Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

School-based suicide prevention using the gatekeeper programme: a cluster-randomized trial

Nature Health volume 1, pages 251–261 (2026)Cite this article

Subjects

Abstract

Gatekeeper training enables teachers to identify and refer students at risk of suicide and can play a role in school-based prevention efforts. A cluster-randomized controlled trial in Chinese schools assessed the impact of the Life Gatekeeper Training Program (LGTP), a standardized one-day programme comprising eight sessions, delivered through a train-the-trainer cascade. School-based clusters were randomized 1:1 to either the LGTP intervention group (42 schools, n = 2,051; female, 1,536 (74.9%); male, 515 (25.1%)) or a waitlist control group (42 schools, n = 2,089; female, 1,556 (74.5%); male, 533 (25.5%)). Primary outcomes were stigma against suicide, suicide literacy, perceived competence and willingness to intervene. Assessments were conducted at baseline, after training and at 6-month and 12-month follow-ups with a 91.4% retention at 12 months. Intention-to-treat analyses using linear mixed models showed significant improvements in all primary outcomes for the intervention group after training: stigma (β = –0.80, 95% confidence interval (CI) (–0.87, –0.73)), suicide literacy (β = 0.98, 95% CI (0.92, 1.05)), perceived competence (β = 1.03, 95% CI (0.97, 1.10)) and willingness to intervene (β = 0.76, 95% CI (0.70, 0.82)); all false discovery rate-adjusted P values < 2.0 × 10−16. Effects remained significant at 6 and 12 months, with reduced but sustained effect sizes. No adverse or serious adverse events were reported. This trial supports LGTP as a brief, well-tolerated and effective intervention for enhancing suicide prevention competencies in schools. Chinese Clinical Trial Registry: ChiCTR2200066142.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on SpringerLink
  • Instant access to the full article PDF.

USD 39.95

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Trial profile of participants.
Fig. 2: Change in primary outcomes between two groups over 12 months among participants.
Fig. 3: Difference in gatekeeper behaviours between groups at 12-month follow-up among participants.

Similar content being viewed by others

Data availability

The de-identified data are available from R.C., Vanke School of Public Health, Tsinghua University, Beijing, China, upon reasonable request and subject to approval by the relevant institutional and ethics committees. Requests will be considered, reviewed and acted upon within 6 months of receipt.

Code availability

The code used for de-identified data processing and analysis is available from R.C., Vanke School of Public Health, upon reasonable request and subject to approval by the relevant institutional and ethics committees. Requests will be considered, reviewed and actioned within 6 months of receipt.

References

  1. Knipe, D., Padmanathan, P., Newton-Howes, G., Chan, L. F. & Kapur, N. Suicide and self-harm. Lancet 399, 1903–1916 (2022).

    Article  PubMed  Google Scholar 

  2. Uddin, R., Burton, N. W., Maple, M., Khan, S. R. & Khan, A. Suicidal ideation, suicide planning, and suicide attempts among adolescents in 59 low-income and middle-income countries: a population-based study. Lancet Child Adolesc. Health 3, 223–233 (2019).

    Article  PubMed  Google Scholar 

  3. World Health Organization. Suicide worldwide in 2019: global health estimates. World Health Organization https://www.who.int/publications/i/item/9789240026643 (2021).

  4. Tian, Y., Luan, M., Chen, H. & Zhang, J. Temporal trend in suicide mortality for Chinese adolescents, 2008 to 2021. JAMA Pediatr. 177, 1224–1226 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  5. Fergusson, D. M., Horwood, L. J., Ridder, E. M. & Beautrais, A. L. Suicidal behaviour in adolescence and subsequent mental health outcomes in young adulthood. Psychol. Med. 35, 983–993 (2005).

    Article  PubMed  Google Scholar 

  6. Ferrer, I. et al. I cannot read your eye expression: suicide attempters have difficulties in interpreting complex social emotions. Front. Psychiatry 11, 543889 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  7. Brent, D. A., Moritz, G., Bridge, J., Perper, J. & Canobbio, R. The impact of adolescent suicide on siblings and parents: a longitudinal follow-up. Suicide Life. Threat. Behav. 26, 253–259 (1996).

    Article  CAS  PubMed  Google Scholar 

  8. Doran, C. M. & Kinchin, I. Economic and epidemiological impact of youth suicide in countries with the highest human development index. PLoS ONE 15, e0232940 (2020).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Zalsman, G. et al. Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry 3, 646–659 (2016).

