The role of randomized trials in testing interventions for the prevention of youth suicide

Abstract

Epidemiological considerations point to a small handful of prevention strategies that have the potential for dramatically reducing suicide rates. Nearly all of those prevention approaches involve population-based strategies to either find an increased number of individuals at high risk for suicide or to reduce the prevalence of risk factors in members of a population that, as a whole, has a relatively low rate of suicide. Few of these approaches have been evaluated in rigorous trials. We argue that there are rigorous randomized trial designs that are both feasible and ethical and can be used to test both programmes and implementation strategies for population-based suicide prevention. We review existing suicide prevention trials and introduce two new randomized trial designs that are likely to achieve sufficient statistical power. The 'dynamic wait-listed design' randomizes across different time periods and is now being used to test a gatekeeper training programme in 32 schools. It could also be used to examine suicide prevention programmes in rural areas. The multi-trial follow-up study builds on the large number of successful population-based preventive interventions aimed at reducing known risk factors for suicide in youths to see whether these also cause a reduction in rates of completed suicide.

The impact of two universal randomized first- and second-grade classroom interventions on young adult suicide ideation and attempts

“…This study is one of the few universal population-based randomized trials to evaluate impact on suicidality (Brown et al, 2007). Most other trials have been based on selected high-risk samples.…”

Methods for testing theory and evaluating impact in randomized field trials: Intent-to-treat analyses for integrating the perspectives of person, place, and time

“…Only by doing so will one be able to examine in meta-analyses how interventions may differ across risk levels (Brown et al, 2007c). Furthermore, the power that one has to look at interaction effects in a single RFT is likely to be modest (Brown et al, 2007d). However, by reporting impact across risk subgroups in each single trial, a metaanalysis can use the accumulation of these results to examine more fully the impact as a function of risk level.…”

“…This comparison may be simple, for example, a difference in observed means for each group. The comparison could also involve complex, sophisticated models with random effects, covariates, and interaction terms that are linearly or nonparametrically related to outcomes, whose outcomes themselves may have normal, binomial, count, or time to event distributions (Brown et al, 2007d;Kellam et al, 2008). Statistical inferences derived from these models are then used to infer causal effects due to the intervention.…”

An evaluation of a brief, theatre-based intervention for the prevention of adolescent cyberbulllying and suicide.

“…Gatekeeper programs focus on the recognition of suicide warning signs and the referral to appropriate help (Brown et al, 2007). This model is increasingly used as a suicide prevention approach across settings, including schools (Isaac et al, 2009;Brown et al, 2007).…”

“…Gatekeeper programs focus on the recognition of suicide warning signs and the referral to appropriate help (Brown et al, 2007). This model is increasingly used as a suicide prevention approach across settings, including schools (Isaac et al, 2009;Brown et al, 2007). Gatekeeper programs have been shown to significantly increase participant's perceived preparedness, self-evaluated knowledge, and lead to greater access to help for suicidal students (Wyman et al, 2008).…”