

Why is it important? We know that the large majority of people who died by suicide saw a doctor within a year of their death and over half within the month prior to their death6. We also know that depression, one of the most potent risk factors for suicide, is underdiagnosed in adolescents in the primary care setting6. Primary care settings have immense potential as prevention sites. It’s our job to equip primary care physicians with the right tools so that we can exploit that potential.

What does the research tell us? Studies show that training primary care physicians to diagnose and treat mood disorders can help reduce the number of suicide attempts6. One study also showed that one-day training helped primary care physicians identify teens experiencing psychological distress and suicidal thoughts in practice6.

What is it? Screening is a method for identifying young people who may be at risk for suicide. Groups of students (either at-risk students or all) fill out questionnaires about suicidal thoughts, behaviours and suicide risk factors such as depression and substance abuse. Afterwards, those who appear to be at increased risk are offered support and/or guided towards treatment.

Why is it important? Youth who struggle with suicidal thoughts and behaviours are under-identified and many struggle with untreated mental illness. Screening is a straight-forward, efficient way to find these youth and get them help.

What does the research tell us? One study reported that suicide screening increased help-seeking in students, as the majority of those who screened positive and were referred to mental health services (70%) followed up with their referral13. Suicide screening has also been incorporated into Signs of Suicide, a suicide awareness curriculum that was shown to be successful in reducing suicide attempts in one study5.

Cautionary note: Massive one-shot screenings might seem like a good way to sweep up all risk statuses within a student body, but since suicide risk can change quickly, it’s likely they’ll miss several vulnerable students - especially when conducted at a random point in time. Ongoing screening for mental illness might be a more thorough approach, because these symptoms tend to be more stable. Suicide screenings might also be more relevant to conduct during vulnerable periods (e.g. following a death by suicide in the community) because that’s when suicidal thoughts tend to be more prevalent. At any rate, suicide screenings shouldn’t be used as stand-alone strategies, but rather as complements to other efforts. Timely referrals to mental health treatment, above all, have to follow any suicide screening. Students who screen positive need to know their call for help was heard and that help is out there.

What is it? Gatekeeper training teaches people how to recognize the warning signs of suicide, how to respond appropriately and talk to young people suspected to be at risk, and how to support them in getting help. People who can become gatekeepers are adults or peers who are well positioned to help young people by virtue of their job, their role in the community or simply their natural aptitudes.

Why is it important?  Many youth struggle in silence, so we need people who can keep an eye out for them and reach out to them when needed. Many young people also won’t seek out help themselves, so we need gatekeepers to help them take their first steps on the pathway to care. Even more valuably, if widespread enough, gatekeeper capacity can weave itself into a large human safety net for children and youth within communities.

What does the research tell us?  Several studies show that gatekeeper training programs can reduce suicide risk in different ways. The Community Helpers program, which recruits natural helpers as gatekeepers through peer nominations, has helped to build significant capacity in communities by creating links between informal (peers) and formal (e.g., service agencies) networks14. Youth who participated in the Sources of Strength program, which uses a peer leadership model, appeared to have better coping strategies, better knowledge of suicide warning signs, and seemed better able to refer peers experiencing distress to adults at school than peers who didn’t participate in the program5. Gatekeeper training programs implemented in other community settings (e.g. university residence halls) have shown similar outcomes1516. However, more research is needed to know if these programs actually help reduce suicidal thoughts and behaviours in the long run5.

What is it? Suicide hotlines or crisis lines are telephone lines, sometimes operated as networks, that people can call when they feel distressed. On the other end of the call, trained crisis counsellors provide assessment and crisis intervention to try to reduce the immediate dangers of self-harm or suicide and encourage people to get the in-person care they need.

Why is it important? Too often, young people – especially those living in rural communities - can’t access the help they need quickly enough. Suicide hotlines and crisis lines help to fill this lapse of time by providing 24/7, timely and convenient support. With a mental health system that’s overflowing with demand, the importance of having rapid and dependable services can’t be undermined.

What does the research tell us? Little research has been done on crisis lines. One reason for this is that crisis line services are anonymous, making it challenging to track callers’ progress or mental health outcomes. In one study, people who called the National Suicide Prevention Lifeline in the U.S. reported feeling less depressed, less suicidal, less overwhelmed and more hopeful by the end of calls handled by ASIST-trained counsellors17. We need more research, as well as more insights from past callers, to determine how to make these services as effective as possible.

What is it? Psychological treatment (or psychotherapy) is the treatment of mental disorders such as mood and anxiety disorders, which commonly underlie suicidal thoughts and behaviours. By definition, psychotherapy doesn’t involve the use of medication, although they’re often paired in practice.

