Resource Types: Program/Practice

The Improving Mood—Promoting Access to Collaborative Treatment (IMPACT) program is a primary care-based integrated care approach for older adults with depression. It is not a single treatment, but rather a systematic and coordinated approach to providing stepped care according to a specific set of principles and structures. While designed as a treatment for depression rather than suicidal thoughts and behaviors (acutely suicidal patients were excluded from the research), IMPACT showed improvements in suicidal ideation (assessed with a single item) at 6, 12, 18, and 24 months, in addition to reducing depression and functional impairment and improving quality of life. 

Individuals in need of depression care are identified in the primary care setting through screening and referral strategies. After further assessment, an individual care plan is developed collaboratively by a team consisting of a trained primary care provider, the patient, a care manager, and an embedded consulting psychiatrist. Plans typically include patient education, self-management support, evidence-based treatments, such as medication and/or brief psychotherapy, and maintenance support once the patient has improved. Close follow-up and regular case consultation ensures that patients do not fall through the cracks. Patient goals and clinical outcomes are systematically tracked and monitored, and the team makes adjustments to the treatment plan as needed. If improvement does not occur, some patients may be referred to specialty mental health services.

IMPACT is one form of Collaborative Care, a specific type of integrated care that provides both medical and mental health care in primary care and other clinical settings. This approach was developed at the University of Washington to address conditions like depression that require systematic follow-up. More recently the approach has been applied to other conditions, including anxiety, PTSD, and co-morbid depression and medical conditions such as heart disease, diabetes, and cancer. Collaborative Care is not simply co-locating a mental health professional in a primary care clinic or simply adding members to a care team. A substantial body of evidence for Collaborative Care has developed over the past 20 years.

Designation as a “Program with Evidence of Effectiveness”

SPRC designated this intervention as a “program with evidence of effectiveness” based on its inclusion in three sources:

1. “A Systematic Review of Elderly Suicide Prevention Programs” (Lapierre et al., 2011)
2. The Centers for Disease Control and Prevention’s (CDC) Preventing Suicide: A Technical Package of Policy, Programs, and Practices (Stone et al., 2017)
3. The Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Programs and Practices (NREPP)

(1) Systematic Review

Lapierre et al. (2011) conducted a systematic review of elderly suicide prevention programs, including rating the level of evidence for each intervention on a scale of one (highest) to five (lowest) based on the Oxford Centre for Evidence-Based Medicine (Oxford CEBM, 2009). The IMPACT study used a randomized controlled trial design, which is level one (strongest evidence) on the Oxford classification of evidence. As noted above, IMPACT reduced suicidal ideation (assessed with a single item) at 6, 12, 18, and 24 months compared to patients who received usual care, in addition to reducing depression and functional impairment and improving quality of life. 

Lapierre, S., Erlangsen, A., Waern, M., De Leo, D., Oyama, H., Scocco, P., . . . International Research Group for Suicide among the Elderly. (2011). A systematic review of elderly suicide prevention programs. Crisis, 32(2), 88–98. Full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3728773/

(2) CDC Technical Package

The CDC’s Preventing Suicide: A Technical Package of Policy, Programs, and Practices lists IMPACT as an evidence-based treatment for people at risk of suicide (p. 37): “The program has been shown to significantly improve quality of life, and to reduce functional impairment, depression, and suicidal ideation over 24 months of follow-up relative to patients who received care as usual.”

Stone, D. M., Holland, K. M., Bartholow, B., Crosby, A. E., Davis, S., & Wilkins, N. (2017). Preventing suicide: A technical package of policy, programs, and practices. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Full text: https://www.cdc.gov/violenceprevention/pdf/suicide-technicalpackage.pdf

Study cited: Unutzer, J., Tang, L., Oishi, S, Katon, W., Williams, J. W., Hunkeler, E., . . . IMPACT Investigators. (2006). Reducing suicidal ideation in depressed older primary care patients. Journal of the American Geriatrics Society, 54(10):1550–1556.

