Prevention Science

, Volume 17, Issue 2, pp 157–166 | Cite as

The SOS Suicide Prevention Program: Further Evidence of Efficacy and Effectiveness

  • Elizabeth A. SchillingEmail author
  • Robert H. AseltineJr
  • Amy James


This study replicated and extended previous evaluations of the Signs of Suicide (SOS) prevention program in a high school population using a more rigorous pre-test post-test randomized control design than used in previous SOS evaluations in high schools (Aseltine and DeMartino 2004; Aseltine et al. 2007). SOS was presented to an ethnically diverse group of ninth grade students in technical high schools in Connecticut. After controlling for the pre-test reports of suicide behaviors, exposure to the SOS program was associated with significantly fewer self-reported suicide attempts in the 3 months following the program. Ninth grade students in the intervention group were approximately 64 % less likely to report a suicide attempt in the past 3 months compared with students in the control group. Similarly, exposure to the SOS program resulted in greater knowledge of depression and suicide and more favorable attitudes toward (1) intervening with friends who may be exhibiting signs of suicidal intent and (2) getting help for themselves if they were depressed or suicidal. In addition, high-risk SOS participants, defined as those with a lifetime history of suicide attempt, were significantly less likely to report planning a suicide in the 3 months following the program compared to lower-risk participants. Differential attrition is the most serious limitation of the study; participants in the intervention group who reported a suicide attempt in the previous 3 months at baseline were more likely to be missing at post-test than their counterparts in the control group.


Adolescent Suicide Prevention Evaluation Schools 


Conflict of Interest

The authors declare that they have no conflict of interest.


