JMIR Publications

ABSTRACT

Background:

Suicide is the third-leading cause of death among 10- to 19-year-olds in the US, and about 10% of adolescents attempt suicide each year. School-based universal prevention may reduce youth suicidal behavior. Sources of Strength uses a peer leader network diffusion model to promote healthy norms across a school population.

Objective:

A key challenge within school-wide programs is reaching a large and diverse array of students, especially those less engaged with their peers. Motivated by this challenge, we developed and previously field-tested Text4Strength, a program of automated, interactive text messages targeting help-seeking attitudes and norms, social coping resources, and emotion regulation skills. We conducted a pilot RCT of Text4Strength in one high school as an extension of an ongoing school-wide program (Sources of Strength) to test the impact of Text4Strength on targets that have potential for reducing suicidal behavior.

Methods:

Students at a high school in upstate New York (N=223) received 1-2 text messages per week for nine weeks, targeting strategies for coping with difficult feelings and experiences through: clarifying emotions and focusing on positive affect concepts; awareness and strengthening of youth-adult relationships; and positive help-seeking norms, skills, and resources. Surveys were administered at baseline, immediately post-intervention, and three months after texting ended. We measured proximal intervention targets (methods of coping during stressful events, ability to make sense of their own emotions, feelings of powerlessness during emotion management and recovery, relations with trusted adults at school, and help-seeking behaviors), symptoms and suicide ideation, and student replies to messages.

Results:

No significant effects were observed for any outcome at either follow-up point. Results also showed that if there is a true (but undetected) intervention effect, it is small. Students with fewer friend nominations did not interact any more or less with the text messages. Exploratory moderation analyses observed no interaction between the intervention condition and number of friends or baseline suicide ideation at any time point.

Conclusions:

In contrast to a promising previous field test, these pilot RCT results suggest the intervention is unlikely to have impacted the outcomes of interest and that undetected moderate or large effects can be ruled out with high confidence. Although motivated by the need to reach more isolated students, results showed that students with fewer friends did not engage more or show a greater effect than other participants. This study was conducted in a single high school that was already implementing Sources of Strength, so the bar for showing a distinct effect from the texting alone was high. Many further channels for reaching youth through private messaging remain unexplored. Alternative delivery systems should be investigated, such as embedding messaging in gaming chat systems and other media. More sophisticated systems drawing on Large Language Model chatbots may also achieve better outcomes. Clinical Trial: NCT03145363 https://clinicaltrials.gov/study/NCT03145363