This review found that gatekeeper training was successful at imparting knowledge, building skills, and moulding the attitudes of trainees, but more work needs to be done on longevity of these traits and referral patterns of gatekeepers. These conclusions should be interpreted with some caution, given the possibility of publication and language bias and lack of details on study quality.

To determine the evidence for gatekeeper training on suicide prevention.

MEDLINE and PsycINFO were searched from inception to present (not defined). Key words were reported. Reference lists of retrieved studies were screened. The review was restricted to published, peer-reviewed English language studies.

Studies that involved training people in suicide and/or depression management were eligible for inclusion. Included studies were required to report pre- and post-training data for the following outcomes: suicidal ideation; suicide attempts; deaths by suicide in a target population; and effects of knowledge, skills and/or attitudes of trainees. Studies on the effects of general suicide education were excluded.

Populations targeted by the intervention included school staff/counsellors, Australian aboriginal community members, Canadian adolescents, youth workers, US veterans affairs workers, primary care physicians, air force personnel, and American aboriginal adolescents.

Two reviewers assessed studies for inclusion.

The authors did not state that they assessed validity.

The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction.

A narrative synthesis was reported.

Thirteen studies were included in the review (number of participants unclear), one RCT, two quasi-experimental cohort studies and ten cohort studies.

Effect on knowledge, skills and attitudes (one RCT, six cohort studies): The RCT (n=342 school staff) reported an increase in self-reported knowledge, appraisals of efficacy and access to services (p<0.001). All cohort studies reported beneficial effects on skills, attitudes, self-efficacy and/or knowledge.

Effect on suicidal ideation, suicide attempts or deaths by suicide (6 cohort studies): Four studies evaluated training of primary care physicians. Three reported decreases in suicide rates; this was statistically significant in one, non-significant in one, and significant when compared to the country as a whole but not when compared to the control condition in the third. The fourth study reported a decrease in suicidal acts by 24% (p<0.004) compared with the control region. A study that assessed training over 5 million air force personnel reported a 33% relative risk reduction (95% confidence interval 0.57 to 0.80) in suicide rate when compared to a historical control group. The final study assessed approximately 800 American Aboriginal adolescents and reported a decrease in the mean number of self-destructive events of 73% (p=0.001), but no change in the mean number of suicide completions.

Gatekeeper training was successful at imparting knowledge, building skills, and moulding the attitudes of trainees, but more work is needed on the longevity of these traits and referral patterns of gatekeepers.

The review addressed a focused question supported by clearly defined inclusion criteria in terms of intervention, participants and outcomes. The literature search appeared adequate for published studies, but as no actual end date for the searches was provided, it was unclear whether it was up to date. The review was restricted to published English language studies, so there was a possibility of language and publication bias. Appropriate methods were used to reduce bias and errors in the selection of studies, but it was unclear whether such steps were also taken for the extraction of data. Study quality was not formally assessed, so the reliability of the included studies was unclear. A narrative synthesis was appropriate given the differences between studies. The authors' conclusions are supported by the data but should be interpreted with some caution, given the possibility of publication bias and lack of details on study quality.

Practice: The authors did not state any implications for practice.

Research: The authors stated that research is needed into how gatekeeper training affects different parts of a prevention program and how it works on its own; further research should also evaluate whether the implementation of a gatekeeper training programme may have an iatrogenic effect of increasing suicides. They also stated that there is a need to develop and test outcome and research measures on the effectiveness of gatekeeper training that are relevant to participants and communities. An RCT assessing efficacy is needed to delineate its potential for reducing the suicide base rate in a given community.

Canadian Institutes of Health Research, grant number #166720; CIHR New Investigator Awards, numbers 80503 and 152348; Manitoba Health Research Council Graduate Studentship; Western Regional Training Centre studentship funded by Canadian Health Services Research Foundation, Alberta Heritage Foundation for Medical Research and Canadian Institutes of Health Research.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.