    Article  PubMed  Google Scholar 

  10. Cross, W. F. et al. Does practice make perfect? A randomized control trial of behavioral rehearsal on suicide prevention gatekeeper skills. J. Prim. Prev. 32, 195–211 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  11. Tompkins, T. L., Witt, J. & Abraibesh, N. Does a gatekeeper suicide prevention program work in a school setting? Evaluating training outcome and moderators of effectiveness. Suicide Life. Threat. Behav. 40, 506–515 (2010).

    Article  PubMed  Google Scholar 

  12. Cross, W., Matthieu, M. M., Lezine, D. & Knox, K. L. Does a brief suicide prevention gatekeeper training program enhance observed skills?. Crisis 31, 149–159 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  13. Liu, H. et al. Gatekeeper training for suicide prevention: a systematic review and meta-analysis of randomized controlled trials. BMC Public Health 25, 1206 (2025).

    Article  PubMed  PubMed Central  Google Scholar 

  14. Mo, P. K. H., Ko, T. T. & Xin, M. Q. School-based gatekeeper training programmes in enhancing gatekeepers’ cognitions and behaviours for adolescent suicide prevention: a systematic review. Child Adolesc. Psychiatry Ment. Health 12, 29 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  15. Wasserman, D. et al. School-based suicide prevention programmes: the SEYLE cluster-randomised, controlled trial. Lancet 385, 1536–1544 (2015).

    Article  PubMed  Google Scholar 

  16. Jordans, M. J. & Kohrt, B. A. Scaling up mental health care and psychosocial support in low-resource settings: a roadmap to impact. Epidemiol. Psychiatr. Sci. 29, e189 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  17. Chu, J. P., Goldblum, P., Floyd, R. & Bongar, B. The cultural theory and model of suicide. Appl. Prev. Psychol. 14, 25–40 (2010).

    Article  Google Scholar 

  18. Cai, C. et al. Development of the Life Gatekeeper suicide prevention training programme in China: a Delphi study. Gen. Psychiatr. 36, e101133 (2023).

  19. Ross, V., Kõlves, K. & De Leo, D. Teachers’ perspectives on preventing suicide in children and adolescents in schools: a qualitative study. Arch. Suicide Res. 21, 519–530 (2017).

    Article  PubMed  Google Scholar 

  20. O’Dea, B. et al. A cluster randomized controlled trial on the effectiveness of the Building Educators’ Skills in Adolescent Mental Health (BEAM) program for improving secondary school educators’ confidence, behavior, knowledge, and attitudes toward student mental health. J. Teach. Educ. 76, 178–194 (2025).

    Article  Google Scholar 

  21. Hamdani, S. U. et al. Scaling-up school mental health services in low resource public schools of rural Pakistan: the Theory of Change (ToC) approach. Int. J. Ment. Health Syst. 15, 8 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  22. Cruz, C. M. et al. Teacher nomination of school-aged children for mental health services in a low and middle income country. Glob. Health Action 14, 1861921 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  23. Li, J., Li, J., Zhang, W., Wang, G. & Qu, Z. Effectiveness of a school-based, lay counselor-delivered cognitive behavioral therapy for Chinese children with posttraumatic stress symptoms: a randomized controlled trial. Lancet Reg. Health 33, 100699 (2023).

    Google Scholar 

  24. Torok, M., Calear, A. L., Smart, A., Nicolopoulos, A. & Wong, Q. Preventing adolescent suicide: a systematic review of the effectiveness and change mechanisms of suicide prevention gatekeeping training programs for teachers and parents. J. Adolesc. 73, 100–112 (2019).

    Article  CAS  PubMed  Google Scholar 

  25. Calear, A. L. et al. A systematic review of psychosocial suicide prevention interventions for youth. Eur. Child Adolesc. Psychiatry 25, 467–482 (2016).

    Article  PubMed  Google Scholar 

  26. Ministry of Education of the People’s Republic of China, Supreme People’s Procuratorate, Central Publicity Department of the Communist Party of China, et al. The special action plan to strengthen and improve students’ mental health in the new era. https://www.gov.cn/zhengce/zhengceku/202305/content_6857361.htm (2023).

  27. Zinzow, H. M., Thompson, M. P., Fulmer, C. B., Goree, J. & Evinger, L. Evaluation of a brief suicide prevention training program for college campuses. Arch. Suicide Res. 24, 82–95 (2020).

    Article  PubMed  Google Scholar 

  28. Gryglewicz, K. et al. Examining the effects of role play practice in enhancing clinical skills to assess and manage suicide risk. J. Ment. Health 29, 549–557 (2020).