  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5--5th ed. Washington, DC: American Psychiatric Publishing.CrossRefGoogle Scholar
  2. Aseltine, R. H., Jr., & DeMartino, R. (2004). An outcome evaluation of the SOS suicide prevention program. American Jounal of Public Health, 94, 446–451.CrossRefGoogle Scholar
  3. Aseltine, R. H., Jr., James, A., Schilling, E. A., & Glanovsky, J. (2007). Evaluating the SOS suicide prevention program: A replication and extension. BMC Public Health, 7, 161.PubMedPubMedCentralCrossRefGoogle Scholar
  4. Bogenschutz, M. P., Donovan, D. M., Adinoff, B., Crandall, C., Forcehimes, A. A., Lindblad, R., & Walker, R. (2011). Design of NIDA CTN protocol 0047: screening, motivational assessment, referral, and treatment in emergency departments (SMART-ED). The American Journal of Drug and Alcohol Abuse, 37, 417–425. doi: 10.3109/00952990.2011.596971.PubMedPubMedCentralCrossRefGoogle Scholar
  5. Brown, M. M., & Grumet, J. G. (2009). School-based suicide prevention with African American youth in an urban setting. Professional Psychology: Research and Practice, 40, 111–117.CrossRefGoogle Scholar
  6. Centers for Disease Control and Prevention. (2012). Data retrieved from, Accessed on 6/13/12.
  7. Chatard, A., & Selimbegovic, L. (2011). When self-destructive thoughts flash through the mind: failure to meet standards affects the accessibility of suicide-related thoughts. Journal of Personality and Social Psychology, 100, 587–605.PubMedCrossRefGoogle Scholar
  8. Connecticut State Department of Education. (2007). Strategic school profile 2006-2007, Connecticut technical high school system. Retrieved from accessed June 26, 2008.
  9. Conner, K. R., Meldrum, S., Wieczorek, W. F., Duberstein, P. R., & Welte, J. W. (2004). The association of irritability and impulsivity with suicidal ideation among 15- to 20-year-old males. Suicide and Life-Threatening Behavior, 34, 363–373.PubMedCrossRefGoogle Scholar
  10. Cusimano, M. D., & Sameem, M. (2011). The effectiveness of middle and high school-based suicide prevention programmes for adolescents: A systematic review. Injury Prevention, 17, 43–49. doi: 10.1136/ip.2009.025502.PubMedCrossRefGoogle Scholar
  11. De Silva, S., Parker, A., Purcell, R., Callahan, P., Liu, P., & Hetrick, S. (2013). Mapping the evidence of prevention and intervention studies for suicidal and self-harming behaviors in young people. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 34, 223–232. doi: 10.1027/0227-5910/a000190.CrossRefGoogle Scholar
  12. Fergusson, D. M., Horwood, L. J., Ridder, E. M., & Beautrais, A. L. (2005). Suicidal behaviour in adolescence and subsequent mental health outcomes in young adulthood. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 35, 983–993.CrossRefGoogle Scholar
  13. Flay, B. R., Biglan, A., Boruch, R. F., Castro, F. G. I., Gottfredson, D., Kellam, S., & Ji, P. (2005). Standards of evidence: criteria for efficacy, effectiveness and dissemination. Prevention Science, 6, 151–175.PubMedCrossRefGoogle Scholar
  14. Gould, M. S., Marrocco, F. A., Kleinman, M., Thomas, J. G., Mostkoff, K., Cote, J., & Davies, M. (2005). Evaluating iatrogenic risk of youth suicide screening programs: A randomized controlled trial. JAMA: Journal of the American Medical Association, 293, 1635–1643.PubMedCrossRefGoogle Scholar
  15. Grunbaum, J. A., Kann, L., Kinchen, S. A., Ross, J. G., Gowda, V. R., Collins, J. L., & Kolbe, L. J. (2000). Youth risk behavior surveillance national alternative high school youth risk behavior survey, United States, 1998. Journal of School Health, 70, 5–17.PubMedCrossRefGoogle Scholar
  16. Grunbaum, J. A., Lowry, R., & Kann, L. (2001). Prevalence of health-related behaviors among alternative high school students as compared with students attending regular high schools. Journal of Adolescent Health, 29, 337–343.PubMedCrossRefGoogle Scholar
  17. Hanley, J. A., Negassa, A., Edwardes, M. D. D., & Forrester, J. E. (2003). Statistical analysis of correlated data using generalized estimating equations: An orientation. American Journal of Epidemiology, 157, 364–375. doi: 10.1093/aje/kwf215.PubMedCrossRefGoogle Scholar
  18. Harel, O., Stratton, J., & Aseltine, R. H. (2011). Designed Missingness to Better Estimate Efficacy of Behavioral Studies. Paper presented at the Tenth Conference on Health Survey Research Methods, Hyattsville, MD.Google Scholar
  19. Horowitz, J. L., Garber, J., Ciesla, J. A., Young, J. F., & Mufson, L. (2007). Prevention of depressive symptoms in adolescents: A randomized trial of cognitive-behavioral and interpersonal prevention programs. Journal of Consulting and Clinical Psychology, 75, 693–706.PubMedCrossRefGoogle Scholar
  20. Jacobs, B., & Beam, L. (2008). Mobilizing extension for youth suicide prevention using the Signs of Suicide (SOS) program. Journal of Extension, 46, Article Number: 1TOT7.Google Scholar
  21. Jacobs, D. G., Brewer, M., & Klein-Benheim, M. (1999). Suicide assessment: overview and recommended protocol. In D. G. Jacobs (Ed.), Guide to suicide assessment and intervention (pp. 3–39). San Francisco: Jossey-Bass.Google Scholar
  22. Joiner, T. E., Jr. (2009). Suicide prevention in schools as viewed through the interpersonal-psychological theory of suicidal behavior. School Psychology Review, 38, 244–248.Google Scholar
  23. Joiner, T. E., Jr., Conwell, Y., Fitzpatrick, K. K., Witte, T. K., Schmidt, N. B., Berlim, M. T., & Rudd, M. D. (2005). Four studies on how past and current suicidality relate even when “everything but the kitchen sink” is covaried. Journal of Abnormal Psychology, 114, 291–303.PubMedCrossRefGoogle Scholar
