Suicide and the Role of Educational Institutions: A 30-Year Systematic Review

Suicide is the second leading cause of death in the 15–29 age group worldwide, and is a severe public health problem worldwide. Adolescent and young adult individuals primarily attend educational institutions which can play an essential role in detecting and preventing suicide. For this reason, the purpose of this research is to examine the role that educational institutions play in suicide prevention. A systematic review was conducted to determine what educational institutions and agents are identied in the literature when addressing suicide. The systematic review yielded 58 articles published over the last 30 years. The results show that a wide variety of educational stakeholders are required to intervene for suicide prevention between primary education and college. Overall, educational suicide initiatives report positive effects on participants’ understanding, attitudes, and beliefs regarding suicide and suicide prevention, although some studies have expressed some caution. The different types of programs and recommendations are discussed.


Introduction
According to the World Health Organization ([WHO], 2020), depression and suicide among adolescents constitutes a global challenge. Worldwide, suicide is the third leading cause of death in 15-to 19-year-olds and is the predominant external cause of death among this age group in Spain. Therefore, suicide prevention among children and adolescents is a high priority. Moreover, in many countries and regions, most people in this age group attend school. Thus, it has been suggested that preventive actions must be taken in educational settings (Cox et al., 2016;WHO, 2020). Schools provide a unique environment in which to identify and respond to youth suicide risk (Singer, 2017). Nevertheless, while schools may contribute to suicide prevention, they may also exacerbate the problem.
The present research intended to examine the role that educational institutions play in suicide prevention. The most signi cant increase in the risk of suicidal ideation, planning, or intent occurs in the second decade of life. Therefore, it is important to determine what role educational institutions may or should play in suicide prevention and to identify whether the literature has made su cient recommendations for educational policy makers.
Schools must be incorporated into the analysis to elucidate the conditions in which young people contemplate and/or plan to in ict lethal self-harm, particularly regarding bullying experiences (Kim & Chun, 2020). A triangular correlation has been found between school bullying, quality of life, and suicidality . Compared with other children with behavioral problems, those who experience school bullying and have mild to severe psychological problems are more likely to engage in non-suicidal self-injury behaviors (Li et al., 2020).
Minority experiences in schools must also be carefully considered. Students who perceive more public stigma may report signi cantly greater odds of experiencing suicidal ideation, planning, and attempts (Goodwill & Method A systematic review was conducted to determine what educational institutions and agents are identi ed in the literature as having a role in addressing suicide. In the words of Grant and Booth, the method used in this article was aimed at "gathering research, getting rid of rubbish and summarizing the best of what remains" (Brown & Grumet, 2009;Grant & Booth, 2009;Hart, 1998; National Institutes for Health, 2019).

Research Questions, Objective, and Hypothesis
The research team gathered the following speci c research questions that embodied scienti c motivation: 1. What educational institutions have been identi ed in the literature as settings for suicide prevention and why?
2. What agents in the educational eld have been described in the literature as having a positive impact on suicide prevention?
Based on these research questions, the authors set the main objective of this study, which was to examine the role of education institutions in suicide prevention. The study also aimed to inform both the research community and policymakers on how to address future research questions and revise educational policies on suicide prevention. Based on the literature, our hypothesis was that the literature would identify the educational stakeholders who should play a role in suicide prevention, intervention, and postvention; and offer recommendations that may guide educational stakeholders when approaching suicide prevention, intervention, and postvention in educational settings.

Search Process and Selection Criteria
Page 4/26 The search strategies were de ned in discussions held by the authors. The search terms were determined based on keywords identi ed in preliminary searches: TITLE: (suici* near/5 education) OR TITLE: (suici* near/5 school*) OR TITLE: (suici* near/5 university) OR TITLE: (suici* near/5 teacher*) OR TITLE: (suici* near/5 student*) OR TITLE: (suici* near/5 educator*). The authors searched the WOS, CCC, DIIDW, KJD, MEDLINE, RSCI, and SCIELO databases. We also examined only those articles published between 1990 and 2020, thus covering three decades of research on suicide prevention.

Inclusion Criteria
The studies selected to be included in this review had to speci cally relate to suicide prevention, intervention, or postvention in an educational setting. Moreover, the studies had to describe and/or assess an educational intervention speci cally designed: For suicide prevention, intervention, and postvention; to raise awareness of suicide-related themes; to identify and/or support at-risk groups; to promote suicide protective factors; to offer rst aid in a suicide-related emergency; and to address postvention. Finally, the studies had to have been published in a peer-reviewed journal between 1990 and 2020.

Exclusion Criteria
Studies were excluded from the review if they did not speci cally address educational aspects of suicide prevention, were not published in a peer-reviewed journal, or contained no unique relevant data about the inclusion criteria.

