A Guide for Schools on Student-Directed Suicide Prevention Programs Eligible for Implementation under the STANDUP Act, a Rapid Review and Evidence Synthesis

Figures & data

FIGURE 1. Definition of Evidence-Based per the Elementary and Secondary Education Act of 1965.

TABLE 1. Quality levels and body of evidence recommendations based on the LEGEND system.

Quality level for study	Definition
1a^a or 1b^b	Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b	Best study design for domain (often Randomized Controlled Trials)
3a or 3b	Fair study design for domain
4a or 4b	Weak study design for domain
5a or 5b	General review, case report, expert opinion, consensus report, or guideline
Body of evidence grade for programs achieving a clinical outcome	Description
High	Sufficient number of high quality studies with consistent results
Moderate	A single well-done trial, multiple lesser quality trials, or multiple large, high-quality observational studies
Low	Studies of lesser quality or with some uncertainty
Very low	Studies with insufficient quality including descriptive studies, case series, general reviews, insufficient design or execution, too few studies, or inconsistent results

^aGood quality study.

^bLesser quality study.

FIGURE 2. Flow diagram for searches of databases, books, and other sources.

TABLE 2. Study features listed by program.

Program	Study	n	Female	Non-Hispanic White	Location(s)	Age/Grade	Length of follow-up	Suicidal behavior outcomes measured
Adolescent Depression Awareness Program	Swartz et al., 2010	3,538	Not Reported	65.9%	Maryland, U.S. Public School	9^th	6 weeks	Not Reported
	Swartz et al., 2017	6,679	50.8%	77%	Multiple states; Urban, Rural, and Suburban	Mean = 15.8 years	4 months	Not Reported
	Townsend et al., 2019	6,679	50.8%	77%	Multiple U.S. states; Urban, Rural, and Suburban	Mean = 15.8 years	4 months	Not Reported
	Beaudry et al., 2019	481	63.7%	77%	Pennsylvania, U.S. Public Schools	Not Reported	4 months	Not Reported
Adapt for Life (Surviving the Teens)	King, Strunk, & Sorter, 2011	1,030	56.1%	85%	Ohio, U.S. Suburban	9^th-12^th	3 months	28% Decrease in SI 47% Decrease in SP^a 67% Decrease in SA^a
	Strunk, King, Vidourek, & Sorter, 2014	966	49.5%	83.6%			4 days	Not Reported
American Indian Life Skills	LaFromboise & Howard-Pitney, 1994	128	64%	N/A	New Mexico, U.S.; Zuni Pueblo	Mean = 15.9 years	8 months	11% Decrease in Suicide Probability Score
Headstrong	Perry et al., 2014	380	Not Reported	Not Reported	Australia	Mean = 14.75 years	6 months	Not Reported
Lifelines	Kalafat & Elias, 1994	253	43%	Not Reported	Northeastern U.S.	10^th	3 weeks	Not Reported
Signs of Suicide	Aseltine & DeMartino, 2004	2,100	48% (Georgia, U.S.) 53% (Connecticut, U.S.)	39% (Georgia, U.S.) 6% (Connecticut, U.S.)	Connecticut and Georgia, U.S.	9^th (Georgia, U.S.) 9^th-12^th (Connecticut, U.S.)	3 months	Decrease in SA (OR = 0.63)^a Decrease in SI (OR = 0.76)^a
	Aseltine et al., 2007	4,133	48.4% (Georgia, U.S.) 48.7% (Connecticut, U.S.) 52.5% (Massachusetts, U.S.)	38.5% (Georgia, U.S.) 5.8% (Connecticut, U.S.) 82.1% (Massachusetts, U.S.)	Connecticut, Georgia, and Massachusetts, U.S.; Urban and Suburban	9^th-12^th	3 months	Decrease in SA (OR = 0.63)^a Decrease in SI (OR = 0.84)
	Schilling et al., 2014	470	40.8%	52.6%	U.S.; Military impact schools	5^th-8^th	3 months	Decrease in SI (OR = 0.59) Decrease in SP (OR-0.70)
	Schilling, Aseltine, & James, 2016	1,302	41.7%	60.2%	Connecticut, U.S. Technical high schools	9^th	3 months	Decrease in SA (OR = 0.36)^a No Change in SP (OR = 1) Decrease in SI (OR = 0.90) Decrease in SP Among At-Risk Students (OR = 0.25)
	Bockhoff et al. 2022	200	28%-47%	Not Reported	Germany	8^th-10^th	3 months	Not Reported
	Ogawa et al., 2022	188	Not Reported	Not Reported	Japan	14 years	3 months	Not Reported
South Elgin	Ciffone, 1993	324	46.9%	Not Reported	Illinois, U.S. Metropolitan	9^th-10^th	30 days	Not Reported
	Ciffone, 2007	421	40%-75%	Not Reported	Illinois, U.S. Metropolitan	9^th-10^th	3 weeks	Not Reported
STAC*	Midgett, Doumas, Peralta, Bond, & Flay, 2020	114	57.4%	59.2%	Northwest public school; Rural	Mean = 12.5 years	6 weeks	48% Decrease in SI Score^a
Sources of Strength	Wyman et al., 2010	5,308	Not Reported	41%-52% (Georgia, U.S.) 95%-98% (New York, U.S.) 94%-98% (North Dakota, U.S.)	Georgia, U.S. (Metropolitan) New York, U.S. (Rural) North Dakota, U.S. (Rural)	9^th-12^th	5 months	Not Reported
	Petrova et al., 2015	706	49.2%	91.6%	Rural and Metropolitan	9^th-12^th	Immediate	Not Reported
	Calear et al., 2022	1,633	58.2%	Not Reported	Australia	7^th-11^th Mean = 13.3 years	18 months	Not Reported
Teen Mental Health First Aid	Hart, Mason, Kelly, Cvetkovski, & Jorm, 2016	520	49%	Not Reported	Melbourne, Australia (Public, Catholic, and Independent schools)	Mean = 16 years	3 months	Not Reported
	Hart et al., 2018	1,605	44.7%	Not Reported	Melbourne, Australia (Metropolitan)	Mean = 15.9 years	3 months	Not Reported
	Hart, Cropper, Morgan, Kelly, & Jorm, 2020	1,605	44.7%	Not Reported			12 months	Not Reported
	Hart et al., 2022	891	44.7%	Not Reported			12 months	Not Reported
Unnamed Video Program	Braun, Till, Pirkis, & Niederkrotenthaler, 2021b	299	75.3%	Not Reported	Austria	Mean = 18 years	4 weeks	7% Decrease in SI After Program^a 4% Decrease in SI 4 weeks After Program
Youth Aware of Mental Health	Wasserman et al., 2015	11,110	59%	Not Reported	Europe (multi-country)	Mean = 14.8 years	12 months	Decrease in SA (OR = 0.45)^a Decrease in Severe SI (OR = 0.50)^a
	Lindow et al., 2020	436	61.3%	49%	Montana, U.S. Texas, U.S.	9^th (92%)	3 months	Not Reported
	McGillivray et al. 20221	556	56.3%	Not Reported	New South Wales, Australia	9^th Mean = 14.4 years	6 months	14% Decrease in SI Severity Score at 3months^a 11% Decrease in SI Severity Score at 6months^a

