Effectiveness of School-Based Suicide Prevention Programs for Adolescents: A Systematic Review

Article information

J Korean Acad Psychiatr Ment Health Nurs. 2025;34(1):91-103

Publication date (electronic) : 2025 March 31

doi : https://doi.org/10.12934/jkpmhn.2025.34.1.91

Young-Ran Kweon¹, Young-Mi Kwon², Hyunsoo Ryu^,3

¹Professor, Department of Nursing, Chonnam National University, Gwangju, Korea

²PhD Student in Counseling Psychology, Department of Education, Chonnam National University, Gwangju, Korea

³Integrated PhD Student & Researcher, Department of Nursing, Chonnam National University, Gwangju, Korea

Corresponding author: Ryu, Hyunsoo Department of Nursing, Chonnam National University, 160 Baekseo-ro, Dong-gu, Gwangju 61469, Korea. Tel: +82-62-530-4966, Fax: +82-62-220-4544, E-mail: 206922@chonnam.edu

- This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (grant number RS-2022-NR075804)

Received 2024 December 11; Revised 2025 March 12; Accepted 2025 March 21.

Abstract

INTRODUCTION

Adolescence is a critical developmental stage characterized by significant psychological, emotional, and physical changes. These changes are often associated with stress from identity formation, academic pressures, and social relationships [1]. Such factors can increase the risk of emotional instability and mental health challenges, including depression and suicidal ideation [2]. Mental health issues during adolescence can have enduring consequences on individual well-being and impose significant burdens on public health systems. Therefore, targeted interventions are essential to address these risks effectively.

Across the globe, one of the most common causes of adolescent mortality is suicide. In South Korea, the youth suicide rate is significantly higher than the average among member countries of the Organization for Economic Cooperation and Development (OECD)[3]. This heightened vulnerability is attributed to adolescents' developmental transitions and increased emotional sensitivity [4]. Adolescents who feel trapped in their environment-such as at school or home-may perceive suicide as their only escape, increasing the likelihood of suicide attempts [5]. Addressing suicide prevention in this population is not only an individual concern but also a societal imperative, requiring evidence-based strategies to mitigate risk factors and strengthen protective mechanisms [6].

Schools provide a uniquely accessible and structured environment for suicide prevention efforts [7]. Universal prevention, which aims to reduce risk factors and promote mental well-being across entire populations regardless of individual risk, targets the broader student population in school-based programs by reducing stigma and promoting mental health awareness [8]. Furthermore, integrating suicide prevention programs into students' daily routines enables early detection and intervention for suicide-related behaviors [9].

Systematic reviews of adolescent suicide prevention programs have revealed several limitations. While previous studies have examined a broad age range, they have not provided sufficient insight into age-specific interventions [10]. Additionally, much of the existing research has focused primarily on gatekeeper training programs for educators and counselors, with limited attention given to student-targeted interventions [11]. Prior research evaluated programs with combined educational and screening components [12], but without separate assessments, the individual impact of each remains unclear. These gaps highlight the need for more targeted research on the direct effects of school-based suicide prevention programs specifically designed for adolescents.

Several school-based suicide prevention programs have been widely implemented to address adolescent suicide risk. The Signs of Suicide (SOS) program, integrates two key suicide prevention strategies: raising awareness through educational curricula and screening for depression and other suicide risk factors [A1-A4]. Curriculumbased suicide prevention programs provide structured educational interventions aimed at increasing students' awareness of suicide risk factors and fostering help-seeking behaviors [A5,A6]. The Saving and Empowering Young Lives in Europe (SEYLE) program is a multicenter, cluster-randomized trial designed to evaluate the effectiveness of school-based interventions in reducing suicidal behavior [A7]. Sources of Strength is a peer-led suicide prevention program that enhances protective factors by training peer leaders to promote mental health awareness and deliver schoolwide messaging [A8]. Furthermore, prior systematic reviews [7,12] have largely included diverse study designs, such as non-randomized controlled trials (NRCTs), observational studies, and quasi-experimental designs. While these methodologies provide valuable insights, randomized controlled trials (RCTs) remain the gold standard for assessing program effectiveness. To address these limitations, this study systematically reviewed randomized controlled trials (RCTs) to ensure methodological rigor and minimize bias [13]. Using the Risk of Bias 2.0 (RoB 2.0) framework, this review systematically evaluated the structure, components, and effectiveness of school-based suicide prevention programs for adolescents. The findings are intended to guide the creation of developmentally appropriate strategies to improve adolescent mental health and prevent suicide.