Why is it important? Mental illness is a root cause of suicidality, so mental health treatment and suicide prevention go hand in hand. When engaged in meaningful and effective mental health treatment, youth can learn new and better ways to cope with adversity, and trade feelings of hopelessness for life-oriented goals.

What does the research tell us? Research on psychotherapy for suicidal youth is still limited compared to adults5, though some approaches show promise. Some studies show that cognitive-behavioural therapy can be effective in reducing suicidal thoughts and behaviours, though other research shows it’s not effective if focused strictly on distress and symptoms5. That underscores the importance of making treatment meaningful by helping young people find hope and ways to thrive, not just to reduce symptoms. Furthermore, one study suggests that dialectical behaviour therapy is effective in reducing suicidal thoughts and behaviours in young people5 and other research shows similar results for multi-systemic therapy6. We need more research to develop treatments for suicidality.

What is it? Psychiatric treatment (or pharmacotherapy) is the use of medication to treat mental health disorders which commonly underlie suicidal thoughts and behaviours.

Why is it important? In serious cases of mental illness, we need medication to restore normal levels of neurotransmitters in the brain and alleviate acute symptoms. By doing so, medication can help young people function better in day-to-day activities and bring them to a headspace where they can dedicate attention and energy to recovery.

What does the research tell us? Research on medications, more particularly on anti-depressants, is mixed and controversial. On one hand, some studies show that anti-depressants can increase the risk for suicidal thoughts and behaviours, suggesting they might be dangerous, while other research shows they reduce suicidality overall by effectively treating severe depression5,6. Researchers think there’s mainly a risk for increased suicidality in the first month of taking anti-depressants, which is when many of the latter studies were conducted6. This speaks to the importance of monitoring youth closely while on medication, especially during the first month of psychiatric treatment.

Cautionary note: For most youth, medication shouldn’t be used as a sole treatment method. Pharmacotherapy can have a healing effect chemically speaking, but it’s not usually enough to help a young person thrive emotionally, cognitively and socially in the face of a serious mental illness. And when left unmonitored, medication can actually cause young people more harm than good. To maximize the effectiveness of mental health treatment, medication should be closely monitored and used in combination with psychological treatment.

What is it? Emergency department (ED) care for suicidal youth takes the form of brief, rapid interventions delivered in the ED to problem solve with the family about ways to keep the youth safe and encourage them to seek the appropriate help after they return home. Then, follow-up care, which is offered to the young person for a period of time following hospital discharge, can take the form of follow up sessions with a counsellor, home visits by a case manager or staff checking in with the youth periodically via text message, phone calls, letters or emails.

Why is it important? The ED is the place we send young people to when there’s an imminent suicide risk, which makes it an important site for suicide prevention. What happens after the ED also warrants attention since we know that many young people re-attempt suicide within one month after their stay in hospital. We need to make the ED a turning point in the lives of young people. ED-based and follow-up care are opportunities to bridge youth to community care and ensure they get the support they need.

What does the research tell us? Studies suggest that ED interventions combined with follow-up care have helped reduce deaths by suicide and suicide-related hospitalizations, and also helped young people engage in treatment5. Those are promising results, however it’s worth noting that the research on ED and follow-up care with adults isn’t as positive, with most intervention models falling short of reducing suicide risk in the long term18. We have to keep finding ways to improve these services and make them as impactful as possible.

What is it? Reducing the harmful use of alcohol is a multifaceted, multilevel prevention strategy that encompasses all efforts to reduce problematic drinking behaviours among youth. While government authorities have a primary role in enforcing relevant policy around drinking (e.g. increasing the drinking age), communities can also lead important local efforts such as health promotion initiatives (e.g. supporting alcohol free environments for youth), intervention programs (e.g. community programs for sub-groups at risk) and treatment (e.g. for substance use and concurrent disorders).

Why is it important? Substance abuse is an important risk factor for suicidal behaviour, not to mention alcohol consumption can worsen mental health problems19. Minimizing harmful drinking can therefore help to minimize suicidal behaviours.

What does the research tell us? Research shows that increasing the minimum drinking age and increasing taxes on alcohol are strategies linked with reduced suicide rates20,21. Based on the evidence, researchers recommend that intervention approaches for substance use disorders integrate different therapeutic strategies such as peer support, school-based programmes, psychological treatment and medication22. FNIM youth may benefit more from holistic programs that focus on increasing protective factors in their lives23.

Helpful resources:
The World Health Organization developed a Global strategy to reduce the harmful use of alcohol. The report includes policy options and interventions for communities.
 
The Canadian Centre on Substance Abuse (CCSA) developed a topic summary, titled Substance Use and Suicide among Youth: Prevention and Intervention Strategies, which discusses the relationship between substance use and suicidality, identifies the most at-risk youth, and presents several prevention and treatment approaches for youth who are using substances and are at risk for suicide.

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