  24. Kann, L., Kinchen, S. A., Williams, B. I., Ross, J. G., Lowry, R., Grunbaum, J. A., & Kolbe, L. J. (2000). Youth risk behavior surveillance—United States, 1999. MMWR. CDC Surveillance Summaries, 49, 1–32.PubMedGoogle Scholar
  25. Kessler, R. C., & Greenberg, D. F. (1981). Linear panel analysis: Models of quantitative change. New York: Academic.Google Scholar
  26. Lester, D., Wood, P., Williams, C., & Haines, J. (2004). Motives for suicide—a study of Australian suicide notes. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 25, 33–34.Google Scholar
  27. Lowry, R., Crosby, A. E., Brener, N. D., & Kann, L. (2014). Suicidal thoughts and attempts among U.S. high school students: Trends and associated health-risk behaviors, 1991–2011. Journal of Adolescent Health, 54, 100–108.PubMedCrossRefGoogle Scholar
  28. Miller, D. N., Eckert, T. L., & Mazza, J. J. (2009). Suicide prevention programs in the schools: a review and public health perspective. School Psychology Review, 38, 168–188.Google Scholar
  29. Miranda, R., De Jaegere, E., Restifo, K., & Shaffer, D. (2014). Longitudinal follow-up study of adolescents who report a suicide attempt: Aspects of suicidal behavior that increase risk of a future attempt. Depression and Anxiety, 31, 19–26.PubMedCrossRefGoogle Scholar
  30. Pena, J. B., Matthieu, M. M., Zayas, L. H., Masyn, K. E., & Caine, E. D. (2012). Co-occurring risk behaviors among white, black, and Hispanic US high school adolescents with suicide attempts requiring medical attention, 1999–2007: implications for future prevention initiatives. Social Psychiatry and Psychiatric Epidemiology, 47, 29–42. doi: 10.1007/s00127-010-0322-z.PubMedCrossRefGoogle Scholar
  31. Perez, V. W. (2005). The relationship between seriously considering, planning, and attempting suicide in the youth risk behavior survey. Suicide and Life-Threatening Behavior, 35, 35–49.PubMedCrossRefGoogle Scholar
  32. Raich, R. M., Portell, M., & Pelaez-Fernandez, M. A. (2010). Evaluation of a school-based programme of universal eating disorders prevention: is it more effective in girls at risk? European Eating Disorders Review, 18, 49–57.PubMedCrossRefGoogle Scholar
  33. Robinson, J., Cox, G., Malone, A., Williamson, M., Baldwin, G., Fletcher, K., & O’Brien, M. (2013). A systematic review of school-based interventions aimed at preventing, treating, and responding to suicide-related behavior in young people. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 34, 164–182. doi: 10.1027/0227-5910/a000168.CrossRefGoogle Scholar
  34. Rudd, M. D., Joiner, T., Brown, G. K., Cukrowicz, K., Jobes, D. A., Silverman, M., & Cordero, L. (2009). Informed consent with suicidal patients: Rethinking risks in (and out of) treatment. Psychotherapy: Theory, Research, Practice, Training, 46, 459–468. doi: 10.1037/a0017902.CrossRefGoogle Scholar
  35. Schilling, E. A., Aseltine, R. H., Jr., Glanovsky, J. L., James, A., & Jacobs, D. (2009). Adolescent alcohol use, suicidal ideation, and suicide attempts. Journal of Adolescent Health, 44, 335–341.PubMedCrossRefGoogle Scholar
  36. Schilling, E. A., Lawless, M., Buchanan, L., & Aseltine, R. H. (2014). Signs of Suicide (SOS) shows promise as a middle school suicide prevention program. Suicide and Life-Threatening Behavior, 44, 653–667. doi: 10.1111/sltb.12097.PubMedCrossRefGoogle Scholar
  37. Shaffer, D., Garland, A., Vieland, V., & Underwood, M. (1991). The impact of curriculum-based suicide prevention programs for teenagers. Journal of the American Academy of Child & Adolescent Psychiatry, 30, 588–596.CrossRefGoogle Scholar
  38. Spirito, A., Overholser, J., Ashworth, S., & Morgan, J. (1988). Evaluation of a suicide awareness curriculum for high school students. Journal of the American Academy of Child & Adolescent Psychiatry, 27, 705–711.CrossRefGoogle Scholar
  39. Substance Abuse and Mental Health Services Administration. (2011). SAMHSA’s National registry of evidence-based programs and practices: SOS Signs of Suicide. Retrieved March 8, 2011 from
  40. Sveticic, J., McPhedran, S., & De Leo, D. (2013). Reviewing the revisions: What are the Australian Bureau of Statistics suicide figures really telling us? Medical Journal of Australia, 198, 478.PubMedCrossRefGoogle Scholar
  41. Timmons, K. A., Selby, E. A., Lewinsohn, P. M., & Joiner, T. E. (2011). Parental displacement and adolescent suicidality: exploring the role of failed belonging. Journal of Clinical Child and Adolescent Psychology, 40, 807–817. doi: 10.1080/15374416.2011.614584.PubMedPubMedCentralCrossRefGoogle Scholar
  42. Tkaczyk, J. M., & Edelson, A. (2009). School nurses: a bridge to suicide prevention. NASN School Nurse, 24, 124–127.PubMedCrossRefGoogle Scholar
  43. Valentine, J. C., Biglan, A., Boruch, R. F., Castro, F. G., Collins, L. M., Flay, B. R., & Schinke, S. P. (2011). Replication in prevention science. Prevention Science, 12, 103–117. doi: 10.1007/s11121-011-0217-6.PubMedCrossRefGoogle Scholar
  44. Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E., Jr. (2010). The interpersonal theory of suicide. Psychological Review, 117, 575–600. doi: 10.1037/a0018697.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Society for Prevention Research 2015

Authors and Affiliations

  • Elizabeth A. Schilling
    • 1
    Email author
  • Robert H. AseltineJr
    • 1
    • 2
  • Amy James
    • 1
    • 3
  1. 1.Center for Public Health and Health PolicyUConn HealthFarmingtonUSA
  2. 2.Division of Behavioral Sciences and Community HealthUConn HealthFarmingtonUSA
  3. 3.Connecticut Department of Mental Health and Addiction Services and the School of Social WorkUniversity of ConnecticutStorrsUSA

Personalised recommendations