Method

Results

A total of 89 publications were obtained from the databases (Science Direct = 21; PubMed = 36; PsycInfo = 32), 19 of which were excluded due to being duplicates. After reading the abstracts, based on the inclusion and exclusion criteria, 41 works were selected. The complete texts were retrieved, and, after reading them in full, another 15 were excluded as their objectives differed from those this review intended to identify, leaving 26 articles for evaluation. In Figure 1, the flowchart of decisions based on the PRISMA guidelines is presented (^{Page et al., 2021}).

Source: Adapted from ^{Page et al. (2021)}.

Figure 1 Flow diagram 

The year of publication; authorship; name, format, and duration of the preventive program; target audience of the program; and country of application were the characteristics identified in the 26 articles selected for this review. The data are presented in Table 1.

As shown in Table 1, two studies (7.7%) from the 1990s were identified, eight (30.8%) from the years between 2000 and 2010 and 16 (61.5%) between 2011 and 2021. Most of the programs (n = 18; 69.2%) were applied in the United States, with a few being identified in Asia (n = 3; 11.5%), Europe (n = 2; 7.7%), Oceania (n = 2; 7.7%) and South America (n = 1; 3.9%).

In relation to the public for whom the programs were intended, the fact that all the proposals were aimed at the school context stands out. The majority were aimed at high school (n = 10; 38.5%), elementary II (n = 3; 11.5%), university (n = 5; 19.2%) and elementary/high school (n = 2; 7.7%) students. In addition, some programs were aimed at students and school staff (e.g. teachers, inspectors, among others; n = 3; 11.5%), school staff only (n = 2; 7.7%) and students, their parents and school staff (n = 1; 3.9%).

There were several suicide prevention programs, although some of them were applied in more than one study, such as Signs of Suicide (n = 4; 15.4%), safeTALK (n = 2; 7.7%), and the Question Persuade Refer (QPR) Suicide Prevention Program (n = 4; 15.4%). There was also a great variation in the duration of the interventions, with some lasting for months, while others lasted a few weeks or more focused meetings, which lasted just a few hours.

Another highlight is the fact that most of the programs were carried out face to face (n = 17; 65.4%), followed by programs in formats that mixed in-person and online meetings (n = 7; 26.9%) and online only (n = 1; 3.9%). The work of ^{Kalafat and Ryerson (1999)} was also identified, which initially used the in-person format, with the post-test (follow-up) evaluations carried out through letters. It is important to emphasize that this is a publication from the 1990s, and the use of letters is justified due to the absence of evolved computer systems like those of today.

Next, Table 2 is presented, which describes in detail the stages of the programs. The 18 types of interventions included in the final synthesis will be presented considering the target audience (definition of the participants), materials (instruments used), and skills offered (constructs covered).

Among the suicide intervention projects, some audiences were the focus, including students, school staff, or mixed (students and staff). Most of the interventions were proposed for mixed audience (n = 11; 42.4%), including guidance for students and staff and training for the professionals. For example, the Question Persuade Refer (QPR) Suicide Prevention Program is intended to teach and train all professionals in the school (administrators, teachers, educational assistants etc.) and provide educational lectures for students.

Other intervention programs were focused only on students (n = 5; 27.8%), such as the Surviving the Teens^® Program, with the aim of training emotional skills in young people at school. Finally, a few focused only on staff (n = 3; 16.7%); such as the Sources of Strength program, which aims to prepare professional members to act in the prevention of suicide in the school community.

Diverse materials, instruments, and techniques were used in these interventions. One of the most used strategies was the training of gatekeepers (n = 7; 26.9%), who are people trained to act in the recognition of at-risk individuals and, then, refer them to a specialized service, as mentioned by ^{Tompkins et al. (2010)}. There was also the use of a questionnaire and tests to assess the level of suicidal behavior in students (n = 6; 33.3%). In some publications, it was not clear which instruments were used to carry out this screening assessment. Another interesting mechanism employed in several prevention programs (n = 6; 33.3%) was the use of a follow-up and/or post-test, to check whether the students had a decrease in suicidal behavior. Various tools were used for this, with the application of psychological instruments, an information questionnaire, or even a follow-up by e-mail, to observe the student’s improvement. This post-test was carried out between 21 and 120 days after the end of the program.

All the interventions used media content (videos, slides, films etc.) and/or lectures with the aim of training or providing educational information for the professionals and students. Only one study used a fully online program - Kognito, a platform in which the user (student or school employee) learns about the universe of suicide prevention from recorded audiovisual modules.

