A systematic protocol was established for the implementation of a S-BZS model, aiming to explicitly define project goals, objectives, and scope and ensuring enhanced access to quality mental health service provision. The process of contextualizing the model involved extensive consultation with diverse local stakeholders to strategically outline the implementation procedures in the Ghizer district (Figure 1). The vulnerable youth populace has limited access to psychological care within the region, further spiking the suicide risk. Therefore, the localized S-BZS model entails implementation and clinical components that are imperative for a holistic suicide care pathway as shown in Table 1.
Table 1: School-Based Zero Suicide Implementation and Clinical Components
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Category
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Description
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Implementation Components
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Connect
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Develop collaborative synergy with cross-sector organizations for suicide prevention efforts in schools
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Empower
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Engage relevant stakeholders (school administration and teachers, caregivers) in community education and mobilization using arts-based methodologies
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Train
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Building capacity of local workforce to implement evidence-based practices to suicide care
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Sustain
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Process and outcome evaluation for data-driven decision-making and institutional policy recommendations to prevent suicides
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Clinical Components
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Assess
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Conducting suicide risk screening and assessment of students in schools
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Refer
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Timely referral of at-risk individuals for suicide-specific clinical interventions
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Respond
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Provision of school- and family-level support through innovative approaches, follow-ups, and monitoring of suicide risk.
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The ‘Connect’ component implies strategic and outcome-oriented collaborations with regional and district governmental departments, academic institutions, and mental health organizations to efficiently implement field activities. These entities were actively engaged for developing systematic protocol and risk mitigation strategies for ensuring appropriate utilization of resources making iterative adjustments to the planned activities. Each leadership shared responsibility and aligned their goals for preventing suicide among youth, reflecting their commitment to assist project team for improving access to quality mental healthcare for the vulnerable populace.
A novel adaptation to zero-suicide model is an inclusion of participatory innovative approach for mental health education and behaviour change among gatekeepers. For that, the next implementation step, ‘Empower’, focuses on integrating community mobilization and sensitization activities using arts-based methodologies for parents, school leadership, mental health assessors, and community mental health supporters. The CASEL's Social and Emotional Learning Framework (Ross & Tolan, 2017; Payton et al., 2000) was integrated into the Agency-Awareness-Motivation (AAM) modules, encompassing psychoeducation, skill development, and the encouragement of help-seeking behaviors. The activities utilized expressive and reflective arts-based methodologies, including emotional regulation through body mapping, symbolic clay work, metaphorical storytelling, collective expression, and culturally adapted meditation for providing self-Awareness, Agency for coping, and Motivation to seek professional mental health services. The use of art transcends language barriers, creates safe space for creative dialogue, and enhances community cohesiveness and resiliency for a reduction in suicide cases in low-resourced rural communities.
The ‘Train’ component underscores the significance of deploying a capable and efficient workforce for rightly identifying suicide risk, humanistically interacting with suicidal individuals, and timely referring for supportive clinical interventions. It involves specialists and non-specialists contributing to the lives of at-risk individuals with variations in their roles and responsibilities. Specifically, the screening process entails the involvement of individuals from within the community, and those with lived experiences to increase communities’ trust and enhances trained staff’s sense of responsibility to rightly respond to individuals with suicidal tendencies.
There are two important clinical components within the implementation model. First, ‘Assess’, highlights the identification of suicide risk through standardized tools, coupled with a humanistic approach and brief psychoeducation and lay counselling services to ensure comprehensive and compassionate care for at-risk students. The screening and suicide risk assessment are conducted at several intervals to track the progress of each student. Those identified at elevated risk of suicide were timely referred to specialized services who can assess and develop a personalized evidence-informed suicide care management plan, indicated as the ‘Refer’ component. Pre-set schedules for specialized psychological services were defined to systematically streamline the referral mechanism through a direct way (connecting students with specialists) or an indirect way (connecting students with specialists via schools). It further entails the provision of suicide-specific and evidence-informed clinical intervention to those identified at elevated risk of suicide. Following that, the ‘Respond’ component emphasizes on engaging at-risk student population in ABM-informed activities, as well as care partner, family, and school-level involvement to create nurturing space for their child for risk reduction and treatment adherence, follow-up, and monitoring of suicide risk.