Therefore, this study systematically evaluates the structure, components, and effectiveness of school-based suicide prevention programs for adolescents, with a focus on their impact on suicide attempts, knowledge or attitudes about suicide, and help-seeking behaviors.

METHODS

RESULTS

1. Study Selection

The study selection process began with the identification of 1,738 records from various databases: PubMed (n=172), Cochrane Library (n=1,145), EMBASE (n=101), CINAHL (n=34), PsycINFO (n=180), KMBASE (n=67), KoreaMed (n=7), and Science ON (n=32). During the initial screening phase, 257 duplicate records were removed using EndNote, and 180 ineligible records were excluded using Excel's conditional formatting. This step left 1,301 records for title and abstract screening. During this phase, 1,228 records were excluded for the following reasons: 14 were not randomized controlled trials (RCTs), 119 did not focus on adolescents, 1,027 were not school-based universal programs or involved ineligible settings, and 68 were not written in English. Consequently, 73 studies were selected for full-text retrieval, of which 43 records could not be obtained. The remaining 30 full-text articles were evaluated for eligibility. Among these, 22 studies were excluded: 14 were not RCTs, one did not focus on adolescents, and 15 were not related to school-based programs. Ultimately, eight studies met all the inclusion criteria and were included in the systematic review. This process ensured methodological rigor and is summarized in the PRISMA flow diagram shown in Figure 1.

Fig. 1.

Flow diagram showing the process of selecting articles for the present study.

2. Quality of the Included Studies

Based on the RoB 2.0 assessment, five studies (62.5%) [A1-A3,A7,A8] were rated as "low risk" in the randomization process (D1), while three studies (37.5%) [A4-A6] were rated as "high risk" due to insufficient information on randomization or baseline comparability. For deviations from intended interventions (D2), seven studies (87.5%) [A1-A4,A6-A8] were rated as "low risk" due to proper blinding or appropriate statistical adjustments, while one study [A5] had "some concerns" due to unaddressed awareness of group assignments by participants or intervention providers. Bias related to missing outcome data (D3) was assessed, with five studies (62.5%) [A2-A4,A7, A8] were judged to be at "low risk," while one study (12.5%) [A1] had "some concerns due to lack of clarity regarding reasons for missing data." In contrast, two studies (25%) [A5,A6] were rated as "high risk" due to significant missing data without corrective measures. For the bias due to the outcome measurement (D4), five studies (62.5%) [A1-A3,A7,A8] were rated as "low risk" due to appropriate and consistent measurement methods. One study (12.5%, [A4]) was rated as having "some concerns", due to insufficient details about measurement consistency, and two studies (25%, [A5,A6]) were rated as "high risk" due to inappropriate methods or potential bias from group assignment awareness. For selective reporting, two studies (25%, [A7,A8]) were rated as "low risk" because their results were based on predefined analytical plans. However, six studies (75%, [A1-A6]) were rated as having "some concerns" due to unclear reporting practices or the potential for selective reporting.

The overall risk of bias across the included studies was "high risk". While the majority of studies demonstrated methodological rigor in key areas such as randomization and intervention control, issues related to missing data, outcome measurement, and selective reporting were observed in a significant number of studies, particularly those rated as "high risk" in specific domains [A4-A6]. These findings highlight the need for caution when interpreting results, and future research should prioritize improving study design by addressing biases in randomization, intervention implementation, outcome measurement, and selective reporting to enhance the reliability of findings. A detailed summary of these results is provided in Figure 2.

Fig. 2.

RoB 2 Summary & Traffic-light plot of included studies.

3. Characteristics of the Participants and Studies

Among the included studies, one study [A7] focused on adolescents aged 14~16 years across multiple European countries. The remaining studies targeted school populations in the United States, with six studies involving high school students [A1-A3,A5-A7] and one study involving middle school students [A4]. Sample sizes varied significantly, ranging from 200 participants [A5] to 8,000 participants [A6]. Intervention and control groups were generally evenly distributed, with approximately 50% of participants assigned to each group. The included studies were published between 1991 and 2016. Among them, one study was conducted in Europe, while the remaining seven studies were conducted in the United States. A detailed summary of study characteristics, including authors, publication year, country, school grade, and sample size, is provided in Table 1.