(3) NREPP

The most recent NREPP review of IMPACT in 2012 provides a useful summary of the intervention and measurement of the outcomes related to depression, functional impairment, and quality of life (the summary does not discuss the research results specific to suicide that are cited in the two sources above).

Outcome(s) Reviewed (Overall Quality of Research Rating-scale of 0 to 4)*

1: Severity of depression (3.8)
2: Functional impairment (3.7)
3: Health-related quality of life (3.8)

Read more about this program’s ratings.

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* NREPP changed its review criteria in 2015. This program is a “legacy program,” meaning that it was reviewed under the previous criteria. The evidence for each outcome was reviewed and scored on a scale of 0-4, with 4 indicating the highest quality of evidence and 0 indicating very poor quality of evidence. The overall rating was based on ratings of six criteria: 1) reliability of measures, 2) validity of measures, 3) intervention fidelity, 4) missing data and attrition, 5) potential confounding variables, and 6) appropriateness of analysis.  Over time, all legacy programs will be re-reviewed using the current criteria. When considering programs, we recommend (a) assessing whether the specific outcomes achieved by the program are a fit for your needs; and (b) examining the strength of evidence for each outcome.

2012 NSSP Objectives Addressed: 

Objective 7.5: Develop and implement protocols and programs for clinicians and clinical supervisors, first responders, crisis staff, and others on how to implement effective strategies for communicating and collaboratively managing suicide risk.

Objective 8.2: Develop and implement protocols for delivering services for individuals with suicide risk in the most collaborative, responsive, and least restrictive settings.

Objective 9.1: Adopt, disseminate, and implement guidelines for the assessment of suicide risk among persons receiving care in all settings.

Objective 9.2: Develop, disseminate, and implement guidelines for clinical practice and continuity of care for providers who treat persons with suicide risk.

QPR (Question, Persuade, and Refer) Gatekeeper Training for Suicide Prevention is a 1-2 hour educational program designed to teach lay and professional “gatekeepers” the warning signs of a suicide crisis and how to respond. Gatekeepers can include anyone who is strategically positioned to recognize and refer someone at risk of suicide (e.g., parents, friends, neighbors, teachers, coaches, caseworkers, police officers). The process follows three steps: (1) Question the individual’s desire or intent regarding suicide, (2) Persuade the person to seek and accept help, and (3) Refer the person to appropriate resources. Trainees receive a QPR booklet and wallet card as a review and resource tool that includes local referral resources.

The training is delivered in person by certified QPR gatekeeper instructors or online. Although the foundation for the QPR Gatekeeper Training for Suicide Prevention is the same for all audiences, the training can be customized for use with specific audiences in collaboration with the QPR Institute. Extended learning modules on specific topics are available to complement the basic 1-2 hour course.

Specialized modules exist for various frontline practitioners (e.g. law enforcement, first responders, medical professionals, corrections, individuals who work with veterans, and others). These courses are taught in classroom, online, or blended training formats and range from approximately 3-8 hours in length. Training hours, certificates, and CEs vary with each course. See the QPR website for details.

Designation as a “Program with Evidence of Effectiveness”

SPRC designated this intervention as a “program with evidence of effectiveness” based on its inclusion in SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP).

Outcomes Reviewed (Overall Quality of Research Rating-scale of 0 to 4)*

1: Knowledge about suicide (2.6)

2: Gatekeeper self-efficacy (2.6)

3: Knowledge of suicide prevention resources (2.9)

4: Gatekeeper skills (2.8)

5: Diffusion of gatekeeper training information (2.5)

In the three studies reviewed by NREPP, the training was delivered to school staff; parents; and clinical providers and nonclinical staff from the U.S. Department of Veterans Affairs. Outcomes 1 and 2 were measured in all three studies reviewed, while outcomes 3, 4, and 5 were each measured in one study. 

Read more about this program’s ratings.

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* NREPP changed its review criteria in 2015. This program is a “legacy program,” meaning that it was reviewed under the pre-2015 criteria. The evidence for each outcome was reviewed and scored on a scale of 0-4, with 4 indicating the highest quality of evidence and 0 indicating very poor quality of evidence. The overall rating was based on ratings of six criteria: 1) reliability of measures, 2) validity of measures, 3) intervention fidelity, 4) missing data and attrition, 5) potential confounding variables, and 6) appropriateness of analysis. When considering programs, we recommend (a) assessing whether the specific outcomes achieved by the program are a fit for your needs; and (b) examining the strength of evidence for each outcome. 

Program Objectives

After minimum training, QPR participants should be able to:

1. Recognize someone at risk for suicide,
2. Intervene with those at risk; and,
3. Refer them to an appropriate resource.

After expanded training for various professions, additional objectives are included in each course. See the program website for details.

Implementation Essentials

• Training must be conducted by a certified QPR instructor or online by the QPR Institute.
• Training must include standardized PowerPoint slides, and distribution of the QPR Booklet and wallet card in hard copy or electronically.

2012 NSSP Objectives Addressed: 

Objective 7.1: Provide training on suicide prevention to community groups that have a role in the prevention of suicide and related behaviors.

Kognito Family of Heroes is a one-hour, online, interactive gatekeeper training simulation that teaches family members of veterans how to (1) identify signs of post-deployment stress, including post-traumatic stress disorder (PTSD), traumatic brain injury (TBI), depression, and thoughts of suicide; (2) approach veterans to discuss their concern, and (3) access mental health support services. Through the training, family members learn what to expect when a veteran returns from deployment; what postdeployment stress is and how to identify it, How to de-escalate arguments and negotiate family responsibilities; how to talk with a veteran about seeking professional help; and how to find support services appropriate for veterans and their families.

In the training, users engage in simulated conversations with three interactive veteran avatars that exhibit signs of post-deployment stress. In these virtual role-plays, they learn conversation strategies for broaching the topic of psychological distress; motivating the veteran to seek help; and avoiding pitfalls, such as pressuring and criticizing the veteran. The course is available from Kognito Interactive for a fee.

Designation as a “Program with Evidence of Effectiveness”

SPRC designated this intervention as a “program with evidence of effectiveness” based on its inclusion in SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP).

Outcome(s) Reviewed (Overall Quality of Research Rating-scale of 0 to 4)

1: Preparedness to recognize signs of postdeployment stress (2.4)
2: Preparedness to discuss concern with veteran and motivate him or her to seek help at a VA hospital or Vet center (2.4)
3: Self-efficacy in motivating veteran to seek help at a VA hospital or Vet center (2.5)
4: Intention to approach veteran to discuss concerns (2.4)
5: Intention to mention the VA as a helpful resource (2.4)

Read more about this program’s ratings.

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* NREPP changed its review criteria in 2015. This program is a “legacy program,” meaning that it was reviewed under the pre-2015 criteria. The evidence for each outcome was reviewed and scored on a scale of 0-4, with 4 indicating the highest quality of evidence and 0 indicating very poor quality of evidence. The overall rating was based on ratings of six criteria: 1) reliability of measures, 2) validity of measures, 3) intervention fidelity, 4) missing data and attrition, 5) potential confounding variables, and 6) appropriateness of analysis. When considering programs, we recommend (a) assessing whether the specific outcomes achieved by the program are a fit for your needs; and (b) examining the strength of evidence for each outcome.

Implementation Essentials

• Training participants should be given a variety of local and national resources for veterans who may be at risk for psychological distress.

2012 NSSP Objectives Addressed: 

Objective 5.3: Intervene to reduce suicidal thoughts and behaviors in populations with suicide risk.

Objective 7.1: Provide training on suicide prevention to community groups that have a role in the prevention of suicide and related behaviors.

Question, Persuade, Refer (QPR) for Law Enforcement is a 90-minute online certificate training program that teaches law enforcement professionals how to detect, intervene with, and refer someone at risk for suicide. Adapted from the broader Question, Persuade, and Refer emergency mental health gatekeeper training intervention, it teaches members of the law enforcement community to recognize and respond positively to someone exhibiting suicide warning signs and behaviors. Like CPR, QPR uses a “chain of survival” approach in which the gatekeeper learns to recognize early suicide warning signs, Question their meaning to determine suicide intent or desire, Persuade the person to accept or seek help, and Refer the person to appropriate resources. Law enforcement content was created with the help of Dr. John Violanti and Lt. Dell Hackett (Ret.), veteran police officers who are involved in the design, implementation, research and analysis of programs related to police stress, health improvement, and suicide prevention. The two officers have more than 50 years of combined law enforcement experience.

An additional 4-5 hour advanced certificate course is included in the online training program. The advanced certificate course covers suicide risk assessment and management, including: how to detect risk; how to interview suicidal people; what questions to ask; how to ask them; and what the answers to these questions mean in terms of determining level of immediate risk and steps to implement safe outcomes, including means restriction efforts. One objective of the advanced course is to help law enforcement, emergency departments, jails, and mental health providers “speak the same language” about suicide when sharing responsibility for citizen safety. To supplement online training, a free companion post-online First Responder Instructor Manual is available on request. Final peer review of both courses was provided by Chief Roger Bragdon (Ret.), Spokane Police Department.

Program Objectives

At the end of the training, QPR for Law Enforcement participants will have increased knowledge of:

1. Warning signs for suicide.
2. How to effectively intervene with those at risk for suicide.
3. How to refer someone at risk for suicide to an appropriate helping resource.

Implementation Essentials

• QPR for Law Enforcement participants should have knowledge of local helping resources.

2012 NSSP Objectives Addressed: 

Objective 7.1: Provide training on suicide prevention to community groups that have a role in the prevention of suicide and related behaviors.

Kognito At-Risk for University and College Students is a 30-minute, online, interactive gatekeeper training program that teaches students how to (1) identify students exhibiting signs of psychological distress, including depression and thoughts of suicide; (2) approach students to discuss their concern; and (3) make referrals to university counseling centers. Students also learn about support services and resources at their campus, including counseling centers. In the training, learners assume the role of a college student concerned about four friends. The user explores four different social circumstances throughout the school year to locate and learn about warning signs related to their “friends.” Then, they engage in a simulated conversation with the student avatar they have identified as being most at risk. In the virtual conversation, users learn effective conversation tactics and motivational interviewing techniques to effectively broach the topic of their concern, motivate the student to seek help, and avoid pitfalls, such as attempting to counsel.

Designation as a “Program with Evidence of Effectiveness”

SPRC designated this intervention as a “program with evidence of effectiveness” based on its inclusion in SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP).

Outcome(s) Reviewed (Overall Quality of Research Rating-scale of 0 to 4)*

1: Preparedness to recognize fellow students in psychological distress (2.4)
2: Preparedness to approach fellow students in psychological distress (2.4)
3: Preparedeness to refer fellow students in psychological distress (2.4)
4: Likelihood of approaching and referring fellow students exhibting signs of psychological distress (2.5)
5: Willingness to seek mental health counseling for self (2.4)

Read more about this program’s ratings.

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* NREPP changed its review criteria in 2015. This program is a “legacy program,” meaning that it was reviewed under the post-2015 criteria.The evidence for each outcome was reviewed and scored on a scale of 0-4, with 4 indicating the highest quality of evidence and 0 indicating very poor quality of evidence. The overall rating was based on ratings of six criteria: 1) reliability of measures, 2) validity of measures, 3) intervention fidelity, 4) missing data and attrition, 5) potential confounding variables, and 6) appropriateness of analysis. When considering programs, we recommend (a) assessing whether the specific outcomes achieved by the program are a fit for your needs; and (b) examining the strength of evidence for each outcome.

Implementation Essentials

• The program’s implementation manual should be thoroughly reviewed prior to program implementation.  
• The institution’s Counseling Center staff should have the ability to assess and manage students who may be at risk for suicide prior to program implementation.
• This course is most effective when used as part of a college or university’s larger strategic plan to identify and help at-risk students.

2012 NSSP Objectives Addressed: 

Objective 7.1: Provide training on suicide prevention to community groups that have a role in the prevention of suicide and related behaviors.

