Where protocol meets pragmatism: Learnings from a large suicide prevention research project in Australian schools

By Eleanor Bailey.

My team has spent the better part of the past two years trying to get our large school-based suicide prevention project off the ground here in Melbourne. The project is titled “Multimodal Approach to Preventing Suicide in Schools” (or MAPSS for short), and is currently in its second of five years. For all the details please see our trial protocol [1]; in brief, the project involves the following: 1) delivering 3.5-hour suicide prevention workshops to all students in year 10^a at participating schools; 2) screening students for possible suicide risk and referring them to the school wellbeing team; 3) offering students endorsing past-month suicidal ideation participation in a RCT of internet-based Cognitive Behavioural Therapy (iCBT). Students complete four surveys over a 24-week period (baseline, 2-weeks, 12-weeks, and 24-weeks). Surveys are generally completed in class groups at school, facilitated by a member of the research team.

COVID-related disruptions aside, the roll-out of the MAPSS project has not been without challenges. Our experience with the project so far has brought to light several assumptions we made at the outset about the nature of working with schools, and we have been required to adapt certain elements of our protocol in response to the reality of the school environment. For the purposes of this World Suicide Prevention Day blog post, I wanted to reflect on three (of many!) key learnings from this project.

Learning 1: Risk management protocols need to account for resources of the school

Two measures are embedded in the surveys to screen participants for possible suicide risk. Criteria requiring follow up are: 1) scores of 1 or higher on the Suicide Ideation Attributes Scale (SIDAS) [2], indicating presence of suicidal thoughts over the past month (with scores of 21 and over considered “clinically significant”); 2) endorsing any level of current suicidal ideation, categorized as “mild”, “moderate”, or “severe” based on extent of planning and intent.

In the first iteration of our study protocol, we specified that following each survey we would compile a list of students meeting the aforementioned criteria and pass this list to the school wellbeing team. We specified that the wellbeing team would be primarily responsible for following up with the students, but that the research team would assist (e.g., by calling students and conducting brief risk assessments) if required. We also stipulated that all students would be followed up on the same day as the survey session. This was lovely and neat in theory but turned out to be completely unfeasible in practice. Some of the challenges we encountered in the early stages are as follows.

First, on average, about one-quarter of students in any given cohort were identified as needing follow-up based on the screening criteria (this could be up to 40 students on a single day). The majority of these students were scoring in the very low range on the SIDAS and reporting no current suicidal thoughts (i.e., likely to be at low risk of suicide). Second, survey sessions were often scheduled during the last period of the school day; although this was the school’s preference, it meant that students had left the school campus by the time school staff were notified about the need to assess their risk. Third, school wellbeing teams generally lacked the resources (i.e., number of team members) to conduct risk assessments with all students within the time frames specified. Fourth, although we offer suicide prevention training (ASIST [3]) to school wellbeing staff at the outset, some staff had not undergone this training before the survey session and did not feel comfortable following up with students at-risk. The cumulative effect of these challenges resulted in the bulk of the risk assessment load being passed back to our research team, and both school and research staff experiencing significant stress.

Several ethics amendments later, our current protocol better-reflects the reality of the school environment and the pressures faced by school wellbeing staff. We’ve included a system to split students into higher- and lower-priority for follow up based on their scores, with higher priority students requiring follow-up within 24 hours and allowing up to five business days to follow-up with lower-scoring students. We’ve also relaxed our requirements to follow up within the specified time frames, in that schools now have some flexibility to delay follow-up based on their prior knowledge of the student. We are strongly encouraging school wellbeing staff to participate in the ASIST training prior to the baseline survey, particularly if they have not had previous training in managing suicide risk. Finally, we now strongly recommend schools schedule assessment sessions for early in the school day and make clear the potential consequences for follow-up if they are unable to do so.

Learning 2: Students don’t necessarily want to seek help from the school wellbeing team

A core assumption of this study is that students will benefit from being identified and referred to the school wellbeing team for support. Although literature suggests this is likely to be true on a broad level [4, 5], we have observed that some students object to being referred to the school wellbeing team. This poses a challenge in terms of students’ willingness to disclose risk in their surveys; indeed, our research team have heard comments to the effect of “you can’t be honest because they will tell the wellbeing team” from students during survey sessions. To assess this, we have added a series of items to the Time 4 survey regarding the acceptability of the screening process and honesty of responses.

Anecdotally, attitudes towards seeking support from the wellbeing team appear to vary between schools, although reasons for this variation are unknown. We can speculate that perhaps the policy adhered to by some schools to inform parents about any expression of suicidal ideation may play a role. Alternatively, differences in therapeutic approaches taken by wellbeing team members and their relationship with the student body could explain variations in attitudes. A third explanation may be that school communities vary in the level of stigma surrounding mental health issues and help seeking (cultural factors could be a factor here too). At present the MAPSS study is unable to assess this, but it could be a focus in future school-based research projects.  

Learning 3: School staff should be consulted from the outset

We put substantial resourcing into involving young people in the adaption of the two main interventions used in this project, and young people were also consulted regarding the study design. Where we fell short, however, was in failing to consult school wellbeing staff in the design of the project. Had we done so, we may have been able to foresee and prepare for some of the challenges I have described above. We therefore strongly recommend that any researchers wanting to conduct research in schools consider involving school staff as well as students in the project planning phase.

Although the MAPSS project is still in its relatively early stages, we have already learned some valuable lessons and identified many opportunities for further research and work that can be undertaken to support the implementation of suicide prevention research projects in schools. A focus on creating pragmatic protocols, enhancing relationships between students and school wellbeing staff, and including school staff in studies from the outset are just a few of the areas where such opportunities lie.

Acknowledgments

Although this blog post was written by one person, getting this project to where it is today has been a monumental team effort within which I have played a relatively small role. I’d like to especially acknowledge the immediate project team – Sam McKay, India Bellairs-Walsh, Maria Veresova and Michelle Lamblin – as well as the project lead, Jo Robinson, and our clinical supervisor, Simon Rice. And special mention to the wonderful Sadhbh Byrne who was instrumental in getting the project up and running.

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^aThird-last year of secondary school (aged 15-16)

References

1. Byrne, S., Bailey, E., Lamblin, M., et al. (2021) Study protocol for the Multimodal Approach to Preventing Suicide in Schools (MAPSS) project: A regionally-based trial of an integrated response to suicide risk among secondary school students. PREPRINT (Version 1) available at Research Square [https://doi.org/10.21203/rs.3.rs-518233/v1]
2. van Spijker, B. A., Batterham, P. J., Calear, A. L., Farrer, L., Christensen, H., Reynolds, J., & Kerkhof, A. J. (2014). The suicidal ideation attributes scale (SIDAS): Community-based validation study of a new scale for the measurement of suicidal ideation. Suicide Life Threat Behav, 44(4), 408-419. doi:10.1111/sltb.12084
3. ASIST: https://www.livingworks.com.au/programs/asist/
4. Gould, M. S., Marrocco, F. A., Kleinman, M., Thomas, J. G., Mostkoff, K., Cote, J., & Davies, M. (2005). Evaluating iatrogenic risk of youth suicide screening programs: a randomized controlled trial. Jama, 293(13), 1635-1643. doi:10.1001/jama.293.13.1635
5. Scott, M. A., Wilcox, H. C., Schonfeld, I. S., Davies, M., Hicks, R. C., Turner, J. B., & Shaffer, D. (2009). School-based screening to identify at-risk students not already known to school professionals: the Columbia suicide screen. Am J Public Health, 99(2), 334-339. doi:10.2105/ajph.2007.127928

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*Article featuring photo by kyo azuma on Unsplash.