Table 1.

Characteristics of Participants, Interventions, and Measurement

DISCUSSION

This study employed a systematic review methodology to evaluate the characteristics and effectiveness of schoolbased suicide prevention programs for adolescents, focusing specifically on their impact on suicide attempts or ideation, mental health knowledge or attitudes about suicide, and help-seeking behaviors.

According to the study selection and analysis of the quality of included studies, the findings reveal substantial gaps in the literature, as only eight studies met the inclusion criteria. This underscores the urgent need for more rigorous research to develop standardized, scalable, and evidence-based programs, ensuring equitable access to effective suicide prevention resources across diverse educational settings [17]. Critical methodological concerns were also identified. While some studies demonstrated a low risk of bias in randomization and intervention control, others exhibited limitations such as missing data, selective reporting, and inconsistent measurement methods. These issues may undermine the reliability and generalizability of findings, as bias in mental health interventions can distort interpretations of effectiveness [18]. To address these concerns, future research should adhere to rigorous methodological standards, including clearly defined randomization processes, comprehensive strategies for managing missing data, and transparent reporting practices, as emphasized by Moher et al. [19]. Strengthening methodological rigor will enhance the reliability of findings and contribute to the development of more effective schoolbased suicide prevention programs.

Regarding participant and study characteristics, developmental factors played a critical role in intervention effectiveness. Programs for high school students primarily relied on psychoeducational approaches and cognitivebased strategies, whereas interventions for younger adolescents incorporated interactive, emotionally engaging techniques such as role-playing and storytelling [A4,A7]. These findings align with previous research emphasizing the need for developmentally tailored interventions that consider cognitive maturity, emotional regulation skills, and appropriate engagement strategies [20]. Geographic distribution also influenced intervention outcomes. While SEYLE [A7] was conducted across multiple European countries, most studies were based in the United States, raising concerns about the generalizability of findings across different educational and mental health systems. Variability in mental health literacy, access to school-based resources, and cultural attitudes toward suicide prevention may affect program effectiveness. Research suggests that culturally tailored interventions improve engagement and outcomes, particularly in diverse school settings where stigma and barriers to mental health care differ significantly [21]. Sample size and study design also played a role in intervention effectiveness. Larger studies, such as A6 with 8,000 participants, provided strong statistical power but faced challenges in maintaining implementation fidelity across diverse school settings. Conversely, smaller studies allowed for more controlled assessments but had limited generalizability. Future research should adopt mixed-methods approaches that assess both quantitative outcomes and qualitative participant experiences to provide a comprehensive evaluation of intervention impact [22].

Based on the analysis of intervention characteristics, significant gaps exist in current suicide prevention strategies, particularly the lack of standardized, universally applicable school-based approaches. While structured programs provide effective prevention, their impact varies by duration, content, and delivery methods [23]. Shortterm programs like SOS (1~2 hours) efficiently addressed immediate concerns, whereas longer interventions like SEYLE, spanning multiple sessions, showed sustained benefits such as improved coping skills and emotional resilience. This suggests that program duration is critical, with extended interventions and follow-up reinforcement enhancing knowledge retention and long-term behavioral change [24]. A hybrid model-combining an intensive workshop with periodic booster sessions could balance time constraints with program effectiveness [25]. Content and delivery methods also influenced outcomes. Psychoeducational approaches improved mental health literacy and reduced stigma. Lecture-based education, combined with interactive discussions, raised awareness, while experiential learning (e.g., role-playing, used in 87.5% of programs) fostered emotional resilience and decision-making skills [26]. Creative methods, such as storytelling and artbased expression, enhanced engagement and relatability [A8]. Given that adolescence is a crucial period for cognitive and emotional development [1], integrating structured mental health education into school curricula can strengthen resilience and reduce suicide risk. These findings underscore the need to tailor interventions to developmental stages while maximizing accessibility and sustainability in school settings