Among the constructs addressed and skills taught in the intervention programs, all worked with the content of suicide prevention, linking it with mental health. Some interventions went beyond the content of prevention and information about suicidal behavior in the school population. More than half of the interventions addressed several constructs, such as hopelessness, identity, coping, self-efficacy, family relationships, social support, support networks, and the help of parents during the interventions. The use of cognitive-behavioral psychology approaches was evident in two studies.

In addition to the theoretical and informative part, the psychoeducation technique was present in some lectures of the programs. Didactic strategies (safeTALK) were also implemented in some situations, based on the use of information cards, which could be taken away by the students. These cards served as brief information and alerts so that the student could notice possible signs of suicide risk. In some more robust interventions, there was a more complex preparation, both for the students and for the school community, taking into account the information and the importance of working with the assumptions of mental health prevention, interconnected with various constructs, mentioned above.

Discussion

The aim of this literature review was to conduct an investigation of the literature and detail the suicide prevention programs in the PubMed, PsycInfo, and ScienceDirect databases. The main characteristics were the year of publication, program name, format (e.g., in person or online) and duration, target audience, and country of application. In a second part, the aim was to describe the main initiatives and strategies used by each program. Two aspects guided the focus of the article: firstly, the authors did not find any international studies with the aim of describing the various interventional programs (^{Katz et al., 2013}); and, secondly, identifying the main programs existing in the world could help healthcare providers, in various contexts, to develop and improve initiatives directed towards the prevention of suicidal behavior, since suicide is currently one of the main public health problems (^{Jacob, 2016}).

The results show that, over the years, there has been an increase in the number of proposals for preventive programs, largely due to the initiatives of the WHO (^{WHO, 2014}) for the prevention of suicide in various countries. Another reason that may explain the increase in literature on the subject is the fact that preventive programs are effective in combating suicide attempts and suicides (^{Turecki & Brent, 2016}), with positive impacts in different areas of people’s lives, such as family, social and economic life, mental health, among others (^{Stone et al., 2017}).

Most of the publications took place in the United States, with only one carried out in South America. Accordingly, it must be considered that the implementation of suicide prevention programs requires the presence of financial resources, trained healthcare providers, and well-established public health policies (^{Mascayano et al., 2015}). These characteristics, allied with the countries’ level of adherence to the WHO’s prevention programs (^{WHO, 2014}) could explain the fact that the United States conduct more research than the developing countries of South America.

The format of the programs also seems to be face to face mostly. However, the use of remote media has been growing, and, probably, after the coronavirus disease 2019 (Covid-19) pandemic, it will increase even more. There is a projected increase in mental health problems and, consequently, an increase in post-pandemic suicide rates. Furthermore, social isolation should encourage the development of virtual platforms for prevention, as pointed out by ^{Gunnell et al. (2020)}. Therefore, programs developed entirely for the internet are already being tested (^{van Spijker et al., 2010}), demonstrating a reduction in the frequency and intensity of suicidal behaviors.

The programs found in this study were specific to educational environments, with a focus on students and educational institutions (^{Cusimano & Sameem, 2011}; ^{Katz et al., 2013}; ^{Robinson et al., 2013}; ^{Zalsman et al., 2016}). However, it is considered important that other age groups (adults and older adults) and different contexts, such as workplaces (especially those linked to the health area) and communities (rest homes and nursing homes for older adults), be taken into account in the development of suicide prevention programs, with a view to reducing the incidence of the phenomenon more effectively (^{Turecki & Brent, 2016}). As national statistics highlight, for example, the rates of attempts and suicides among older adults have been worrying, reaching 8.9 people per 100,000 inhabitants, a rate much higher than that currently observed in the general population - 6 per 100,000 (^{WHO, 2017}).

A wide range of programs was observed: from those with a short duration and specific focus (^{Katsumata et al., 2017}) to others that are much more comprehensive in terms of training people directly or indirectly involved with the problem (e.g., school bus drivers) and of longer duration (^{Kalafat & Ryerson, 1999}). In this sense, as the WHO emphasizes, suicide is highly preventable, however, the development of a suicide prevention program must involve several actors, in addition to multisectoral and multidisciplinary collaboration, with evaluation of services, continuous training of personnel, data integration, and integrated public health policies (^{WHO, 2014}).

Several focuses were found, and in some the most common aim was the detection of people with high self-efficacy in suicide and the presence of risk factors and associated mental illnesses (e.g., depression), with the use of constructed questionnaires and scales suitable for this detection (e.g., depression, suicidal ideation, coping, and self-efficacy scales). Others were much broader and had different focuses, such as training people to identify and support students with a suicidal ideation profile, concern with family/school cohesion, or the reduction of stigma (^{Gijzen et al., 2018}; ^{Portzky & Heeringen, 2006}). Many of the programs invested in the strategy of training students, teachers, and school employees to the detection of signs of suicidal ideation expressed by students, which seems to be one of the main methodologies developed. The so-called gatekeepers seems to be an important strategy in schools, as students end up having greater access to their peers, who become a reference when they need help.

