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Currently accepted at: JMIR Mental Health

Date Submitted: Mar 20, 2018
Open Peer Review Period: Mar 20, 2018 - May 3, 2018
Date Accepted: May 3, 2018
(closed for review but you can still tweet)

This paper has been accepted and is currently in production.

It will appear shortly on 10.2196/10425

The final accepted version (not copyedited yet) is in this tab.

The final, peer-reviewed published version of this preprint can be found here:

Mobile Phone Intervention to Reduce Youth Suicide in Rural Communities: Field Test

Pisani AR, Wyman PA, Gurditta K, Schmeelk-Cone K, Anderson CL, Judd E

Mobile Phone Intervention to Reduce Youth Suicide in Rural Communities: Field Test

JMIR Ment Health 2018;5(2):e10425

DOI: 10.2196/10425

PMID: 29853439

PMCID: 6002669

Mobile Phone Intervention to Reduce Youth Suicide in Rural Communities: Field Test

  • Anthony R Pisani; 
  • Peter A Wyman; 
  • Kunali Gurditta; 
  • Karen Schmeelk-Cone; 
  • Carolyn L Anderson; 
  • Emily Judd



Suicide is a leading cause of death among 10- to 19-year-olds in the United States, with 5% to 8% attempting suicide each year. Suicide risk rises significantly during early adolescence and is higher in rural and underserved communities. School-based universal prevention programs offer a promising way of reducing suicide by providing strategies for emotion regulation and encouraging help-seeking behaviors and youth-adult connectedness. However, such programs frequently run into difficulties in trying to engage a broad range of students. Text messaging is a dominant medium of communication among youths, and studies show both efficacy and uptake in text messaging interventions aimed at adolescents. Text-based interventions may, thus, offer a means for school-based universal prevention programs to engage adolescents who would otherwise be difficult to reach.


We field tested Text4Strength, an automated, interactive text messaging intervention that seeks to reach a broad range of early adolescents in rural communities. Text4Strength extends Sources of Strength, a peer-led school suicide prevention program, by encouraging emotion regulation, help-seeking behaviors, and youth-adult connectedness in adolescents. The study tested the appeal and feasibility of Text4Strength and its potential to extend universal school-based suicide prevention.


We field tested Text4Strength with 42 ninth-grade students. Over 9 weeks, students received 28 interactive message sequences across 9 categories (Sources of Strength introduction, positive friend, mentors, family support, healthy activities, generosity, spirituality, medical access, and emotion regulation strategies). The message sequences included games, requests for advice, questions about students’ own experiences, and peer testimonial videos. We measured baseline mental health characteristics, frequency of replies, completion of sequences and video viewing, appeal to students, and their perception of having benefited from the program.


Of the 42 participating students, 38 (91%) responded to at least one sequence and 22 (52%) responded to more than a third of the sequences. The proportion of students who completed multistep sequences they had started ranged from 35% (6/17) to 100% (3/3 to 28/28), with responses dropping off when more than 4 replies were needed. With the exception of spirituality and generosity, each of the content areas generated at least a moderate number of student replies from both boys and girls. Students with higher and lower levels of risk and distress interacted with the sequences at similar rates. Contrary to expectations, few students watched videos. Students viewed the intervention as useful—even those who rarely responded to messages. More than 70% found the texts useful (3 items, n range 29-34) and 90% (36) agreed the program should be repeated.


Text4Strength offers a potentially engaging way to extend school-based interventions that promote protective factors for suicide. Text4Strength is ready to be revised, based on findings and student feedback from this field test, and rigorously tested for efficacy.


Please cite as:

Pisani AR, Wyman PA, Gurditta K, Schmeelk-Cone K, Anderson CL, Judd E

Mobile Phone Intervention to Reduce Youth Suicide in Rural Communities: Field Test

JMIR Mental Health. (forthcoming/in press)

DOI: 10.2196/10425


PMID: 29853439

PMCID: 6002669

© The authors. All rights reserved. This is a privileged document currently under peer-review/community review (or an accepted/rejected manuscript). Authors have provided JMIR Publications with an exclusive license to publish this preprint on it's website for review and ahead-of-print citation purposes only. While the final peer-reviewed paper may be licensed under a cc-by license on publication, at this stage authors and publisher expressively prohibit redistribution of this draft paper other than for review purposes.