The implementation component, ‘Sustain’ signifies the utilization of evidence generated through implementing the clinical measures in decision-making and improving the overall procedures for reducing the suicide rate. It also involves the evaluation of processes and individual outcomes to devise institutional policies and integration of a holistic suicide care system within schools. This also highlights the need for providing the academic leadership an ownership for sustaining these efforts for long-term as well as maintaining the feedback mechanism with the workforce and beneficiaries to ensure that suicide care provision is appropriately suited to their needs.
Study Setting:
The study was conducted in the Ghizer District of Gilgit-Baltistan, northern region of Pakistan. Concerning the high suicidal rates, Puniyal (Sherqilla, Singul, Ghakuch), Gupis, and Yasin were selected for the study implementation.
Collaborations with Relevant Stakeholders:
For smooth and effective implementation of project-related activities, buy-in from relevant departments and stakeholders was taken into account. The Chief Secretary of Gilgit-Baltistan prioritizes suicide prevention and mental wellness of students and thus approves of innovative school-based programs to achieve the desired outcome. Given the strong commitment, the Chief Secretary supported mobilizing other pertinent government department heads to provide their assistance in the execution of planned research. It involved the Education and Social and Population Welfare Department to facilitate streamlining the research activities and notify the administration of select high schools and colleges for partaking in the implementation process. The leadership at these educational institutions was introduced to the school-based zero suicide model, ensuring goal alignment and consistent support. Additionally, to create a local competent workforce, synergy with the management of the local university was developed to train their psychology students who qualify for conducting field activities. Parallel to this, collaboration with a mental health organization was a necessary step for coordinated efforts in delivering quality and evidence-based treatment approaches to reducing suicide risk and behaviors and promoting mental health.
School Selection and Participant Recruitment:
The Deputy Director of the Education Department provided a separate list of high schools and colleges within the Ghizer district. Stratification sampling was employed to select and onboard schools and enrol students for the screening process. In total, 76 high schools and 20 colleges served as two separate stratums with a factor of homogeneity and a representation of the entire target population. The total number of students within each high school and college was separately sorted in ascending order followed by their distribution in four parts, with each quartile containing 25% of the data. Four high schools and two colleges within each quartile were highlighted using a random number generator. Following that, 10 high schools and 5 colleges were selected for project implementation. Students within grade 9th to 12th within the selected 15 educational institution served as target population and recruited in totality for the mental health and suicide risk screening and referral process, as well as based on the parental consent received for those aged below 17 years and self-consent for those aged 18 years and above.
Parental and School Leadership Engagement using Arts-based Methodologies (ABM):
Once the educational institutions have been onboarded and before commencing the screening process, the project team conducted school leadership engagement sessions involving school principals and focal teachers. This strategic engagement aimed to sensitize and build the capacity of educational leaders to understand mental health issues and the underpinnings of suicidal behaviours among students. Similarly, project team organized arts-based parental engagement sessions in all selected schools/colleges. The nominated focal teachers from each select high school and college invited parents via individual calls or community announcements for their participation in the session. The schedule of each session was mutually decided with the school administration.
During these sessions, purposeful and interactive ABM activities were conducted which focused on enhancing emotional expression and processing, increasing understanding of their coping strategies, prioritizing their mental and emotional well-being, strengthening familial and social network for a child’s well-being, and emphasizing the importance of mental health-seeking behaviours by emphasizing the role of counsellor/psychologists. For example, reflective zine-making activity induced individual responsibility to growth and acknowledging self-worth, whereas creative painting on black canvas led to community expression, expansion of emotional vocabulary, and understanding social cues/norms. Another activity, ‘Yarn Circle’ performance, conveyed complex concepts of emotional belongingness, collectively working towards improving mental health of young people, strengthening social connectivity, and impact of decision-making to seek professional help.
Training Procedure:
A recruitment activity was conducted to select the most eligible and competent candidates to work as Mental Health Assessors (MHAs) and community volunteers (CVs). The process included interactive assessment-based interviews with 50 shortlisted enrolled or graduated psychology students residing in the Ghizer or Gilgit district. The interview consisted of role plays, case study prompts, and practical activities to assess the candidate’s skills and capability of screening young students, building rapport, and providing support to a distressed respondent. In total, 20 MHAs were selected based on the interviews and pre-set eligibility criteria. Similarly, based on the assessment and evaluation of communication skills, 12 community volunteers were selected and grouped with MHAs.