This strategy can also be used in other contexts and appears to be quite functional. For example, training nurses in detecting signs of suicidal ideation in hospital settings has increased the detection of patients with these characteristics and, subsequently, their referral to counseling services (^{Tsai et al., 2010}).

Another aspect widely used in the programs was the training of socio-emotional skills, including empathy training, discussion groups about friendships, a tutorial for senior university students regarding freshmen, training in social integration and social and family support (^{Ciffone, 2007}; ^{Katsumata et al., 2017}; ^{Strunk et al., 2014}; ^{Zinzow et al., 2020}). As highlighted by ^{Miller et al. (2014)}, family and friends seem to be important mediators in preventing the development of mental disorders (e.g., depression) and suicidal ideation, with socio-emotional skills also playing an important role in prevention. For example, ^{Sánchez-Teruel and Robles-Bello (2014)} found several socio-emotional cognitive, affective, and behavioral variables related to resilience in suicide, including self-regulation and cognitive flexibility, self-image, positive attribution style, self-control, gratitude, perseverance, impulse control, ability to ask for help in critical moments, expressiveness of emotions, sense of humor, empathy, seeking meaning in life and reasons to live. Likewise, from an ecological perspective, the authors also cited social and family support, feelings of belonging, social activism, and access to health services as some of the most important variables.

Several didactic strategies were adopted in the different programs, such as the development of booklets and information cards, discussion of the theme via groups, role-playing, psychoeducation, lectures, and workshops (^{Johnson & Parsons, 2012}; ^{Rein et al., 2018}). Specific training (e.g., persuasion by the gatekeepers in order to make the ideation holder to seek help) and the use of some techniques (e.g., cognitive restructuring, problem-solving, and relaxation) (^{Orbach & Bar-Joseph, 1993}; ^{Strunk et al., 2014}) were also found. Other suicide prevention programs demonstrated the importance of counselors within schools, as well as peer educators (^{Zachariah et al., 2018}), a school culture that is present in some countries.

The use of various teaching methods and techniques that are well documented can be useful tools in suicide prevention programs, including their use in parallel with drug interventions (^{Ougrin et al., 2015}). The study of the effectiveness of different programs may be a next step in the course of this research, however, as ^{Balaguru et al. (2013)} emphasize, such a comparison seems to be a very difficult and broad objective since the programs are highly complex and they work at different levels of ecological action (e.g., personal, relational, and microcultural levels).

It is important to remember that the aim of this study was to carry out a literature analysis in international databases, which can disregard several initiatives that occur without being published in scientific databases. The use of other keywords in the search could also reveal other initiatives. Furthermore, the gray literature was not consulted, and there may be several other initiatives and other prevention programs in this type of material. Finally, no article of origin and/or with data from Brazil was found during the review of the articles. This result does not mean that the initiatives in the country are non-existent, therefore a necessary next step (in a new future study) would be to carry out a similar search procedure in national databases, in order to identify national initiatives and/or compare international and national programs.

Final considerations

Overall, the results of the current study indicate some conclusions. Among the main ones, it can be seen that: 1. the number of publications on intervention programs in the international literature (in the evaluated databases) has been growing chronologically, in North America, specifically in the United States, the country where most articles were published on this topic; 2. most prevention programs adopted a hybrid format in the evaluation and intervention processes, mixing face-to-face and remote activities, however, totally remote programs are emerging, which will probably be very useful in this area, especially during a pandemic period; 3. all programs found were aimed at school environments, at various levels of education and age groups, which demonstrates that the school/university can be fundamental, as it brings together elements that are conducive to intervention (e.g., a controlled environment, with scheduled activities), however, there is also a need to develop intervention programs aimed at other environments, contexts and age groups (e.g., labor organizations, health environments, older adults); 4. there was a wide variation in the programs regarding their scope, objectives, focus, duration and breadth, with the programs varying from a few hours to weeks, focusing only on the individual with ideation and/or the social group (school, staff), development of specific skills in the individual with ideation and/or relationship skills among students, assistance with information on how and where to seek help; 5. various strategies/techniques and measures were used in the different programs, such as videos and discussions on the subject, role-playing, active listening, cards with information on suicide prevention, peer support training, self-report and associated risk factor measures (self-efficacy for suicide, empathy, communication, coping, hopelessness, self-regulation), semi-structured interviews, with several programs using gatekeepers as a strategy for the detection and referral to specialized services of students at high risk for suicide, besides programs to strengthen bonds between students (e.g., freshmen and senior university students).