U.S.= United States of America; STAC = Stealing the Show, Turning it Over, Accompanying Others, and Coaching Compassion; SI = Suicidal Ideation; SP = Suicidal Plan; SA = Suicide Attempt; OR = Odds Ratio.

^aResults reported as statistically significant.

TABLE 3. Program features and contextual factors for implementation.

Program	Duration of program	Facilitator	Duration of facilitator training	Contents	Contact information	Costa
Adolescent Depression Awareness Program	3 hr over two to three sessions	Health Teachers or School Counselors	5 hr (online)	Depression symptoms; Stigma; Treatment	www.adapeducation.org [e-mail]	Free
Adapt For Life (Surviving the Teens)	Four 45 min sessions	Trained Facilitators from program	(done by program)	Depression and Suicide Risk Factors; Coping Strategies; Help-seeking Behaviors; Recognizing suicide warning signs	www.adaptforlife.org [e-mail]	Varies, financial support available
American Indian Life Skills	Three times per week for 30 weeks, with variations including shorter duration of more focused lessons	Teachers, cultural resource person, or mental health professionals	Self-guided curriculum; optional 3 day workshop highly recommended	Self-esteem, emotions and stress, problem-solving, self-destructive behavior, suicide knowledge and intervention, goal setting	[e-mail]	Workshop training cost varies; curriculum book purchase $29.95
Headstrong	10 hr over 5-8 weeks	Teachers	Booklet; 1 day workshop	Mood disorders; Help-seeking for self and others	www.blackdoginstitute.org.aa/education-services/school/school-resources/headstrong/ [e-mail]	Free
Lifelines	Three 40-45 min classes	Health teachers	Book purchase	Suicide information and attitudes; Warning signs; Helping peers in crisis	Hazelden Publishing	$295
Signs of Suicide	50 min	Videos and materials	Minimal required	Depression; Warning signs of suicide; Substance use; Helping peers in crisis	http://learn.mindwise.org/sos-signs-of-suicide	$300-$495 per school
South Elgin	Varies based on # of SWs and class sizes. ∼15 hr-80 hr across 3 facets	School SW	Self-guided; SW uses online materials and previous training	Mental Health literacy; Screenings and Intervention; Access to Social Workers	www.jerryciffone.com	Free
STAC	90 min w/ two 15 min booster sessions	School counselor	Self-guided; materials and video provided	Protecting Peers from Bullying	https://www.boisestate.edu/education-counselored/stac	Sliding Scale
Sources of Strength	4-6 hr of key staff; 1 hr general staff; 4 hr peer leader	Certified trainers w/ “train the trainer” option	(done by program)	Peer support; Identify trusted adults; Social connectedness	https://sourcesofstrength.org	$750-$6,000; varies by level of support
Teen Mental Health First Aid	Six 45 min sessions or three 90 min sessions	Certified instructor (video or in-person)	2-3 days in-person	Mental health literacy; Stigma; Helping peers in crisis; Skills to help others; help seeking skills	https://www.mentalhealthfirstaid.org/population-focused-modules/teens/	Varies; apply through website
Unnamed Video Program	10 min video developed by students	Six 50 min learning sessions led by psychologist	N/A	Help-seeking; Positive messaging; Stigma; Media reporting for suicide	See Braun, Till, Pirkis, & Niederkrotenthaler, 2021a	No cost; see materials on associated article to replicate design
Youth Aware of Mental Health	Five 1 hr sessions over 3-5 weeks	Trained instructors	4-5 days training; 31-page instruction manual	Suicide risk and protective Factors; Depression and anxiety knowledge; Coping skills; role play sessions	https://www.y-a-m.org/	Varies