For recruiting professional clinical psychologists, an online application form was launched and shared through various social media platforms, including WhatsApp, Facebook, Instagram, LinkedIn, and Twitter to reach these professionals. With over 150 applications, 50 eligible and competent clinical psychologists were selected. Following the selection of the ZS workforce, orientation meetings were held with these candidates to explain the project implementation strategy, scope of work, roles and responsibilities, project protocols, and project timelines.
The training sessions with MHAs and CVs were scheduled in-person, whereas a hybrid format was adopted for building the capacity of clinical psychologists. The training was delivered by the implementation lead BA. Through reflective and interactive learning methods, MHAs and CVs were given comprehensive knowledge to understand the S-BZS model and equip oneself with the screening process using a digital App (KoBo Toolbox). The mental health and suicide risk screening with young people was blended with culturally relevant humanistic lay counseling and emotional support. A full three-day training session was provided to produce a competent team of MHAs and CVs who could proactively assist the project implementation team in carrying out activities in the selected educational institutions.
The clinical psychologists were provided with self-paced e-learning modules and supplementary material for evidence-based therapeutic approaches to prevent suicidal tendencies. Subsequently, these professionals participated in a full two-day training, utilizing a participatory learning approach through open discussions and case presentations to effectively deliver training content with continuous mentorship throughout the referral process. The training extensively covered comprehensive suicide risk assessment, collaborative safety planning development, counselling on reducing access to lethal means, engaging family and supportive others to create a safe space for suicidal individuals, cultural competency, routine follow-up monitoring, and protocols for delivering specialized services. These interventions combined with empirically based psychological therapies were aimed at suicide risk reduction and targeting intense suicidal ideations and behaviours. Additionally, referral protocols were explicitly defined to ensure strict adherence to the systematic way of tracking and sharing the progress of each referred individual.
Mental Health and Suicide Risk Screening and Referral Procedure:
The MHAs and CVs were placed in select high school and colleges in assigned tehsils. The screening process entailed obtaining informed assent/consent from the students (depending on their age), assuring them of confidentiality, and type of free-of-cost mental health specialized services that would be made available to at-risk students. The validated screening tools utilized for the study were Patient Health Questionnaire-9 (PHQ-9) adult (Kroenke et al., 2001) and adapted for adolescent version (Naveed et al., 2019) for screening depression and Columbia Suicide Severity Rating Scale (CSSR-S) to screen recent and lifetime suicidal ideation and behavior (Posner et al., 2011). MHA-administered screening was conducted with all the selected students with careful instructions given before each screening tool to get the most accurate responses. In case, where student need further explanation, relevant examples were provided to them. Following the screening process, an interpretation of the risk-level identified via screening was provided to the participants. Here, the MHA explicitly informed the participant about the indication of risk level (high, moderate, and low) and provided lay counseling services as they shared adverse events and associated distress. Students at elevated risk of suicide were asked about their preferences of day and time to attend 8 weeks of online psychological therapy sessions and encouraged to seek professional help. Students identified to be at risk were referred to professional and trained clinical psychologists within 24-48 hours to place them on suicide care management plan. The direct referrals were made for students who had access to smart phones and internet at their home, where indirect referrals via schools were initiated to provide resources to those who do not have such access and mitigate the risks related to direct interaction between specialist and student. The school administrators were introduced to the school-based referral protocols and provided a confidential list of students who need mental health support. The focal teacher served as a mediator to coordinate with assigned clinical psychologist and at-risk referred student for scheduling and monitoring therapy sessions.
Suicide-Specific Clinical Interventions:
The mental health specialists were provided with systematic protocols and guidelines for delivering evidence-based care and treatment to at-risk students (Table 2). Comprehensive suicide risk assessments stratify risk levels as low, moderate, or high based on the distal or proximal risk factors and different types of protective factors (individual, relationships, community, societal), both modifiable and non-modifiable. The identification of these factors is sourced from detailed suicide and clinical history. Subsequently, the clinician weighs risk factors against protective to make a thorough clinical judgment. To determine the level of care and type of intervention required, suicide risk formulation per individual’s context was conducted, where level of risk will increase or decrease depending on number and extent of risk and protective factors (Menon, 2013). Clinical assessment of suicide risk is an effective strategy for developing tailored treatment plans to reduce suicidal ideations and behaviors (Zortea et al., 2020). For young students to accurately recognize these factors, trained specialists adequately prompted and provided psychoeducation to them to elicit responses.
