Table 1.
Characteristics and main results of the studies included in the systematic review (N = 14)
| Participants | Intervention | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Study | Location | Sample size | Sample type | Mean age | % of male | Name of the programme | Intervention group (INT) | Comparison group (COM) | Program duration and attrition rate at post-test3 | Follow-up duration and attrition rate at follow-up | Outcomes | Instruments | Main results |
| Controlled trials with pre- and post-test | |||||||||||||
| Cross et al. [13] | New York, United States | INT = 72 CON = 75 | School staff (N = 91) and parents (N = 56) | School staff = 42.07 (SD = 10.41) Parents = 43.49 (SD = 4.65) | School staff = 23.1% Parents = 5.4% | QPR | Gatekeeper training plus behavioral rehearsal | QPR | INT = 1 h 25 min; NA CON = 1 h; NA | 3 months | 1. Knowledge | Declarative knowledge: Adapted from previous studies [52, 53]; 14 items Self-perceived knowledge: Adapted from previous studies [52, 54, 55]; 5 items |
Significant increase in both groups at post-test (d = 0.61 for INT; d = 0.74 for COM) and maintained at follow-up (d = 0.57 for INT; d = 0.46 for COM); no group (d = − 0.11 at post-test; d = 0.12 at follow-up) or interaction effects were found Significant increase in both groups at post-test (d = 2.08 for INT; d = 2.01 for COM) and maintained at follow-up (d = 1.86 for INT; d = 1.63 for COM); no group (d = 0.18 at post-test; d = 0.27 at follow-up) or interaction effects were found |
| 2. Self-efficacy | Adapted from previous studies [52–55]; 5 items | Significant increase in both groups at post-test (d = 1.27 for INT; d = 1.34 for COM) and maintained at follow-up (d = 1.22 for INT; d = 1.48 for COM); no group (d = 0.16 at post-test; d = 0.07 at follow-up) or interaction effects were found | |||||||||||
| 3. Gatekeeper skills | Adapted from Observational Rating Scale of Gatekeeper Skills (ORS-GS) Scoring System [54, 55]; 5 items | Higher score in INT compared to COM at post-test (d = 0.46); no group difference at follow-up (d = 0.25) | |||||||||||
| 4. Gatekeeper behavior | Self-reported referrals: Self-developed items; 1 item | No difference between INT and COM at follow-up (d = 0.01) | |||||||||||
| Klingman [40] | Northern Israel | 30 | Teachers and counselors | NR | 0% | Gatekeeper training in group-oriented workshop format | Gatekeeper training in problem-oriented workshop format | 3 h; NR | NA | 1. Knowledge | General knowledge: Self-developed items, 13 items | Both groups scored significantly higher at post-test (d = 3.30 for INT; d = 3.63 for COM); no significant difference between groups (d = 0.00) | |
| Identification of warning signs: self-developed items, 12 items | Both groups scored significantly higher at post-test (d = 1.36 for INT; d = 1.53 for COM); no significant difference between groups (d = − 0.23) | ||||||||||||
| Knowledge about prevention: Self-developed items, 7 items | Both groups scored significantly higher at post-test (d = 1.59 for INT; d = 0.68 for COM); problem-oriented group showed significantly more knowledge than group oriented group (d = 0.68) | ||||||||||||
| 2. Self-efficacy | Personal competence: Self-developed items, 7 items | Both groups scored significantly higher at post-test (d = 1.04 for INT; d = 1.24 for COM); no significant difference between groups (d = − 0.15) | |||||||||||
| Tompkins et al. [21] | The pacific Northwest | INT = 106 CON = 35 | School personnel | NR | 22.6% | QPR | Gatekeeper training | No intervention | 1 h; 27.7% % | 3 months, 72.3% | 1. Knowledge | Knowledge of QPR: Adapted from previous studies; 15 items | Significant increase in INT compared to COM in at post-test (d = 1.52) but not maintained at follow-up (d = 0.46) |
| Self evaluation of knowledge: Adapted from previous studies; 6 items | Significant increase in INT compared to COM in at post-test (d = 1.63) but not maintained at follow-up (d = 0.76) | ||||||||||||
| 2. Attitudes | Adapted from previous studies; 3 items | Significant increase in INT compared to COM in 1 of the 3 items at post-test (d = 0.93) and follow-up (d = 0.24) | |||||||||||
| 3. Likelihood to intervene | Likelihood to question about suicide intent: Adapted from previous studies; 4 items | Significant increase in INT compared to COM at post-test (d = 1.51) and follow-up (d = 1.26) | |||||||||||
| Likelihood to intervene: Adapted from previous studies; 7 items | Significant increase in INT compared to COM at post-test (d = 0.47) and follow-up (d = 0.33) | ||||||||||||
| 4. Self-efficacy | Adapted from previous studies; 3 items | Significant increase in INT compared to COM at post-test (d = 0.75) and follow-up (d = 0.51) | |||||||||||
| Wyman et al. [29] | United States | INT = 166 CON = 176 | School staff | 44.5 (range = 22–75) | 18.1% | QPR | Gatekeeper training | Waitlist control | 1.5 h; NA | 1 year; 22.6% | 1. Knowledge | QPR knowledge: Self-developed items; 14 items | Significant intervention effect at follow-up (d = 0.44) |
| Self-evaluation knowledge: Self-developed items; 9 items | Significant intervention effect at follow-up (d = 0.74) | ||||||||||||
| 2. Self-efficacy | Self-developed items; 7 items | Significant intervention effect at follow-up (d = 0.95) | |||||||||||
| 3. Gatekeeper behavior | Asking students about suicide: Self-developed items; 1 item | No intervention effect at follow-up (d = 0.11); significant intervention by baseline interaction effect at follow-up | |||||||||||
| Referral behaviors: Self-developed items; 6 items | No intervention effect at follow-up (d = 0.09) | ||||||||||||
| Controlled trials without a pre-test | |||||||||||||
| Angerstein et al. [49] | North Texas, United States | INT = 53 COM1 = 26 COM2 = 46 | Counselors (N = 79) and building administrators (N = 71) | NR | NR | Project SOAR | Gatekeeper training | No intervention | 18 h; 12.8% | NA | 1. Knowledge | Suicide awareness Survey; Self-developed items; 10 items | Significant higher score in INT compared to COM1 at post-test (d = 2.04); significant higher score in INT compared to COM2 at post-test (d = 1.12) |
| 2. Attitudes | Suicide awareness Survey; Self-developed items; 5 items | Significant higher score in INT compared to COM1 at post-test (d = 0.83); no significant difference between INT and COM2 at post-test (d = 0.32) | |||||||||||
| Reis and Cornell [41] | Virginia, United States | INT = 238 CON = 172 | Counselors (N = 147) and teachers (N = 263) | NR | NR | QPR | Gatekeeper training | No intervention | 1–3 h; NA | 4.7 months (range from 1–22 months) | 1. Knowledge | The Student Suicide Prevention Survey; Self-developed items; 7 items | Significant intervention effect at follow-up (d = 0.20) |
| 2. Gatekeeper behavior | The Student Suicide Prevention Survey; Self-developed items; 3 items | INT made more contract with students (d = 0.44), but made fewer referrals for mental health services (d = 0.37) and questioned fewer potentially suicidal students (d = 0.36) than did COM | |||||||||||
| Before- and after comparison | |||||||||||||
| Angerstein et al. [49] | North Texas, United States | 62 | Counselors | NR | NR | Project SOAR | Gatekeeper training | NA | 8 h; 28% | NA | 1. Knowledge | Adapted from previous study [56]; 16 items | Significant increase in knowledge at post-test for high school of both groups (d for group A = 1.75; d for group B = 0.84) and for middle school of group B (d = 1.48) but not for group A (d = 0.24) |
| Mackesy-Amiti et al. [46] | United States | 205 | School personnel and community representatives | NR | 28.3% | Preparing for Crisis | Gatekeeper training | NA | 4 h; NR | NA | 1. Knowledge | PFC Knowledge test; Self-developed items; 25 items | Significant increase in knowledge at post-test (d = 0.79) |
| Robinson et al. [47] | Australia | 213 | School welfare staff | 42.5 (SD = 10.6) | 14.1% | Gatekeeper training | NA | 1 or 2 days; 13.2% | 6 months; 20.1% | 1. Knowledge | Knowledge of Deliberate Self-harm Questionnaire [57]; 10 items | Significant increase in knowledge at post-test (d = 0.56). 26% of participants who rated at high level at post-test demonstrated a reduction in knowledge; while 70% of those who had moderate level at post-test demonstrated increase in knowledge at follow-up | |
| 2. Attitudes | Attitudes towards Children who Self-Harm Questionnaire; [57]; 17 items | No significant change was observed at post-test (d = − 0.05) and follow-up (d = 0.08) | |||||||||||
| 3. Gatekeeper skills | (1) Skills in dealing with mental illness: Self-developed item; 1 item (2) Skills in dealing with self-harm: Self-developed item; 1 item |
Significant increase in perceived skills at post-test (d = 0.78) and maintained at follow-up (d = − 0.66) Significant increase in perceived skills at post-test (d = 1.40) and maintained at follow-up (d = − 0.20) |
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| 4. Self-efficacy | (1) Confidence in dealing with mental illness: Self-developed item; 1 item (2) Confidence in dealing with self-harm: Self-developed item; 1 item |
Significant increase in confidence at post-test (d = 0.58) and maintained at follow-up (d = − 0.14) Significant increase in confidence at post-test (d = 1.12) and maintained at follow-up (d = − 0.09) |
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| Suldo et al. [43] | United States | 121 | School Psychologists | 41.1 (SD = 10.8) | 18.3% | Gatekeeper | NA | 4 h; 53% | 9 months; 66.1% | 1. Knowledge | Knowledge on prevention, intervention, postvention, and overall knowledge score: Adapted from previous study [58]; 15 items | Significant time effect in all 4 scores at post-test (d = 0.45, 0.37, 0.75 and 0.80, respectively). Significant decrease in knowledge on prevention (d = − 0.69), postvention (d = − 0.52), and overall knowledge score (d = − 0.46) from post-test to follow-up. Score on intervention maintained from post-test to follow-up (d = 0.15) | |