Procedure
The search strategy described above retrieved 1107 items, which were downloaded to Endnote. After duplicate items were removed, 1103 articles remained. The authors then conducted a pilot study in which they analyzed 10% of the corpus and re ned the inclusion and exclusion criteria. After this pilot stage, the 1103 article titles and abstracts retrieved were systematically screened by three of the co-authors in an initial process to select and remove items by applying the re ned inclusion and exclusion criteria. The extraction of data from all relevant papers was completed at this point using an online Excel document shared by the authors. Research meetings were held to discuss questionable items. Seventy-four articles were selected by two or three researchers to make up the corpus of the second stage of the analysis. This was reduced to a nal corpus of 58 articles after the inclusion and exclusion criteria were revised, this time after reading the full manuscripts. The 58 papers in the nal corpus were nally uploaded to the software Atlas and coded for: type of educational institution (e.g., school, university, others); agents (e.g., teachers, school directors, parents, social educators, policy makers); agents' skills and knowledge (e.g., suicide risk and protective factors, crisis management); research objectives pursued; recommendations for educational stakeholders; and future research directions suggested. Figure 1 shows the procedure for applying the PRISMA criteria (PRISMA, 2015).

Results
Fifty-eight studies published between 1990 and 2020 described and/or assessed an educational intervention on suicide prevention, intervention, or postvention. Table 1 summarizes the various methodological approaches used by researchers to pursue their objectives. Of the 58 studies, 44 (75.86%) used quantitative methods, 10 (17.24%) used qualitative methods, and 2 (3.44%) used a mixed-method approach. The methodology applied in 2 (3.44%) of the studies was not clearly described. Thirty-four programs designed to approach suicide prevention (30), intervention (3), or postvention (2) in educational settings were described and/or assessed in the literature. Table 2 presents the list of programs identi ed, a brief description of the programs, and the study in which they appear. The educational settings addressed by the studies ranged from primary school to college. Regarding geographical distribution, of the studies that analyzed data from a single country, 35, 5, 2, and 2 were conducted in the United States, Australia, Canada, and Italy, respectively. One study came from each of the following countries: Brazil, Chile, Germany, Korea, Hong Kong, Kenya, Puerto Rico, Japan, and the Netherlands.  Figure 2 shows the data.

Assessment of Suicide Educational Programs
Overall, the programs were described as safe ( reduced anxiety. Additionally, they identi ed improvements in students' ability to recognize emotions and communicate them verbally (Testoni et al., 2020).  reported an increase in the number of referrals to the local mental health provider, less resistance to asking for help, improved communication, enhanced trust between students and suicide prevention program personnel, and a decrease in the number of suicides in participating school systems ). Zenere and Lazarus (2009) and Wasserman et al.
(2015) found that comprehensive school-based suicide prevention programs reduced youth suicidal behavior. Conforti et al. (2020) showed that a teacher-delivered cognitive behavior therapy skills curriculum was feasible and associated with reduced suicidality (ideation and behavior) in middle school-aged youth. Breux  prevention programs.  recommended that extensive research into the target educational context and student population should be conducted before initiating a suicide educational program, and that as many key players as possible should be involved in the tailoring process. Tierney et al. (1990) stated that a suicide prevention program must be based on a system-wide policy and address all aspects of suicide: prevention, intervention, and postvention. Tierney et al. (1990) recommended the creation of comprehensive programs that require coordination and networking components, along with implementation commitments from every major stakeholder group in the school system. These included board members, administrators, professional staff, support staff, parents, and students. programs can be bene cial. Brown and Grumet (2009) contended that when considering screening for mental health issues in schools, the ability to follow up with at-risk youth is essential. They further stated that it is essential for positively screened young people to be linked to some additional evaluation or treatment, and that this should not be decided solely by the parents. Cha et al. (2018) warned that having a crisis protocol intervention when a peer suicide occurs helps to improve trauma-related symptoms and might be an effective way to prevent suicide spreading among students by alleviating such trauma-related symptoms.
Additionally, White and Morris (2010) highlighted the complexity of suicide as a culturally situated phenomenon. They argued against conceptualizing suicide through singular, stable, or universalizing terms that transcend time and context. They also claim that several factors contradict the overall aims of youth suicide prevention. These include expecting educators to rely exclusively on narrow "evidence-based" curricula that authorizes expert knowledge and precludes all other knowledge, locate problems within people, dismiss any uncertainty or ambiguity, inhibit local and relational meaning-making, and sti e creativity by rigidly adhering to pre-speci ed and "safe" learning outcomes.
Regarding recommendations made speci cally for young adults, Fernandes et al. (2020) discussed the importance of developing projects for the university community. Given the need to discuss and re ect on suicide prevention, they recommend that these projects be integrated with the health network and student support services of educational institutions. Chugani et al. (2020) recommended that campuses that can invest additional resources in student mental health and suicidality should focus on primary prevention, such as increasing coping skills and resilience. Rivero et al. (2014) suggested that campus staff should consider the array of policies, programmatic infrastructures, on-and off-campus mental health, and other support resources that can be mobilized so that each student can be managed according to their needs.
If a suicide occurs, Mintz-Binder (2007) points out that faculty and staff involved in teaching should neither be expected to handle these events alone, nor be made to feel responsible. They urge educational institutions to have a well-rehearsed plan established before sudden events occur. This can help to minimize the shock and denial responses to a traumatic situation and allows for an organized systematic approach to be implemented.
The literature review also identi ed recommendations regarding the dissemination of materials related to suicide. Fendrich et al. (2000) warned that when unsolicited materials are sent to schools, the most appropriate school contact person should be identi ed in advance. Their experience shows that distribution to the right contact person, especially when preceded by personal contact through telephone calls, is more likely to result in effective dissemination than a mass-mailing approach.