Safety plans incorporate elements of several evidence-based suicide risk reduction strategies that are a pivotal part of the Zero Suicide approach. It is a brief clinical intervention that helps those who struggle with suicidal thoughts and have the urge to act on those thoughts and has been found effective in comparison with the usual suicidal care (Nuij et al., 2021; Stanley et al., 2018). The intervention is collaboratively completed with the individual at risk of suicide and entails a six-step plan, including recognizing warning signs, employing internal coping strategies, socializing with others, contacting family members, friends, or care partner, contacting mental health professionals/organizations, and reducing the potential use of lethal means and to create a safe environment (Moscardini et al., 2020).
Counseling on reducing access to lethal means is another best practice intervention that emphasizes how a person attempts suicide, and the method used can determine whether those individuals live or die. Means Reduction is an important part of a broader set of strategies for suicide prevention. A systematic review found that reducing access to lethal means was among a limited number of interventions with strong evidence of effectiveness for preventing suicide (Spitzer et al., 2024). Availability and socio-cultural acceptability of lethal methods also significantly impact the suicide method used (Hepp et al., 2012). The counseling process should include a collaborative conversation between clinicians, individuals at risk of suicide, and family members or significant others and enlist their support in reducing access to lethal means.
The trained specialists have experience in diverse psychological modalities and integrated evidence-informed approaches within their service provision to at-risk students. It included empirically supported psychological treatment to improve an individual tendency to respond appropriately to a suicidal crisis, such as Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP) which has been demonstrated as a feasible and acceptable treatment for suicidal adolescents (Stanley et al., 2009). In line with this, CBT-SP delivered via online medium has been shown to have promising outcomes in reducing suicide ideations (Yu et al., 2021). Similarly, findings from a randomized clinical trial also revealed that Dialectical Behavioral Therapy (DBT) can effectively reduce recurrent suicide attempts among adolescents (Santamarina‐Perez et al., 2020; McCauley et al., 2018). Other psychological therapies that have shown effectiveness in reducing suicidal ideations and behaviors are Brief CBT, Psychodynamic Therapy, Mindfulness-based Stress Reduction, Acceptance and Commitment Therapy, and Collaborative Assessment and Management of Suicidality (Calati et al., 2022). Coupled with evidence-based therapies, parental involvement and school-level adult supervision are essential in suicide risk reduction and mental health promotion of young people (Wang et al., 2021; Madjar et al., 2018). The specialists commonly utilized these therapeutic strategies and approaches to devise an individualized care management plan and timely activate it.
Table 2: Risk Stratification for Intervention Delivery (informed from original Zero Suicide Guidelines)
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Level of Risk
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Indicators
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Interventions to Modify Risk
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Referral
Timeframe
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High Risk
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PHQ-9
- A Score of >14 (i.e., Severe depression - PHQ-9 >20; and Score range 15-19 - moderately severe)
Columbia-Suicide Severity Rating Scale
- Question # 4, 5, and 6 with a response of YES in the past month.
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The Procedures below are *Required*:
- Brief Clinical ZS-related interventions
- Weekly appointment and follow-ups
- Parent-teacher involvement
- Evidence-based psychological therapies
- Crisis digital Toolkit
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Psychotherapy referral:
Same day referral and appointment within 72 hours (about 3 days)
Psychiatric Evaluation:
As clinically indicated.
(Within same day)
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Moderate Risk
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PHQ-9
- A score between 5-14 (i.e., 10-14 moderate depression and 5-9 is mild depression)
Columbia-Suicide Severity Rating Scale
- Question # 3 with a response of YES in the past month and Question # 4, 5, and 6 with a response of YES in lifetime.
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The procedures below are *Strongly Recommended*:
- Brief Clinical ZS-related interventions
- Weekly appointment and follow-ups
- Parent-teacher involvement
- Evidence-based psychological therapies
- Crisis digital Toolkit
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Psychotherapy referral:
Same day referral and appointment within 5 days
Psychiatric evaluation:
As clinically indicated (within 48 hours (about 2 days)
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Low Risk
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PHQ-9
- A score of ≤ 4 (i.e., 0-4 minimal depression)
Columbia-Suicide Severity Rating Scale
- Question # 1 and 2 with a response of YES in the past month and Question # 3, 4, 5, and 6 with a response of NO.
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The procedures can be followed as clinically Indicated and dependent upon individual's need.
- Brief Clinical ZS-related interventions
- Weekly appointment and follow-ups
- Parent-teacher involvement
- Evidence-based psychological therapies
- Crisis digital Toolkit
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Dependent on Individual’s current needs and as clinically indicated.
