This is the first study examining the effects of a blended CBT-based indicated intervention to reduce suicidal ideation among adolescents in school settings. We found a significant reduction in suicidal ideation at post-intervention, which fits with prior evidence (4, 16). We additionally observed reductions in depressive and anxiety symptoms and hopelessness, as reported in previous studies (13, 47–49). Finally, in the exploratory analyses, we found that social solving-problem skills were the main mediator of the reduction in SI, depressive, and anxiety symptoms.
Our results support literature revealing that indicated iCBT-based programs can effectively reduce SI (4, 16) and that blended interventions could improve its effectiveness (20). However, only two iCBT interventions to reduce SI have been targeted at adolescents. The self-guided community-based program by Hill and Pettit (2019) showed significant effects on perceived burdensomeness, thwarted belongingness, and depressive symptoms but not on SI (50). On the other hand, the guided school-based program by Hetrick et al. (2017) yielded positive but not significant effects on SI, depressive symptoms, hopelessness, and problem-solving skills (13). Additionally, other differences may arise when comparing or studying with other interventions. For instance, we observed a slightly larger effect size and adherence to the intervention than reported by recent meta-analyses (10, 16) on iCBT interventions. Despite some similarities between our program and those by Hill & Petit (2019) (51) and Hetrick et al. (2017) (13) (e.g., sample size, iCBT-based interventions), direct comparisons must be cautionary done. Reframe-IT + is a blended intervention with a face-to-face component to reinforce specific themes (emotion recognition, understanding relationships between emotions, thoughts and behaviors, social problem-solving skills, and cognitive restructuring), highlighted as relevant aspects of traditional CBT interventions (52). Aligned with prior findings on depression and anxiety (18, 53), we hypothesized that reinforcing iCBT contents using a guided approach with adding the face-to-face component might explain our better results. However, this interpretation needs further research with a larger sample size.
A significant impact of Reframe-IT + in our study was also found on depressive and anxiety symptoms and hopelessness. By contrast, a recent meta-analysis by Sander et al. (2023) (54) of iCBT suicide preventive interventions only found significant effects on depression outcomes but inconsistent effects on anxiety and no effects on hopelessness, and the authors suggested that the revised interventions needed additional components for managing anxiety symptoms and hopelessness. Reframe-IT + has several components to help students develop social problem-solving skills, behavioral activation, and cognitive reappraisal; each could have a different role in improving outcomes beyond suicide ideation. Very few studies have explored the potential mediators of preventive interventions to understand better the mechanisms of change (55) on suicidal ideation.
To our knowledge, this is the first study providing evidence about the role of potential mediators in explaining the effectiveness of an iCBT blended intervention to reduce SI among adolescents at schools, which is highly relevant to developing evidence-based treatment decision models (10, 11). Our exploratory mediation analyses yielded that social-problem skills fully mediated the effect of the intervention on SI. Other studies have highlighted that enhancing problem-solving skills may act as a protective factor over SI (26, 56, 57). Our findings are similar to those reported by Xavier et al. (2019)(58) among adolescents and young people in Brazil, studying the effectiveness of a group and face-to-face intervention to reduce suicide ideation. Moreover, as we previously mentioned, Reframe-IT + was also effective in reducing depressive and anxiety symptoms by improving social problem-solving skills. A recent systematic review concluded that problem-solving skills seem to be the active ingredient in indicated prevention interventions for young people (59), especially in reducing depressive symptoms. The authors proposed that problem-solving skills help adolescents improve mechanisms such as cognitive appraisal, self-efficacy, and optimism (59). Specifically, social problem-solving skills may help adolescents create meaningful social relationships, find support from others, improve other cognitive skills such as inhibitory control (60), and manage depressive and anxiety symptoms using a proactive strategy to regulate these symptoms (61). More research is needed to explain the underlying pathways of how social problem-solving reduces SI and depressive and anxiety symptoms and also to understand the specific effect on these and other outcomes.
Limitations
This study has some limitations. First, although we met the sample size requirements regarding the number of schools, the recruitment rate of students was low, as found in other studies (13, 62). One explanation for the lower recruitment rate in the control arm might be related to the reduced interest of parents or main caregivers in participating due to the little incentive, knowing that the control schools will not receive the intervention but the usual care (63, 64). Second, during the interview, to confirm inclusion and exclusion criteria, more students and parents in the Intervention Group refused to participate in the study than in the Control Group. Sometimes, there could be less interest in participating in the intervention group in a clinical trial setting due to various concerns and barriers. Participants might perceive higher risks or discomfort associated with the intervention, such as potential side effects or inconvenience (63). Even though the interviewer was trained to communicate the objectives of the study clearly, a lack of understanding of the benefits and purpose of the intervention can also reduce interest (63). Trust issues with researchers, the intervention itself, and previous negative experiences can further discourage participation (65). Additionally, participants may be less inclined to engage if they do not see immediate benefits or have other competing health or personal priorities (65). Social influence and skepticism from family can also significantly diminish interest in the intervention group. Third, we used self-report questionnaires. This may overestimate the prevalence of symptoms and influence the responses due to memory biases. However, we used valid and reliable measures, and the scores of the outcomes and mediating factors were similar between groups at baseline, reducing the measuring bias effect. Fourth, we only recruited participants from public schools. Therefore, the results might not apply to adolescents from higher socioeconomic backgrounds who usually attend private schools. Fifth, our pre-post-test analyses without a follow-up have limitations on knowing the duration of the effect of this kind of intervention. The impact of psychological interventions in the school setting can diminish and disappear over time due to several factors, including the lack of continuous reinforcement, changes in the school environment, loss of student interest or motivation, and transitions to new educational levels. Additionally, external influences such as family or social issues and the need to integrate the intervention into the school curriculum can further reduce its effectiveness. We need to explore the results with the follow-up undertaken during this year. Finally, regarding the sustainability and potential scaling up of this intervention, the fact that we used an external health professional to implement the intervention with the students in the school may have limitations. While young people see school welfare staff as an acceptable source of help, there are some reasons why these professionals might not feel confident working with at-risk students. On the one hand, there is a lack of training on mental health issues among school staff, which reduces the possibility of working effectively with the students. On the other hand, school welfare staff already have a heavy workload, which reduces the chances of having the time to work with these students.