    Article  PubMed  Google Scholar 

  29. Holmes, G., Clacy, A., Hamilton, A. & Kõlves, K. Effectiveness of suicide prevention gatekeeper training: 12-month follow-up of SafeTALK training to community members. Australas. Psychiatry 31, 835–840 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  30. Whisman, M. A. The efficacy of booster maintenance sessions in behavior therapy: review and methodological critique. Clin. Psychol. Rev. 10, 155–170 (1990).

  31. Van de Mortel, T. F. Faking it: social desirability response bias in self-report research. Aust. J. Adv. Nurs. 25, 40–48 (2008).

    Google Scholar 

  32. Cai, C. et al. Effectiveness of a localised and systematically developed gatekeeper training program in preventing suicide among Chinese adolescents. Asian J. Psychiatr. 89, 103755 (2023).

    Article  PubMed  Google Scholar 

  33. Qu, D. et al. Effectiveness of a school-based Life Gatekeeper Training Program on suicide prevention in China: protocol for a randomized controlled trial. Trials 25, 335 (2024).

    Article  PubMed  PubMed Central  Google Scholar 

  34. Borrelli, B. The assessment, monitoring, and enhancement of treatment fidelity in public health clinical trials. J. Public Health Dent. 71, S52–S63 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  35. Kleinman, K., Moyer, J., Reich, N. & Obeng, D. clusterPower: power calculations for cluster-randomized and cluster-randomized crossover trials. R version 0.6.111 (2017).

  36. Whelan, J., Marshall, H. & Sullivan, T. R. Intracluster correlation coefficients in a large cluster randomized vaccine trial in schools: Transmission and impact of shared characteristics. PLoS ONE 16, e0254330 (2021).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Batterham, P. J., Calear, A. L. & Christensen, H. The Stigma of Suicide Scale. Crisis https://doi.org/10.1027/0227-5910/a000156 (2013).

  38. Han, J. et al. Translation and validation of the Chinese versions of the suicidal ideation attributes scale, Stigma of Suicide Scale, and literacy of suicide scale. Death Stud. 41, 173–179 (2017).

    Article  PubMed  Google Scholar 

  39. Calear, A. L., Batterham, P. J., Trias, A. & Christensen, H. The Literacy Of Suicide Scale: development, validation, and application. Crisis 43, 385–390 (2021).

    Article  PubMed  Google Scholar 

  40. Aldrich, R. S., Harrington, N. G. & Cerel, J. The Willingness to Intervene Against Suicide Questionnaire. Death Stud. 38, 100–108 (2014).

    Article  PubMed  Google Scholar 

  41. Aldrich, R. S. Suicide prevention: college students’ intention to intervene. Arch. Suicide Res. 21, 403–412 (2017).

    Article  PubMed  Google Scholar 

  42. Wyman, P. A. et al. Randomized trial of a gatekeeper program for suicide prevention: 1-year impact on secondary school staff. J. Consult. Clin. Psychol. 76, 104–115 (2008).

    Article  PubMed  PubMed Central  Google Scholar 

  43. Bartgis, J. & Albright, G. Online role-play simulations with emotionally responsive avatars for the early detection of native youth psychological distress, including depression and suicidal ideation. Am. Indian Alsk. Native Ment. Health Res. 23, 1–27 (2016).

    Article  PubMed  Google Scholar 

  44. R Core Team R: A Language and Environment for Statistical Computing (R Foundation for Statistical Computing, 2013).

  45. Van Buuren, S. & Groothuis-Oudshoorn, K. mice: multivariate imputation by chained equations in R. J. Stat. Softw. 45, 1–67 (2011).

    Article  Google Scholar 

  46. Cohen, J. Statistical Power Analysis for the Behavioral Sciences (Routledge, 2013).

Download references

Acknowledgements

D.Q. received funding from the Shuimu Tsinghua Scholar programme. J.A. received funding from Beijing High Level Public Health Technical Specialist Development Fund (Discipline backbone-02-07). Funding was provided from the Research Fund of Vanke School of Public Health, Tsinghua University (100009001).

