Nuñez Daniel, Meza Daniela, Andaur Javiera, Robinson Jo, Gaete Jorge
Faculty of Psychology, Universidad de Talca, Talca, Chile.
Millennium Science Initiative Program, Millennium Nucleus to Improve the Mental Health of Adolescents and Youths, Imhay, Santiago, Chile.
BMC Psychol. 2024 Dec 24;12(1):780. doi: 10.1186/s40359-024-02300-9.
Suicide prevention programs delivered in school settings have been shown to reduce suicide attempts and ideation among adolescents. School-based digital interventions targeting at-risk youth are a promising avenue for suicide prevention, and some evidence has shown that blending digital and face-to-face components may improve the effectiveness. However, further evidence is needed, especially in Latin America, where mental health support is limited. We tested the effectiveness of the Reframe-IT+, a blended cognitive behavioral indicated intervention to reduce suicidal ideation, designed to be delivered in school settings. It includes 13 sessions, combining eight internet-based sessions and five face-to-face sessions.
We conducted a cluster RCT and delivered the Reframe-IT + among secondary students attending Years 9-11. We recruited 21 schools that were randomized into two groups: (1) Intervention Reframe-IT + Group (IG) (n = 863) and (2) Control Group (CG) (n = 683). All consented students completed online screening self-reported questionnaires at baseline. The primary outcome was suicidal ideation . Additionally, we tested the impact of the intervention on depressive and anxiety symptoms, hopelessness, and emotion regulatory strategies, including social solving-problems skills, behavioral activation, cognitive reappraisal, and emotion suppression. A total of 303 students (IG, n = 164; CG, n = 139) were identified as at risk and eligible for inclusion in the study. From those, 224 students (IG, n = 123; CG, n = 101) and their caregivers were interviewed to confirm inclusion and exclusion criteria. Finally, 48 and 47 students were allocated to control and intervention groups, respectively, and answered the online questionnaires at post-intervention. We performed an intention-to-treat analysis using repetitive measures and multilevel regression analyses.
We found a significant reduction in suicidal ideation (b=-6.7, p = 0.015, Cohen´s d = 0.49), depressive (b=-3.1, p = 0.002, Cohen´s d = 0.81) and anxiety (b=-2.60, p < 0.001, Cohen´s d = 0.72) symptoms, and hopelessness (b=-3.7, p < 0.001, Cohen´s d = 0.70) in the intervention group compared to the control group at post-intervention. We also found improvement in solving-problems skills (b=-1.6, p = 0.002, Cohen´s d = 0.58), behavioral activation (b = 2.8, p = 0.019, Cohen´s d = 0.47), and cognitive reappraisal (b = 2.2, p = 0.029, Cohen´s d = 0.53). In the exploration of the intervention mechanisms concerning suicidal ideation, the total indirect effect of the intervention (b = -5.727923; p = 0.008) was significant, whereas the direct effect (b = - 0.03195473, p = 0.903) was not significant (Suppl 2, Table 1). Problem-solving skill (b=-2.84, p = 0.016) was a significant mediator of intervention effects on suicidal ideation (Path a*b).
This is the first clustered RCT evaluation of the effectiveness of a blended indicated intervention to prevent suicidality in school settings in Latin America. This is the first step to informing policymakers to scale up an effective intervention for an important public health problem.
Clinical Trials NCT05229302. Registered on January 27th, 2022.
在学校开展的自杀预防项目已被证明可减少青少年的自杀未遂行为和自杀念头。针对高危青少年的校内数字干预措施是预防自杀的一个有前景的途径，一些证据表明，将数字和面对面两种方式相结合可能会提高干预效果。然而，还需要更多证据，尤其是在心理健康支持有限的拉丁美洲。我们测试了Reframe-IT+的有效性，这是一种旨在在学校环境中实施的、结合了认知行为疗法的混合式干预措施，用于减少自杀念头。该干预包括13节课程，其中8节基于互联网，5节面对面授课。
我们开展了一项整群随机对照试验，并在9至11年级的中学生中实施Reframe-IT+。我们招募了21所学校，随机分为两组：（1）干预组（Reframe-IT+组，IG）（n = 863）和（2）对照组（CG）（n = 683）。所有同意参与的学生在基线时完成了在线筛查自我报告问卷。主要结局是自杀念头。此外，我们测试了该干预对抑郁和焦虑症状、绝望感以及情绪调节策略的影响，包括社交解决问题技能、行为激活、认知重评和情绪抑制。共有303名学生（IG组164名；CG组139名）被确定为高危且符合纳入研究的条件。其中，224名学生（IG组123名；CG组101名）及其照料者接受了访谈，以确认纳入和排除标准。最后，分别有48名和47名学生被分配到对照组和干预组，并在干预后回答了在线问卷。我们使用重复测量和多水平回归分析进行意向性分析。
我们发现，与对照组相比，干预组在干预后自杀念头（b = -6.7，p = 0.015，Cohen's d = 0.49）、抑郁（b = -3.1，p = 0.002，Cohen's d = 0.81）和焦虑（b = -2.60，p < 0.001，Cohen's d = 0.72）症状以及绝望感（b = -3.7，p < 0.001，Cohen's d = 0.70）均显著降低。我们还发现解决问题技能（b = -1.6，p = 0.002，Cohen's d = 0.58）、行为激活（b =
2.8，p = 0.01九，Cohen's d = 0.47）和认知重评（b = 2.2，p = 0.029，Cohen's d = 0.53）有所改善。在探索干预与自杀念头相关的机制时，干预的总间接效应（b = -5.727923；p = 0.008）显著，而直接效应（b = -0.03195473，p = 0.903）不显著（补充材料2，表1）。解决问题技能（b = -2.84，p = 0.016）是干预对自杀念头影响的显著中介因素（路径a*b）。
这是拉丁美洲首次对学校环境中预防自杀的混合式针对性干预措施的有效性进行整群随机对照试验评估。这是为政策制定者提供信息以扩大针对这一重要公共卫生问题的有效干预措施的第一步。
临床试验编号NCT05229302。于2022年1月27日注册。
