Stratified-Care School-Based Intervention for Adolescent Suicidal Ideation

Summary

Background. Suicidal ideation and depressive symptoms are highly prevalent among adolescents, with suicide representing a leading cause of death in this age group worldwide. School-based indicated prevention programs using cognitive behavioral therapy (CBT) have shown promise in addressing these mental health challenges. The Reframe-IT+ (Chile) and CARIBOU (Canada) programs are CBT-based, individually delivered interventions targeting adolescents at risk of suicide. This study aims to evaluate a culturally adapted stratified-care model using these two interventions, matched to depressive symptom severity. Methods. This is a quasi-experimental, single-arm study with pre-post assessments and follow-ups at 3, 6, 9, and 12 months. Six secondary schools with high socioeconomic vulnerability in Santiago, Chile, will participate. Students with suicidal ideation and mild/moderate depressive symptoms (PHQ-9 \< 20) will be offered Reframe-IT+, while those with severe symptoms (PHQ-9 ≥ 20) will be offered CARIBOU. Primary outcomes include the acceptability of CARIBOU, feasibility of the stratified-care model, and implementation fidelity. Secondary outcomes include reductions in suicidal ideation, depression, anxiety, hopelessness, and improvements in functioning, quality of life, behavioral activation, emotional regulation, and problem-solving skills. Discussion. This protocol addresses the need for scalable, culturally sensitive interventions for adolescent suicide prevention in school settings. By evaluating both the process and early outcomes of a stratified-care approach, this study will generate valuable evidence to inform future large-scale effectiveness trials and policy development in adolescent mental health.

Eligibility

Inclusion Criteria:

* Inclusion Criteria for Educational Institutions

  * Located in Santiago, Chile.
  * Secondary education level (grades I-IV Medio).
  * Coeducational schools.
  * At least two classes per grade level in secondary education.
  * A minimum of 30 students per class.
  * Socioeconomic vulnerability level of ≥ 50%, as measured by the School Vulnerability Index (Índice de Vulnerabilidad Escolar - IVE-SINAE), which includes factors such as parental education and total household income.

Inclusion Criteria for Students

* Enrolled in grades I, II, or III Medio.
* Suicidal ideation within the past month, defined as a score ≥ 3 on the Columbia-Suicide Severity Rating Scale (C-SSRS).
* For the Reframe-IT+ program: mild or moderate depressive symptoms, defined as a PHQ-9 score \< 20.
* For the CARIBOU program: severe depressive symptoms, defined as a PHQ-9 score ≥ 20.

Exclusion Criteria:

* Exclusion Criteria for Students

  * Participation in a structured suicide prevention program (Reframe-IT+) during 2024.
  * Severe psychotic symptoms, such as perceptual disturbances or delusional ideas, assessed during the eligibility interview.
  * Suicide attempt(s) in the past three months, assessed during the eligibility interview.

Conditions2

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