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Qualitative Process Evaluation:
Qualitative methods play a vital role in assessing the overall program implementation, including intervention acceptability, feasibility, and cultural appropriateness, as well as the perceived impact of the delivered zero suicide intervention in the school setting. To achieve this, semi-structured interview guides were developed to facilitate comprehensive discussion with at-risk students, mental health assessors, school administrators, and clinical psychologists. Purposive sampling was employed to select participants, ensuring a diverse and representative sample of 5-7 participants in each respondent category. Data collection was continued until saturation is reached. With consent, all interviews were recorded, translated, and transcribed for thematic analysis. During weekly follow-ups with at-risk referred students, risk assessment, safety planning intervention, and their overall therapeutic progress were also qualitatively evaluated.
Quantitative Data Analysis:
For the study's purpose, we reported mean and standard deviation for all quantitative variables based on the overall normal distribution and by suicide risk. In case the quantitative variables were not normally distributed, we reported median and interquartile ranges. Normality of the quantitative variables was assessed using Kolmogorov-Smirnov test. For qualitative variables, number and percentage were reported overall and by suicide risk status. To check the relationship of the suicide risk with other independent variables we computed a multinomial logistic regression model to compute crude and adjusted odds ratio.
Qualitative Data Analysis:
The qualitative data was analyzed using the directed content analysis method (Assarroudi et al., 2018). This method incorporates a pre-established framework to organize and categorize participant responses into specific themes and categories, enabling to focus on defined objectives and explore predetermined areas of interest in the data. The open coding method and iterative process were employed to accommodate unique responses, allowing for a more flexible and exploratory approach to integrate new emerging concepts and gain additional insights from the data. It allowed a better understanding of barriers and enablers to receive and access mental healthcare alongside its overall acceptability and feasibility as a nuanced strategy for suicide prevention. In the final phase of the analysis, identified themes and categories were reviewed critically to ensure that each theme represented a distinct aspect of the participants' responses. Additionally, some responses were repositioned or reallocated to better align with the most appropriate theme, improving the accuracy and precision of the key findings. This approach allowed for a comprehensive exploration of the data, capturing diverse perspectives of each participant category.
Data Management:
The quantitative screening data from all the participating students was collected on the Kobo Toolbox by the trained MHAs on their electronic devices. The trained staff used both online and offline versions of Kobo Toolbox per internet availability. The project manager routinely monitored the submission of final offline data after each screening day. The screening data was exported as the Comma Separated Values (CSV) file and uploaded on a password-protected digital portal in a secure location. The data sheets comprised the student information, responses to screening questions, risk level and scores on screening tools, referral and care partner details, data submission date and time stamp. These sheets were checked at the end of the screening day to ensure data quality and consistency and to use the information of at-risk students for referrals to mental health professionals. In addition to this, referral sheets for individual psychologists were manually created and shared with the assigned psychologists. These referral sheets included referred student details, contact and care partner details, depression and suicide risk level, and presenting problems. The data of process monitoring, suicide-specific clinical intervention delivery, psychotherapy session schedule, check-in meetings, comprehensive risk assessments, and re-screening at specified intervals were collected digitally in different formats and later added to a consolidated CSV file for further analysis. All the data sheets were only accessible to the project lead to ensure data safety and confidentiality. In the case of referrals, the psychologists could only access details of the referred client, whereas the school leadership was provided with the identified risk level of each screened student within their school/college along with the details of assigned psychologists for streamlining indirect referrals. For the quantitative analysis of screening data, the identifiable information was removed.
The qualitative data for process evaluation was collected via online Teams meeting, the audios for which were recorded per participant’s consent. The audio recordings were exported from the Teams App and stored in a secure and password-protected digital folder using a specific identifier for participant category. The recorded data was used for translating and transcribing the audios and manually entered to a CSV file for qualitative analysis after deidentification.
Ethical Considerations:
The study was approved by Advanced Education Institute and Research Center (AEIRC) Ethics Committee (ERC/S20/P-025). Given the focus of this study on suicide prevention among high school and college students, the study adhered to the principles of confidentiality and informed assent and parental consent. Prior to participation, all students, caregivers, and teachers were informed about the study's aims, procedures, potential risks, and benefits, and their consent was obtained for mental health and suicide risk screening and referrals. Special attention was given to the sensitive nature of the data being collected, with strict protocols in place to protect participant privacy and data security.