According to the analysis of outcome measures, intervention outcomes were categorized into three domains: reduction in suicide attempts or ideation, improvement in mental health knowledge or attitudes, and changes in help-seeking behaviors. Effectiveness varied; SEYLE reduced suicide attempts by 55%, demonstrating strong preventive impact [A7]. In contrast, SOS, designed for younger adolescents, had limited success in this area, suggesting that developmental factors and intervention duration are key determinants [A4,A27]. While school-based programs improved mental health literacy and help-seeking behavior, their success depended on factors such as age group, implementation methods, and supportive components like parental involvement and follow-up sessions. Some studies [A1-A5,A8] assessed outcomes within 1~6 months, leaving long-term effects uncertain. Without follow-up, students may revert to prior behaviors, reducing intervention sustainability. Future research should prioritize extended follow-ups to determine whether initial gains translate into lasting behavioral changes. Reinforcement mechanisms, such as refresher courses and peer support networks, could help maintain positive outcomes.

While psychoeducational interventions increased awareness, attitudinal shifts were inconsistent [A4], highlighting the need for complementary strategies to reinforce behavioral change. Psychological model provide insight into intervention effectiveness. The Health Belief Model (HBM) suggests that individuals take preventive action when they perceive higher personal risk and tangible benefits [28]. Given the mixed results in help-seeking behavior, integrating these models could optimize intervention strategies. Help-seeking improvements varied. Sources of Strength increased peer leaders' willingness to seek help, while SOS showed mixed results [A1-A4,A8]. Awareness alone is insufficient; interventions must actively reduce stigma and teach skills for seeking help. Steinberg [1] notes that help-seeking is shaped by individual factors (e.g., self-efficacy, stigma) and systemic factors (e.g., resource availability, school climate). Addressing these barriers requires normalizing help-seeking through peer testimonials and stronger student-adult relationships [29].

Future research should incorporate objective measures, such as school counseling utilization rates, to assess program impact more accurately. Emerging evidence suggests that digital interventions, such as mobile apps, online counseling, and AI-driven mental health tools, could complement traditional programs [21]. These scalable, cost-effective solutions enhance accessibility, particularly for students hesitant to seek face-to-face help. A hybrid approach combining digital resources with in-person interventions may improve engagement and effectiveness. Psychiatric-Mental Health (PMH) nurses could play a crucial role in addressing intervention barriers [30]. Their expertise in mental health education, crisis intervention, and counseling facilitates early identification of at-risk students and promotes help-seeking within schools. Collaboration between PMH nurses, educators, parents, and community organizations could enhance program sustainability and impact. However, many programs lack skill-building activities specifically targeting help-seeking behaviors. To maximize effectiveness, interventions should integrate structured peer support training and direct engagement with mental health professionals.

In summary, this study highlights the effectiveness, challenges, and future directions of school-based suicide prevention programs for adolescents. While these programs show promise, gaps remain in implementation quality, long-term sustainability, and standardized approaches. Effective interventions should incorporate structured implementation, interactive and peer-based methods, follow-up reinforcement, and involvement of trusted adults. To enhance real-world impact, policymakers should consider mandating mental health education, increasing funding, establishing national support standards, and fostering school-community partnerships. Expanding the evidence base through longitudinal studies and international collaboration will be crucial for developing adaptable and effective prevention strategies.

This study identifies several limitations. The limited number of included studies limits generalizability, and variability in implementation quality and reporting practices complicates synthesis, potentially introducing bias. Additionally, restricting the review to RCTs may limit comprehensiveness. Future research should conduct a meta-analysis once more homogeneous RCTs become available, enabling precise effect size estimations and stronger conclusions.

CONCLUSION

This study systematically reviewed the effectiveness of school-based suicide prevention programs for adolescents, focusing on suicide attempts or ideation, mental health knowledge or attitudes, and help-seeking behaviors. Interventions were effective in improving suicide-related knowledge; however, their impact on suicidal ideation, planning, and behaviors was less conclusive. Several studies showed limited or non-significant reductions in suicidal thoughts or behaviors, suggesting these programs may primarily enhance awareness rather than significantly prevent suicide outcomes. Additionally, the effectiveness in fostering help-seeking behaviors remains uncertain. Methodological limitations further reduced result reliability. Future research should prioritize developing standardized, tailored interventions for diverse adolescent populations, integrate community resources, and ensure rigorous evaluation to enhance effectiveness and sustainability in educational settings.

SUPPLEMENTARY MATERIAL

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