SW = Social Worker; STAC = Stealing the Show, Turning it Over, Accompanying Others, and Coaching Compassion.

^aAt time of manuscript submission date.

TABLE 4. Grading for program body of evidence stratified by outcome.

Outcome	Program	Study	Study quality level^a	Program evidence gradea
Suicidal Thoughts and Behaviors	Adapt for Life (Surviving the Teens)	King et al., 2011	4a	Very Low
	American Indian Life Skills	LaFromboise & Howard-Pitney, 1994	3b	Low
	Signs of Suicide	Aseltine & DeMartino, 2004	2a	High
		Aseltine et al., 2007	2a
		Schilling et al., 2014	2b
		Schilling et al., 2016	2a
	STAC ^b	Midgett et al., 2020	2b	Moderate
	Unnamed Video Program	Braun, Till, Pirkis, & Niederkrotenthaler, 2021b	2b	Low
	Youth Aware of Mental Health	Wasserman et al., 2015	2a	High
		McGillivray et al., 2021	4a
Help-Seeking, for Self or Others	Adolescent Depression Awareness Program	Beaudry et al., 2019	4b	Very Low
	Adapt for Life (Surviving the Teens)	King et al., 2011	4a	Low
		Strunk et al., 2014	3b
	American Indian Life Skills	LaFromboise & Howard-Pitney, 1994	3b	Low
	Lifelines	Kalafat & Elias, 1994	3a	Low
	South Elgin	Ciffone, 1993	3b	Moderate
		Ciffone, 2007	2b
	Sources of Strength	Wyman et al., 2010	2b	Moderate
		Petrova et al., 2015	2b
		Calear et al., 2022	2b
	Teen Mental Health First Aid	Hart et al., 2016	4b	Moderate
		Hart et al., 2018	2b
		Hart et al., 2022	2b
	Unnamed Video Program	Braun, Till, Pirkis, & Niederkrotenthaler, 2021b	2b	Low
	Youth Aware of Mental Health	Lindow et al., 2020	4a	Low
		McGillivray et al., 2021	4b
Suicide Education and Awareness, Including Suicide Risk Factors	Adolescent Depression Awareness Program	Swartz et al., 2010	4a	Moderate
		Swartz et al., 2017	2b
		Townsend et al., 2019	2b
		Beaudry et al., 2019	2b
	Adapt for Life (Surviving the Teens)	King et al., 2011	4a	Very Low
		Strunk et al., 2014	3b
	American Indian Life Skills	LaFromboise & Howard-Pitney, 1994	3b	Low
	Headstrong	Perry et al., 2014	2b	Moderate
	Lifelines	Kalafat & Elias, 1994	3a	Low
	Signs of Suicide	Aseltine & DeMartino, 2004	2a	High
		Aseltine et al., 2007	2a
		Schilling et al., 2014	2b
		Schilling et al., 2016	2a
	South Elgin	Ciffone, 1993	3b	Moderate
		Ciffone, 2007	2b
	Teen Mental Health First Aid	Hart et al., 2020	2b	Low
	Youth Aware of Mental Health	Lindow et al., 2020	4b	Very Low
		McGillivray et al., 2021	4b
Resource Awareness	Adapt for Life (Surviving the Teens)	King et al., 2011	4a	Very Low
	Signs of Suicide	Ogawa et al., 2022	3b	Low
	Sources of Strength	Wyman et al., 2010	2b	Moderate
		Petrova et al., 2015	2b
	Teen Mental Health First Aid	Hart et al., 2016	4b	Very Low
	Youth Aware of Mental Health	Lindow et al., 2020	4a	Very Low

STAC = Stealing the Show, Turning it Over, Accompanying Others, and Coaching Compassion.

^aSee text for evidence evaluation methods—Evidence Levels and Evidence Grades.

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