| 2. Self-efficacy | Perceived competence in suicide-related professional activities of prevention, assessment, referral, counselling and postvention: Adapted from previous study [58]; 5 items | Significant increase in confidence to execute all 5 suicide-related professional activities at post-test (d = 0.72, 0.62, 0.60, 0.30, and 0.61, respectively), the effect was maintained in all of the activities at follow-up (d = − 0.36, − 0.03, − 0.04, − 0.02 and − 0.17, respectively) | |||||||||||
| Confidence in working with diverse youth, in terms of culture, English language speaking, disability, sexual orientation and strong religious affiliation) around suicide issues: self-developed items: 5 items | Significant increase in all 5 populations at post-test (d = 0.58, 0.70, 0.59, 0.64 and 0.51); the effect was maintained among the first four types of diverse youths (d = 0, − 0.07, − 0.16, 0.12, respectively), and further increase in youth with strong religious affiliations (d = 0.22) at follow-up | ||||||||||||
| Walsh et al. [22] | United States | 220 | School personnel | NR | 23% | Gatekeeper training | NA | 1.5 h; 18.1% | NA | 1. Likelihood to intervene | Adapted from previous studies [59, 60]; 1 item | Significant increase in likelihood to intervene at post-test (d = 0.69) | |
| 2. Self-efficacy | Confidence: Adapted from previous studies [59, 60]; 1 item | Significant increase in confidence at post-test (d = 0.59) | |||||||||||
| Comfort in asking: Adapted from previous studies [59, 60]; 1 item | Significant increase comfort in asking at post-test (d = 0.68) | ||||||||||||
| Johnson et al. [42] | Midwest, United States | 36 | High school and middle school staff | NA | NA | QPR suicide prevention program | in-person QPR Gatekeeper training + online conference work group | NA | three 90 min sessions; 100% | Monthly email for a 3 month time period following training; 100% | 1. Knowledge | QPR Knowledge: self-developed survey; 9 items | Significant increases in means of all knowledge items at post-test (d ranged from 1.11 to 1.90) |
| Lamis et al. [44] | Atlanta, Georgia, United States | 700 | School teachers (N = 620); school administrators (N = 35); classroom aids (N = 26); guidance counselors (N = 19) | 40.24 (SD = 12.03) | 20.4 | Act on FACTS: Making Educators Partners in Youth Suicide Prevention (MEP) | Online gatekeeper training | NA | 2 h; 100% | NA | 1. Knowledge | Suicide knowledge: self-developed items; 15 items | Significant increase in knowledge at post-test (d = 1.51) |
| 2. Self-efficacy | Self-developed items; 7 items | Significant increase in self-efficacy at post-test (d = 1.66) | |||||||||||
| Santos et al. [45] | Coimbra, Portugal | 66 | School primary healthcare professionals | 41.5 (MIN = 26, MAX = 61) | 7.6 | “+ Contigo” training | Gatekeeper training | NA | three 21 h courses; 100% | NA | 1. Knowledge | Knowledge about suicide prevention: Adapted from Suicide Behavior Attitude Questionnaire [61]; 13 items | Significant increase in knowledge at post-testa |
| 2. Attitudes | Adapted from Suicide Behavior Attitude Questionnaire [61]a: 1) negative feelings towards individuals with suicidal behaviors; item no. NA 2) attitudes towards the right to suicide; item no. NA |
No significant differences in attitudes toward individuals with suicidal behaviors or towards the right to suicide at post-testa | |||||||||||
| 3. Gatekeeper skills | Perceived professional skills: Adapted from Suicide Behavior Attitude Questionnaire [61]; item no. NA | Significant increase in perceived skills at post-testa | |||||||||||
| Groschwitz et al. [48] | Baden-Wuerttemberg, Germany | 236 | school psychologists (N = 22), school social workers (N = 143), teachers (N = 55) and other school staff (N = 15) | NA | 16.9 | Strong Schools against Suicidality and Self-Injury (4S) program | Workshops | NA | 2 days; 99.6% | 6 months; 20.8% | 1. Knowledge | Adapted from Mental Health First Aid Training [62] and the Teacher Knowledge and Attitudes About Self-Injuries Questionnaire [63]; 8 items | Significant increase in perceived knowledge at post-test (d = 1.67) and maintained at follow-up (d = 1.41) |
| 2. Self-efficacy | Confidence in Gatekeeper skills: Adapted from Mental Health First Aid Training [62] and the Teacher Knowledge and Attitudes About Self-Injuries Questionnaire [63]; 8 items | Significant increase in confidence at post-test (d = 1.68) and maintained at follow-up (d = 1.56) | |||||||||||
| 3. Attitudes | Adapted from Attitudes towards Children Who Self-harm Questionaire [57]; 7 items | No significant differences in attitudes toward suicidality at post-test (d = 0.44) or at follow-up (d = 0.23) | |||||||||||
NA relevant information was not available
aThe effect size was not presented due to the necessary information not available