School-based prevention: No RCT or CCS has demonstrated the effect of prevention interventions provided in school settings on death by suicide. Only 2 RCTs have reported reductions in suicide attempts and ideation. Most available trials show reductions in proxy measures of SRB. Other primary studies use weaker designs (controlled or uncontrolled cohort studies). Therefore, we provide a qualified recommendation—that decision makers consider the following intervention options, considering the limited evidence currently available regarding the impact of these interventions on death by suicide, suicide attempts, and suicidal ideation and the need for implementation to be linked to rigorous evaluation. Universal prevention interventions: a) suicide awareness curriculum plus screening (that is, Signs of Suicide); b) skills training (that is, Good Behaviour Game); and c) gatekeeper training, including peer support (that is, Sources of Strength). Targeted prevention interventions: a) suicide awareness curriculum (that is, Signs of Suicide); b) skills training (that is, Good Behaviour Game); c) screening (that is, Signs of Suicide and [or] TeenScreen). Prevention of repeat suicide attempts in youth who seek care: One RCT reported that an ED intervention (brief intervention and contact) reduced death by suicide. Reductions in suicide attempts and suicidal ideation were reported based on RCTs of ED transition programs, training primary care providers to provide evidence-based depression care, and treatment of adolescent depression with antidepressants, but more evidence is needed to determine the magnitude of impact on death by suicide, suicide attempts, and suicidal ideation. To date, psychosocial interventions (manualized or nonmanualized psychotherapeutic strategies) have not been shown to reduce death by suicide, suicide attempts, or suicidal ideation or other proxy suicide risk measures— further research is needed. Therefore, we provide a qualified recommendation—that decision makers consider the following intervention options, considering the limited evidence currently available regarding the impact of these interventions on death by suicide, suicide attempts, and suicidal ideation and the need for implementation to be linked to rigorous evaluation: a) ED transition programs; b) training of primary care providers in the provision of evidence-based care for adolescent depression; b) treatment of adolescent depression with antidepressants. Prevention of repeat suicide attempts in youth who do not seek care: Almost no research has been conducted to determine the effect of prevention interventions on repeat SRB in this group of youth. Gatekeeper training and postvention may increase help seeking in these youth, which could reduce their risk of a repeated suicide attempt. Therefore, we provide a qualified recommendation—that decision makers consider the following intervention options, considering the overall lack of evidence and the need for implementation to be linked to rigorous evaluation: a) gatekeeper training (that is, Sources of Strength); and b) postvention. Sex and gender differences: Conclusions cannot be drawn regarding sex or gender differences in intervention effectiveness. However, it is known that male youth are more likely to die by suicide, with suffocation the most frequent means in Canada. Female youth are more likely to attempt suicide but less likely to die by suicide, compared with male youth. We recommend the design and evaluation of prevention interventions that are sensitive to the distinct SRB profiles of males and females. Relevance to First Nations, Inuit, and Métis Youth: Our EKS identified almost no studies conducted with First Nations, Inuit, and Métis youth meeting defined search criteria (empirical studies published in peer-reviewed academic journals). However, we are aware of numerous ongoing community and culture-based interventions across Canada, and internationally that build on emerging knowledge about why some Aboriginal communities have elevated SRB rates while others do not. Currently, we suggest that First Nations, Inuit, and Métis colleagues, non-Indigenous clinical and research collaborators, and community-based service providers review our EKS general findings, and then consider their own unique cultural and contextual factors when formulating conclusions regarding relevance to the needs of the youth in their communities. We also acknowledge and support the need for community-led and -based suicide prevention initiatives, including evaluation resources, such that unique contextual and cultural needs of Aboriginal communities are respected and incorporated into shorter- and longer-term planning. National youth suicide research to practice network: We recommend coordinated implementation of recommendations 1 through 5 within a national collaborative youth suicide research-to-practice network. The role of the network would be to identify and facilitate increased implementation of promising programs (existing or newly developed) linked to rigorous evaluation, and to eliminate the use of ineffective ones at the regional, provincial, and federal level. The network would also create the national capacity needed to conduct new research to fill priority knowledge gaps identified in our EKS, including: adequately powered RCTs to clarify the magnitude of intervention impact on death by suicide, suicide attempts, and suicidal ideation; effectiveness of programs in common use for which no evaluative data are currently available; effective, gender-sensitive prevention interventions; and effective suicide prevention strategies for Aboriginal youth.
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