Kognito At-Risk for High School Educators is an online, interactive gatekeeper training program that is available in one-hour and two-hour versions. This training teaches high school teachers and other educators how to (1) identify students exhibiting signs of psychological distress, including depression, anxiety, substance abuse, and thoughts of suicide; (2) approach students to discuss their concern; and (3) make a referral to school support services. Through role-plays with animated and responsive avatars, participants engage in simulated conversations with three students of concern with the help of a virtual coach. In these virtual conversations, users learn effective conversation strategies for broaching the topic of psychological distress, motivating the student to seek help, and avoiding pitfalls, such as attempting diagnose the problem or giving unwarranted advice. This online course is available from Kognito Interactive for a fee.

Designation as a “Program with Evidence of Effectiveness”

SPRC designated this intervention as a “program with evidence of effectiveness” based on its inclusion in SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP).

Outcome(s) Reviewed (Overall Quality of Research Rating-scale of 0 to 4)*

1: Preparedness to recognize, approach, and refer students exhibiting signs of psychological distress (2.8)
2: Likelihood of approaching and referring students exhibiting signs of psychological distress (2.8)
3: Confidence in one’s ability to help students exhibiting signs of psychological distress (2.8)

Read more about this program’s ratings.

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* NREPP changed its review criteria in 2015. This program is a “legacy program,” meaning that it was reviewed under the pre-2015 criteria. The evidence for each outcome was reviewed and scored on a scale of 0-4, with 4 indicating the highest quality of evidence and 0 indicating very poor quality of evidence. The overall rating was based on ratings of six criteria: 1) reliability of measures, 2) validity of measures, 3) intervention fidelity, 4) missing data and attrition, 5) potential confounding variables, and 6) appropriateness of analysis. When considering programs, we recommend (a) assessing whether the specific outcomes achieved by the program are a fit for your needs; and (b) examining the strength of evidence for each outcome. 

Implementation Essentials

• The program’s implementation manual should be thoroughly reviewed prior to program implementation.  
• Teachers who take the course should understand their school’s referral policies and protocols.
• This course is most effective when used as part of a high school’s larger strategic plan to identify and help at-risk students.

2012 NSSP Objectives Addressed: 

Objective 7.1: Provide training on suicide prevention to community groups that have a role in the prevention of suicide and related behaviors.

MASPP is a public health-oriented suicide prevention and intervention program originally developed for a small American Indian tribe in rural New Mexico to target high rates of suicide among its adolescents and young adults. The goals of the program are to reduce the incidence of adolescent suicides and suicide attempts through community education about suicide and related behavioral issues, such as child abuse and neglect, family violence, trauma, and alcohol and substance abuse. As a community-wide initiative, the MASPP incorporates universal, selective, and indicated interventions and emphasizes community involvement, ownership, and culturally framed public health approaches appropriate for an American Indian population.

Central features of the program include formalized surveillance of suicide-related behaviors; a school-based suicide prevention curriculum; community education; enhanced screening and clinical services; and extensive outreach provided through health clinics, social services programs, schools, and community gatherings and events. In addition, neighborhood volunteers of various ages are recruited to serve as “natural helpers.” These individuals engage in personal and program advocacy, provide referrals to community mental health services, and offer peer counseling (with guidance from professional mental health staff) to youth who may prefer to seek assistance from trusted laypersons in a less formal setting.

Designation as a “Program with Evidence of Effectiveness”

SPRC designated this intervention as a “program with evidence of effectiveness” based on its inclusion in SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP).

Outcome(s) Reviewed (Overall Quality of Research Rating-scale of 0 to 4)*

1: Suicide attempts (2.0)
2: Suicide gestures (2.0)

Read more about this program’s ratings. 

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* NREPP changed its review criteria in 2015. This program is a “legacy program,” meaning that it was reviewed under the pre-2015 criteria. The evidence for each outcome was reviewed and scored on a scale of 0-4, with 4 indicating the highest quality of evidence and 0 indicating very poor quality of evidence. The overall rating was based on ratings of six criteria: 1) reliability of measures, 2) validity of measures, 3) intervention fidelity, 4) missing data and attrition, 5) potential confounding variables, and 6) appropriateness of analysis. When considering programs, we recommend (a) assessing whether the specific outcomes achieved by the program are a fit for your needs; and (b) examining the strength of evidence for each outcome. 

