Evaluating primary suicide prevention in adolescents with risk factors (ESPAIR)

Background and rationale. Suicide is a leading cause of death in adolescents. As it is preventable, suicide prevention has become a critical public health priority worldwide. Previous encouraging findings, including our own preliminary research in Switzerland, showed that primary suicide prevention interventions are effective to promote suicide awareness and reduce suicidal thoughts in adolescents. The framework of these interventions is psychoeducation, aiming at improving knowledge on suicide and ways to seek help. However, an important gap is the lack of studies conducted among vulnerable populations (i.e., marginalized, disengaged, and disadvantaged populations). These populations, who lack access to (primary) health care, have an increased risk of suicidal behaviors because of biological, psychological, and social risk factors. To date, no primary suicide prevention intervention has been tested in vulnerable adolescents and high-quality studies are therefore needed to identify potential benefits.

 Objectives. This project aims to test the efficacy of a brief primary suicide prevention intervention in vulnerable adolescents, using a cluster randomized controlled trial (RCT). The primary objective is to test the one-week efficacy of the intervention on a composite measure of suicide awareness. Secondary objectives will test the three-month efficacy of the intervention on the composite measure, and the one-week and three-month efficacity on the scores of 1) knowledge of suicide, 2) knowledge of local resources, 3) suicidal thoughts, and 4) psychological distress. We will also explore additional topics which are challenges in vulnerable populations: 5) access to primary suicide prevention, and 6) non-response bias.

Methods. We will conduct an open Swiss superiority cluster RCT with two parallel arms (randomization 1:1, stratified on 8 sites). Participants (aged 14-25) will be randomized to intervention (90-minute primary suicide prevention intervention) or control (90-minute art-based intervention) groups. The intervention will be conducted by a specialized organization, Stop Suicide, with a trained facilitator and a psychologist, in groups of on average 10 adolescents. It aims at improving knowledge on suicide and providing information on ways to get support, as well as improving confidence and willingness to seek help. The intervention has already been successfully tested in a previous trial, not focusing on this population. The study will include a baseline assessment, one-week, and three-month follow-up, with a 2.5-year data collection phase. Vulnerable adolescents include adolescents 1) detained in juvenile detention centers, 2) disconnected from school, 3) in treatment for psychiatric disorders, and 4) forming part of sexual or gender minority. The minimum sample size to detect a three-point difference on the suicide awareness scale with 80% power is n=180. We plan to include n=240 to handle potential attrition and include 2 to 4 clusters per site. Data will be analyzed using mixed-effect regression models with inverse probability of attrition weighting and controlling for baseline factors.

Expected value of the proposed project. We expect that the brief primary suicide prevention intervention will increase suicide awareness and decrease suicidal thoughts and psychological distress. Strengths of this proposal include: 1) unique collaboration between clinicians, epidemiologists, experts in suicide prevention, social scientists, and educational specialists; 2) use of a gold standard design, 3) use of a proven intervention for general population, and 4) excellent statistical power. The ESPAIR project will provide relevant findings to address the current lack of high-quality evidence for primary suicide prevention in adolescent. The study will provide evidence to decision-makers related to policies of primary suicide prevention and protection of vulnerable adolescents.