Discussion
The main objective of the present study was to examine the role of educational institutions in suicide prevention and to inform both researchers and policymakers on how to address future research and educational policies on this issue. The systematic review yielded 58 articles published in the last 30 years that met the inclusion and exclusion criteria. A high percentage of these studies used quantitative methodology to reach their objectives (75.86%), which is useful for objectively assessing the viability and effectiveness of the different programs. However, more qualitative or mixed studies are also needed to analyze aspects that are not possible to assess or identify with quantitative procedures. Regarding the geographical distribution of the studies, the vast majority were carried out in the United States. This result coincides with other systematic reviews in other contexts (for example, with emergency services employees) (Witt et al., 2017); thus, considerably more studies are needed in other countries and cultures. According to the WHO (2021), suicide rates vary considerably between countries, which suggests that sociocultural variables may explain suicidal behavior to some extent. Goldston et al. (2008) contend that consideration should be given to cultural patterns related to suicide, such as the kind of triggers or precipitants of suicidal behavior, the reactions to and interpretations of suicidal behaviors, or the search for help, which may vary across cultures. Furthermore, risk and protective factors for suicidal behavior may also be in uenced by cultural context (Goldston et al., 2008). For this reason, research must focus on interventions in different cultural contexts and countries, because some programs may be more appropriate in speci c settings.
It is also important to develop programs based on cultural characteristics and assess their effectiveness. The shortage of culturally sensitive prevention programs for educational contexts is a limitation that may generate economic and human costs.
Most studies focus speci cally on suicide prevention, particularly in secondary and high schools. The focus on intervention and postvention efforts in the aftermath of suicide acts is less prominent. Therefore, more studies are needed on the development and assessment of intervention and postvention programs in the educational context. In fact, Tierney et al. (1990) pointed out that programs to reduce suicidal behavior should address all aspects of suicide, including prevention, intervention, and postvention. Furthermore, one positive outcome of the current review is that it has identi ed a wide range of stakeholders at different educational levels, including students, teachers, counselors, families, psychologists, administrators, and staff. However, some programs are not designed for the entire educational community, a limitation that several authors have pointed out needs to

Conclusion
In summary, the current systematic review provides an overview of the prevention, intervention, and postvention programs carried out in educational institutions to reduce suicidal manifestations and shows the state of current practice. The study describes the different types of programs that have been provided, the countries in which they have been implemented, and the agents who have been targeted, as well as the recommendations given by various authors. It also identi es gaps in the research on suicide in education, such as the need: 1) for more qualitative or mixed studies that assess or identify aspects that are not easily explored with quantitative procedures; 2) to diversify the countries and cultural contexts in which educational initiatives on suicide are carried out; 3) to promote interventions and postventions in the aftermath of suicide acts; and, most importantly, 4) to reduce suicidal ideation and behavior by doing more than simply identifying participants' perception of changes in understanding of and attitudes toward suicide and suicide prevention. This information may be helpful in designing and developing appropriate new research projects and programs for reducing suicidal behaviors in educational settings.

Declarations
Competing interests: The authors report no potential con ict of interests.
Ethics approval and consent: Ethics approval was waived as this was a review study.
Data availability: Acknowledgements: Authors' contributions: The rst author had the idea for the article, created the study design and performed the literature search. Authors one, two and three were in charge of data analysis. The rst author drafted an initial version of the paper, which was critically revised and improved by the four authors. Author four made the linguistic format review.

Professionals (ProfScreen)
professionals to identify at-risk adolescents based on mental health responses in a selfreport questionnaire. The program promotes awareness of the problem of youth suicide, provides student trainees with the knowledge and resources to  interact with at-risk youth, and encourages referral behaviors.

Applied Suicide Intervention Skills Training (ASIST)
The program is a 14-hour, 2-day, suicide intervention training mode. SafeTALK is a condensed version of ASIST. The program comprised three modules addressed to adolescent peer leaders, parents and schoolteachers.  Beyond the Wall Death education program aimed at helping young people to cope with being told of the suicide of students at their schools and to raise awareness of their negative emotions and their representations of death, to improve their ability to cope with negative thoughts. Team members identify student psychosocial problems, determine if they are within school responsibility, and suggest interventions. When a problem is beyond the array of services provided at school, teams assist in accessing services within the community. The program is a multicomponent seven-step process that is based on step-by-step interventions, timing, activation, goal, and format.

Consultation and Resource Evaluation (CARE) program
Essential components of the program include assessment of student suicide risk, evaluation of student's willingness and ability to refrain from self-harm; consultation regarding needed psychiatric, psychological, and supportive educational services; parent information and supportive educational intervention.   Figure 1 PRISMA ow chart of the selection procedure