Implementation Essentials

• Thoroughly review the program manual prior to implementation.  
• Establish a planning group to adapt the model to fit the local community and guide the process of program implementation.
• Identify qualified staff and informal community supports.

2012 NSSP Objectives Addressed: 

Objective 3.1: Promote effective programs and practices that increase protection from suicide risk.

Objective 7.1: Provide training on suicide prevention to community groups that have a role in the prevention of suicide and related behaviors.

Objective 7.2: Provide training to mental health and substance abuse providers on the recognition, assessment, and management of at-risk behavior, and the delivery of effective clinical care for people with suicide risk.

Objective 8.3: Promote timely access to assessment, intervention, and effective care for individuals with a heightened risk for suicide.

Objective 8.6: Establish linkages between providers of mental health and substance abuse services and community-based programs, including peer support programs.

Objective 9.5: Adopt and implement policies and procedures to assess suicide risk and intervene to promote safety and reduce suicidal behaviors among patients receiving care for mental and/or substance use disorders.

Objective 10.2: Provide appropriate clinical care to individuals affected by a suicide attempt or bereaved by suicide, including trauma treatment and care for complicated grief.

LEADS: For Youth (Linking Education and Awareness of Depression and Suicide) is a curriculum for high school students in grades 9-12 that is designed to increase knowledge of depression and suicide, modify perceptions of depression and suicide, increase knowledge of suicide prevention resources, and improve intentions to engage in help-seeking behaviors. The curriculum addresses such topics as depression and its symptoms, the link between depression and suicide, the risk and protective factors associated with suicide, the warning signs of suicide, seeking help and overcoming barriers to seeking help, and school and community suicide prevention resources. By educating students about seeking help and the resources available to them, the intervention aims to empower students to get help for themselves or others.

Teachers implement the curriculum for 1 hour a day over a 3-day period in a health class or other classroom setting. The curriculum includes lecture, student-driven discussions, and activities such as a simulated blog and an email and instant messaging activity. The curriculum package includes a Teacher’s Guide, presentation materials, group and individual activities, suicide prevention resources and a template for a school suicide crisis management plan.

Designation as a “Program with Evidence of Effectiveness”

SPRC designated this intervention as a “program with evidence of effectiveness” based on its inclusion in SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP).

Outcome(s) Reviewed (Overall Quality of Research Rating-scale of 0 to 4)*

1: Knowledge of depression and suicide (1.8)
2: Perceptions of depression and suicide (1.8)
3: Knowledge of suicide prevention resources (1.8)

Read more about this program’s ratings.

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* NREPP changed its review criteria in 2015. This program is a “legacy program,” meaning that it was reviewed under the pre-2015 criteria. The evidence for each outcome was reviewed and scored on a scale of 0-4, with 4 indicating the highest quality of evidence and 0 indicating very poor quality of evidence. The overall rating was based on ratings of six criteria: 1) reliability of measures, 2) validity of measures, 3) intervention fidelity, 4) missing data and attrition, 5) potential confounding variables, and 6) appropriateness of analysis. When considering programs, we recommend (a) assessing whether the specific outcomes achieved by the program are a fit for your needs; and (b) examining the strength of evidence for each outcome.

Implementation Essentials

• Prior to training the peer team, crisis management and referral protocols should be reviewed and fully implemented and local adult advisors should be identified and trained. For guidance, see the Sources of Strength “First Things First” webpage.

2012 NSSP Objectives Addressed: 

Objective 5.2: Encourage community-based settings to implement effective programs and provide education that promote wellness and prevent suicide and related behaviors.

The THRIVE media campaign provides free suicide prevention posters and a fact sheet geared toward American Indian/Alaska Native youth centered around the theme, Community is the Healer that Breaks the Silence.