A Review of Systematic Reviews: Gatekeeper Training for Suicide Prevention with a Focus on Effectiveness and Findings

Figures & data

FIGURE 1. PRISMA (Moher et al., 2009) diagram of review identification, screening, and selection.

TABLE 1. Participant, study design, criteria, and outcome of systematic reviews.

Systematic review	Participants/target audience	Study designs	Inclusion and exclusion criteria	Risk of bias	Outcome (Knowledge and skills, Self-efficacy, Attitude, and Behavior change) *ASI (All Showed Improvement) *NR (Not Reported)
Isaac et al. (2009)—13 studies	Varied/varied	1 RCT 2 Quasi-experimental 10 Uncontrolled pre/post	Exclusion: general suicide education/awareness training Inclusion: peer reviewed, training people in suicide and (or) depression management, assessed pre- and post-training outcomes. Published between 1950–2009	High	Knowledge and skills: Reported in 7 studies – ASI Self-efficacy: Reported in 3 studies – ASI Attitudes: Reported in 3 studies – ASI Intentions to intervene: - NR Behavioral change: •Intervening behavior - NR •Referral behavior - NR
Nasir et al. (2016)—5 studies	Indigenous communities/Indigenous youth	1 RCT 4 Uncontrolled pre-post	Exclusion: not gatekeeper training, published outside 2000–2016 Inclusion: targets Indigenous populations	High	Knowledge and skills: Reported in 4 studies – ASI Self-efficacy: Reported in 3 studies – ASI Attitudes: NR Intentions to intervene: Reported in 3 studies – 2 showed increase, 1 no change Behavioral change: •Intervening behavior Reported in 2 studies – 1 showed improvements, 1 no change •Referral behavior Reported in 1 study – ASI
Mo et al. (2018)—14 studies	School staff/youth student population	6 RCT 8 Quasi-experimental	Exclusion: non-school based or peers as gatekeepers, nonintervention based, single group design, post-training data only, non-English Inclusion: controlled trial (RCT or quasi-experimental design), targeted suicide prevention, gatekeeper approach, < 60% were school personnel.	Low	Knowledge and skills: Reported in 13 studies – ASI Self-efficacy: Reported in 9 studies – ASI Attitudes: Reported in 5 studies – 2 showed improvements, 3 no change Intentions to intervene: Reported in 2 studies- ASI Behavioral change: •Intervening behavior Reported in  3 studies – 2 showed improvements •Referral behavior Reported in 3 studies  – 2 showed improvements
Torok et al. (2019)—13 studies	12 school staff; one parent only/youth student population	2 RCT 3 Quasi-experimental 8 Uncontrolled pre/post	Exclusion: narrative/systematic/meta-analysis, non-English Inclusion: target audience of teachers and/or parents, reported on knowledge and attitudes	Unclear	Knowledge and skills: Reported in 10 studies – ASI Self-efficacy: Reported in 11 studies – ASI Attitudes: Reported in 8 studies – 6 showed improvements Intentions to intervene: - NR Behavioral change: •Intervening behavior Reported in  4 studies – no improvement •Referral behavior Reported in 4 studies –  no improvement with teachers, 2 showed  improvements with school counselors
Holmes et al. (2021)—24 studies	Varied/varied; one Indigenous population	2 RCT 22 Quasi-experimental	Exclusion: general mental health programs, included medical and health-care professionals. No pre/post assessment and at least one follow-up assessment. Inclusion: peer reviewed, English, published prior to October 2018.	High	Knowledge and skills: Reported in 19 studies – ASI Self-efficacy: Reported in 17 studies – all showed increase Attitudes: Reported in 7 studies – 6 showed weak short-term benefit Intentions to intervene: Reported in 11 studies – 10 showed increase Behavioral change: •Intervening behavior Reported in  11 studies – 6 showed increase •Referral behavior Reported in 11 studies  – 8 showed increase
Yonemoto et al. (2019)—16 studies	Varied/varied	10 RCT 4 Quasi-experimental 2 Uncontrolled pre/post	Exclusion: observational studies Inclusion: no restrictions on participants or populations	Low	Knowledge and skills: Reported in 14 studies – increase in 9 Self-efficacy: Reported in 10 studies – ASI Attitudes: Reported in 1 RCT study – no changes observed Intentions to intervene: Reported in 6 studies – ASI Behavioral change: •Intervening behavior Reported in 8  studies - improvements in 3, unclear in 4 •Referral behavior Reported in 8 studies - improvements in 3 x uncontrolled, unclear in 4 RCTs

* All RCTs are included in the Yonemoto et al. (2019) review.

TABLE 2. Tabular presentation for ROBIS results.

Review	Study eligibility criteria	ID and selection of studies	Data collection and study appraisal	Synthesis and findings	Risk of bias in review
Isaac et al. (2009)	✓	✓	?	✓	High
Nasir et al. (2016)	✓	×	✓	✓	High
Mo et al. (2018)	×	×	×	×	Low
Torok et al. (2019)	×	×	✓	✓	Unclear
Holmes et al. (2021)	×	?	✓	✓	High
Yonemoto et al. (2019)	×	×	×	×	Low

× = low risk; ✓ = high risk; ? = unclear risk.

Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & The PRISMA Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Medicine, 6(7), e1000097. https://doi.org/10.1371/journal.pmed1000097

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Isaac, M., Elias, B., Katz, L. Y., Belik, S.-L., Deane, F. P., Enns, M. W., & Sareen, J. (2009). Gatekeeper training as a preventative intervention for suicide: A systematic review. The Canadian Journal of Psychiatry, 54(4), 260–268. https://doi.org/10.1177/070674370905400407

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Nasir, B. F., Hides, L., Kisely, S., Ranmuthugala, G., Nicholson, G. C., Black, E., Gill, N., Kondalsamy-Chennakesavan, S., & Toombs, M. (2016). The need for a culturally-tailored gatekeeper training intervention program in preventing suicide among Indigenous peoples: A systematic review. BMC Psychiatry, 16(1), 357. https://doi.org/10.1186/s12888-016-1059-3

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Mo, P. K. H., Ko, T. T., & Xin, M. Q. (2018). School-based gatekeeper training programmes in enhancing gatekeepers’ cognitions and behaviours for adolescent suicide prevention: A systematic review. Child and Adolescent Psychiatry and Mental Health, 12, 29. https://doi.org/10.1186/s13034-018-0233-4

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Torok, M., Calear, A. L., Smart, A., Nicolopoulos, A., & Wong, Q. (2019). Preventing adolescent suicide: A systematic review of the effectiveness and change mechanisms of suicide prevention gatekeeping training programs for teachers and parents. Journal of Adolescence, 73(1), 100–112. https://doi.org/10.1016/j.adolescence.2019.04.005

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Holmes, G., Clacy, A., Hermens, D. F., & Lagopoulos, J. (2021). The long-term efficacy of suicide prevention gatekeeper training: A systematic review. Archives of Suicide Research, 25(2), 177–207. https://doi.org/10.1080/13811118.2019.1690608

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Yonemoto, N., Kawashima, Y., Endo, K., & Yamada, M. (2019). Gatekeeper training for suicidal behaviors: A systematic review. Journal of Affective Disorders, 246, 506–514. https://doi.org/10.1016/j.jad.2018.12.052

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