Author information

Author notes

  1. These authors contributed equally: Diyang Qu, Bowen Liu, Xuan Zhang.

Authors and Affiliations

  1. Vanke School of Public Health, Tsinghua University, Beijing, China

    Diyang Qu, Bowen Liu, Xuan Zhang, Chengxi Cai, Dongyang Chen, Dongyu Liu, Xue Wen, Zhijun Wu & Runsen Chen

  2. School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China

    Dongyu Liu

  3. Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA

    Shufang Sun

  4. Mindfulness Center, Brown University, Providence, RI, USA

    Shufang Sun

  5. Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Providence, RI, USA

    Shekhar Saxena

  6. Beijing Huilongguan Hospital, Beijing, Beijing, China

    Jing An

  7. Peking University Huilongguan Clinical Medical School, Beijing, China

    Jing An

  8. WHO Collaborating Center for Research and Training in Suicide Prevention, Beijing, China

    Jing An

Authors
  1. Diyang Qu
    View author publications

    Search author on:PubMed Google Scholar

  2. Bowen Liu
    View author publications

    Search author on:PubMed Google Scholar

  3. Xuan Zhang
    View author publications

    Search author on:PubMed Google Scholar

  4. Chengxi Cai
    View author publications

    Search author on:PubMed Google Scholar

  5. Dongyang Chen
    View author publications

    Search author on:PubMed Google Scholar

  6. Dongyu Liu
    View author publications

    Search author on:PubMed Google Scholar

  7. Xue Wen
    View author publications

    Search author on:PubMed Google Scholar

  8. Zhijun Wu
    View author publications

    Search author on:PubMed Google Scholar

  9. Shufang Sun
    View author publications

    Search author on:PubMed Google Scholar

  10. Shekhar Saxena
    View author publications

    Search author on:PubMed Google Scholar

  11. Jing An
    View author publications

    Search author on:PubMed Google Scholar

  12. Runsen Chen
    View author publications

    Search author on:PubMed Google Scholar

Contributions

R.C., J.A. and D.Q. contributed to the conceptualization and design of the intervention; D.Q. led the project, implemented the intervention and drafted the paper; B.L. implemented the intervention, led the data collection, analysed the data and drafted the paper; X.Z. implemented the intervention, collected data and drafted the paper; C.C. contributed to design of the content of intervention; D.C. and D.L. collected data and performed data curation; X.W. and Z.W. provided critical review and editing of the paper; S. Sun and S. Saxena supervised and provided expertise on the project; J.A. and R.C. served as corresponding authors, providing project oversight, final paper approval and supervision of all stages of the work. All authors reviewed and edited the paper.

Corresponding authors

Correspondence to Jing An or Runsen Chen.

Ethics declarations

Competing interests

The authors declare no competing interests.

Peer review

Peer review information

Nature Health thanks Zhiyi Chen, Lan Guo and the other, anonymous, reviewer(s) for their contribution to the peer review of this work. Primary Handling Editor: Manonmani Soundararajan, in collaboration with the Nature Health team.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Extended Data

Extended Data Table 1 The content of sessions
Full size table
Extended Data Table 2 Generalized estimating equation analysis of changes in primary outcomes between two groups over 12 months among participants (n = 4140)
Full size table
Extended Data Table 3 Mean differences in primary outcomes at post-intervention, 6-month, and 12-month follow-ups among participants (n = 4140)
Full size table
Extended Data Table 4 Generalized estimating equation analysis of changes in primary outcomes between two groups over 12 months among trainer teachers (n = 223)
Full size table
Extended Data Table 5 The between-group comparisons for primary outcomes among trainer teachers (n = 223)
Full size table
Extended Data Table 6 Sensitivity analysis of the primary outcomes analyzed with linear mixed models was assessed at post-intervention, 6-month follow-up, and 12-month follow-up for trainer teachers (n = 223)
Full size table
Extended Data Table 7 Sensitivity analysis of the primary outcomes analyzed with linear mixed models was assessed at post-intervention, 6-month follow-up, and 12-month follow-up for participants and trainer teachers (n = 4363)
Full size table
Extended Data Table 8 Exploratory subgroup analyses of intervention effects on four primary outcomes using linear mixed-effects models among participants (n = 4140)
Full size table
Extended Data Table 9 A linear mixed-effects model analysis of group difference in gatekeeper behaviours at 12-month follow-up among participants. (n = 4140)
Full size table
Extended Data Table 10 Independent samples t-test of gatekeeper behaviours between groups at 12-month follow-up among participants
Full size table

Supplementary information

Supplementary Information (download PDF )

Consort checklist 2025; Tables 1–6; Figs. 1 and 2; statistical analysis plan; protocol; and fidelity checklist example.

Reporting Summary (download PDF )

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Qu, D., Liu, B., Zhang, X. et al. School-based suicide prevention using the gatekeeper programme: a cluster-randomized trial. Nat. Health 1, 251–261 (2026). https://doi.org/10.1038/s44360-025-00037-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Version of record:

  • Issue date:

  • DOI: https://doi.org/10.1038/s44360-025-00037-2

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing