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Cited by 31Suicide and Self-Harm StudiesMental Health Treatment and AccessGender Roles and Identity Studies

Silence is deadly: a cluster-randomised controlled trial of a mental health help-seeking intervention for young men

Open access
Calear, Alison L., Banfield, Michelle, Batterham, Philip J., Morse, Alyssa R., Forbes, Owen, Carron-Arthur, Bradley, Fisk, Martin·2017·BMC Public Health
DOI 10.1186/s12889-017-4845-zPMC PMC5653993
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Abstract

BACKGROUND: Young men are consistently less likely to seek help for mental health problems than their female peers. This is particularly concerning given the high rates of suicide among male adolescents. The school system has been identified as an ideal setting for the implementation of prevention and early intervention programs for young people. The current trial aims to determine the effectiveness of the Silence is Deadly program in increasing positive help-seeking intentions for mental health problems and suicide among male secondary school students. METHODS: This study is a two-arm, cluster-randomised, controlled trial that will compare the Silence is Deadly program to a wait-list control condition. Eight Australian high schools will be recruited to the trial, with male students in grades 11 and 12 (16 to 18 years of age) targeted for participation. The program is an innovative male-tailored suicide prevention intervention, comprising a presentation that emphasises role-modelling and legitimises help-seeking for personal and emotional problems, and a brief video that features celebrity athletes who counter existing male norms around help-seeking and encourage communication about personal and emotional issues. The program also includes a discussion of how to help a friend in distress and ends with a question and answer session. The primary outcome measure for the current study is help-seeking intentions. Secondary outcomes include help-seeking behaviour, help-seeking attitudes, help-seeking stigma, mental health symptoms, and suicidal ideation. Data will be collected pre-intervention, post-intervention, and at 3-month follow-up. Primary analyses will compare changes in help-seeking intentions for the intervention condition relative to the wait-list control condition using mixed-effects repeated-measures analyses that account for clustering within schools. DISCUSSION: If proven to be effective, this targeted help-seeking intervention for adolescent males, which is currently only delivered in one jurisdiction, could be more widely delivered in Australian high schools. The Silence is Deadly program has the potential to significantly contribute to the mental health of young men in Australia by improving help-seeking for suicidality and mental health problems, allowing this population to better access treatment and support sooner. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12617000658314 . Registered on 8 May 2017.

AI snapshot

Written from the paper’s full text.

TL;DR

This is the published protocol for a two-arm cluster-randomised controlled trial testing whether the "Silence is Deadly" school-based program improves mental health help-seeking intentions among Australian male secondary students. No outcome data are reported; recruitment was ongoing at the time of publication.

Key findings

As a protocol, the paper reports no trial results. It states the planned primary outcome is help-seeking intentions (adapted General Help-Seeking Questionnaire, 11 formal and informal sources, rated 1–7), with secondary outcomes of help-seeking behaviour, attitudes, stigma, mental health symptoms and suicidal ideation measured pre-intervention, post-intervention and at 3-month follow-up. The background cites that only 13% of males aged 16–24 with a mental health problem seek professional help versus 31% of females, and that suicide rates are three times higher among young men than young women. The authors state the intervention is novel in targeting gender-specific norms and attitudes, not just male-tailored language, and that up to 59% of variance in men's help-seeking attitudes can be explained by stigma and gender role conflict.

Methods

Two-arm cluster-randomised controlled trial with one active intervention group and one wait-list control group; at least 8 ACT high schools and approximately 800 male students (100 per school) in grades 11–12 (16–18 years) targeted, with extension to Years 7–10 if recruitment is insufficient. Schools are cluster-randomised by a statistician using minimisation on school type (private vs. public) and grade 11–12 enrolment (<300 vs. 300+). Primary and secondary effectiveness analyses use mixed-model repeated measures (MMRM) accounting for clustering within schools, with three-way time × condition × moderator interaction terms for moderation analyses and binary mixed models for binary outcomes; qualitative staff interviews use Framework Analysis. Sample size assumes effect size f = 0.2, repeated-measures correlation 0.5, intra-class correlation 0.03 and 20% attrition, giving >85% power.

Limitations

The paper itself states no limitations; it is a protocol and explicitly notes "Participants are currently being recruited to the trial," so no effectiveness conclusions can be drawn. Evident from the text: the sample is confined to one Australian jurisdiction (ACT) and delivered by a single provider (Menslink), the trial relies on self-reported outcomes, and the wait-list design means control schools receive the program only after the 3-month follow-up.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s12889-017-4845-z

Cites

35 of 35 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 23 cited sources checked · 0 supported · 0 flagged

  • Interpretationreasoning

    In order to change help-seeking behaviours, masculine norms and attitudes must be addressed.

    “Thus in order to change help-seeking behaviours, these norms and attitudes must be addressed.”
    Quote in the paperNot a substantial claim
  • Premisecitation

    Up to 59% of the variance in mental health help-seeking attitudes among men can be explained by stigma and gender role conflict.

    “up to 59% of the variance in mental health help-seeking attitudes among men can be explained by stigma and gender role conflict [8]”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [8] Wahto R, Swift JK. Labels, gender-role conflict, stigma, and attitudes toward seeking psychological help in men. Am J Mens Health. 2016;10(3):181–91. source

      Not checked in the free run.

  • Premisecitation

    Conformity to masculine norms around self-reliance and help-seeking was a significant predictor of increased risk of suicidal thinking in a large all-male cohort study.

    “a recent large all-male cohort study found that conformity to masculine norms around self-reliance and help-seeking was a significant predictor of increased risk of suicidal thinking [9]”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] Pirkis J, Spittal MJ, Keogh L, Mousaferiadis T, Currier D. Masculinity and suicidal thinking. Soc Psychiatry Psychiatr Epidemiol. 2016;52:319–27. source

      Not checked in the free run.

  • Premisecitation

    Rates of suicide are three times higher among young men than young women.

    “rates of suicide are three times higher among young men than young women [2]”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [2] Statistics ABo. Causes of death, Australia. Canberra: Australian Bureau of Statistics; 2014.

      Not checked in the free run.

  • Premisecitation

    Suicide is the most frequent cause of death in this age group.

    “suicide is the most frequent cause of death in this age group [2]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [2] Statistics ABo. Causes of death, Australia. Canberra: Australian Bureau of Statistics; 2014.

      Not checked in the free run.

  • Classified as probably not a substantial claim. 11
  • May combine two claims. 10

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    A minimisation approach to randomisation will be taken in order to balance participant characteristics and numbers across conditions.

    “Given that entire schools will be randomised, a minimisation approach to randomisation will be taken in order to balance participant characteristics and numbers across conditions [22, 23].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [22] Altman DG, Bland JM. Treatment allocation by minimisation. BMJ. 2005;330(7495):843. source

      Not checked in the free run.

    • cites [23] Taves DR. The use of minimization in clinical trials. Contemporary Clinical Trials. 2010;31:180–4. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    None of the studies in that review analysed results according to gender and none were tailored to address gender-based attitudes and perceived norms thought to drive male help-seeking behaviour.

    “However, none of the studies identified in this review analysed results according to gender and none were tailored to address the gender-based attitudes and perceived norms thought to drive male help-seeking behaviour.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [10] Gulliver A, Griffiths KM, Christensen H, Brewer JL. A systematic review of help-seeking interventions for depression, anxiety and general psychological distress. BMC Psychiatry. 2012;12(1):81. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Participants aged 16 years and older can provide informed consent as a 'mature minor'.

    “participants aged 16 years and older being able to provide informed consent as a ‘mature minor’ [20].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [20] Kelly AB, Halford WK. Responses to ethical challenges in conducting research with Australian adolescents. Aust J Psychol. 2007;59:24–33. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Study design and conductnone given

    With the exception of the Confidence Supporting Peers scale, all measures have previously been evaluated with adolescent samples and have good psychometric properties.

    “With the exception of the Confidence Supporting Peers scale (see below), all measures have previously been evaluated with adolescent samples and have good psychometric properties.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Study design and conductnone given

    Cluster randomisation will reduce school and administrative burden and prevent contamination of the wait-list control condition.

    “This approach will reduce school and administrative burden and prevent contamination of the wait-list control condition.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Young men hold more negative attitudes towards help-seeking for mental health issues than young women, due in part to lower levels of openness to acknowledging psychological problems.

    “Young men are known to hold more negative attitudes towards help-seeking for mental health issues than young women [5], due in part to lower levels of openness to acknowledging psychological problems [6].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [5] Oliver M, Pearson N, Coe N, Gunnell D. Help-seeking behaviour in men and women with common mental health problems: cross-sectional study. Br J Psychiatry. 2005;186(4):297–301. source

      Not checked in the free run.

    • cites [6] Mackenzie CS, Gekoski WL, Knox VJ. Age, gender, and the underutilization of mental health services: the influence of help-seeking attitudes. Aging Ment Health. 2006;10(6):574–82. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    MMRM is the standard and most robust methodology for analysing randomised controlled trials.

    “Analyses of primary and secondary effectiveness outcomes will be conducted using a mixed-model repeated measures (MMRM) approach [35], the standard and most robust methodology for analysing randomised controlled trials.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [35] Verbeke G, Molenberghs G. Linear mixed models for longitudinal data. In: Linear mixed models for longitudinal data. New York: Springer-Verlag New York; 2000. p. 240–68.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Randomisation will be conducted by a statistician who is not involved in the day-to-day management of the trial according to ICH Guidelines.

    “Randomisation will be conducted by a statistician who is not involved in the day-to-day management of the trial according to ICH Guidelines [21].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [21] Lewis JA. Statistical principles for clinical trials (ICH E9): an introductory note on an international guideline. Stat Med. 1999;18:1903–42. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    Framework Analysis follows a systematic process of inductive coding, generating a table of findings across participants that is conducive to interpretation and input from multiple researchers.

    “It follows a systematic process of inductive coding, generating a table of findings across participants that is conducive to interpretation and input from multiple researchers.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [36] Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess RG, editors. Analyzing Qualitative Data. UK: Taylor & Francis Books Ltd.; 1994. p. 173–94. source

      Not checked in the free run.

    • cites [37] Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Differences in psychological openness are thought to be due to subjective masculine norms that encourage emotion suppression and lead to the stigmatisation of help-seeking for emotional problems.

    “These differences in psychological openness are thought to be due to subjective masculine norms that encourage emotion suppression and lead to the stigmatisation of help-seeking for emotional problems [7].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [7] Moller-Leimkuhler M. Barriers to help-seeking by men: a review of sociocultural and clinical literature with particular reference to depression. J Affect Disord. 2002;71:1–9. source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    MMRM can include participants with missing data without using biased imputation techniques, assuming that data are missing-at-random.

    “This approach is able to include participants with missing data without using biased imputation techniques, assuming that data are missing-at-random.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    The difference in help-seeking is largest during adolescence; only 13% of males with a mental health problem seek professional help compared to 31% of females aged 16 to 24 years.

    “This difference is largest during adolescence; with only 13% of males with a mental health problem seeking professional help compared to 31% of females aged 16 to 24 years [1].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [1] Slade T, Johnston A, Teesson M, Whiteford H, Burgess P, Pirkis J, Saw S. The mental health of Australians 2: report on the 2007 National Survey of mental health and wellbeing. Canberra: Department of Health and Ageing; 2009.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Research indicates that the measurement of suicidal behaviours in adolescents is acceptable and does not pose an iatrogenic risk.

    “Research indicates that the measurement of suicidal behaviours in adolescents is acceptable and does not pose an iatrogenic risk [32].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [32] Robinson J, Yuen HP, Martin C, Hughes A, Baksheev GN, Dodd S, Bapat S, Schwass W, McGorry P, Yung AR. Does screening high school students for psychological distress, deliberate self-harm, or suicidal ideation cause distress – and is it acceptable? Crisis. 2011;32(5):254–63. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Silence is Deadly has been delivered in ACT schools since 2013 by Menslink.

    “This program has been delivered in Australian Capital Territory (ACT) schools since 2013 by the organisation Menslink, which was established in 2002 [19].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [19] Menslink: Supporting young men in Canberra [ http://menslink.org.au/ ].

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Substituting terms that highlight emotional problems with more generic references to personal problems has led to improved attitudes towards seeking help from a counselling service.

    “substituting terms that highlight emotional problems with more generic references to personal problems has led to improved attitudes towards seeking help from a counselling service [17].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] Rochlen AB. The relation of male gender role conflict and attitudes toward career counseling to interest in and preferences for different career counseling styles. Psychol Men Masculinity. 2002;3(1):9–21. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    Increasing rates of help seeking is an important public health target that could assist in lowering the rate of suicide among young men and reduce the burden of personal and emotional issues that may otherwise go unnoticed and untreated.

    “Increasing rates of help seeking is an important public health target that could assist in lowering the rate of suicide among young men and reduce the burden of personal and emotional issues that may otherwise go unnoticed and untreated.”
    Quote in the paperNot a substantial claim
16 of 16

  • The paper relies on this without support.

    No research to date has evaluated an intervention that is tailored, beyond language, to also address gender specific norms and attitudes that have been shown to be a driver of male help-seeking behaviour.

    “No research to date though has evaluated an intervention that is tailored, beyond language, to also address gender specific norms and attitudes that have been shown to be a driver of male help-seeking behaviour.”

  • The paper relies on this without support.

    Mental health and suicide prevention systems are lacking in Australian schools.

    “Mental health and suicide prevention systems are lacking in Australian schools”
2 of 2

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Four of the six classroom-based stigma interventions focused on providing interpersonal contact with people with mental health conditions in order to improve acceptance and increase help-seeking intentions.

    “Six classroom-based interventions addressing stigma were identified, two of which used psychoeducation to overcome myths regarding mental illness [101, 102] and four focused on providing interpersonal contact with people with mental health conditions in order to improve acceptance and increase help-seeking intentions [103–106].”

    From What are the barriers, facilitators and interventions targeting help-seeking behaviours for common mental health problems in adolescents? A systematic review (2020) · cites this paper as [105]

    The Methods/design > Intervention section describes a face-to-face school session in which facilitators share their positive help-seeking experiences, aiming to reduce stigma and improve help-seeking attitudes. It does not say the facilitators have mental health conditions or that the session aims to increase acceptance of people with those conditions. The paper describes this one intervention, not the four counted across the citing sentence’s grouped references; page numbers are unavailable in our copy. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • Men are less likely to seek help for their mental health concerns in general or psychotherapies in particular.

    “This is consistent with the previous findings that men are less likely to seek help for their mental health concerns in general or psychotherapies in particular. 45”

    From Technology-Based Interventions to Improve Help-Seeking for Mental Health Concerns: A Systematic Review (2022) · cites this paper as [45]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Two different references share the same journal volume and pages

    Minor

    References 26 and 27 assign Psychiatry Research volume 219, pages 525-530 to different articles published in 2014 and 1995. At least one citation's bibliographic details must be wrong.

1 of 1

Cites

Flagged first, then by citations

2 of the 37 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. Statistics ABo. Causes of death, Australia. Canberra: Australian Bureau of Statistics; 2014.
  2. Fischer E, Farina A. Attitudes toward seeking psychological professional help: a shortened form and considerations for research. Psychiatry Res. 1995;219:525–30.
  3. CfDCa P. Youth risk behaviour surveillance - United States, 2009. Morb Mortal Wkly Rep. 2010;55(SS-5):1–142.

Cited by

Sorted by citations

Related

Authors
Calear, A. L., Banfield, M., Batterham, P. J., Morse, A. R., Forbes, O., Carron-Arthur, B., & Fisk, M.
Affiliations
Australian National University (AU)
Corresponding author
Calear, Alison L.
ORCID
Venue
BMC Public Health
Publisher
Springer Science and Business Media LLC
Published
2017-10-23
Volume
17
Issue
1
Pages
834-834
ISSN
1471-2458 (ISSN-L)
DOI
10.1186/s12889-017-4845-z
PMC
PMC5653993
OpenAlex
W2765517834
Semantic Scholar
377cdcda185435964f2df9c9b4952f0dfe91912a
Cited by
31
References
37
Citations by year
2026: 2 · 2025: 3 · 2024: 3 · 2023: 1 · 2022: 5 · 2021: 8 · 2020: 5 · 2019: 1 · 2018: 2 · 2017: 1
FWCI
3.04
Type
journal article
Language
en
Open access
Licence
Locations
  • BMC Public Health (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • ANU Open Research (Australian National University) (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
Funders
  • National Health and Medical Research Council (1122544, 1083311)
  • Australian Research Council (DE150100637)
  • Australian Rotary Health
Topics
  • Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
  • Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
  • Social Sciences › Gender Studies › Gender Roles and Identity Studies
Keywords
help-seeking intentions, men's mental health, suicide prevention, adolescent boys, high school students, help-seeking stigma, suicidal ideation, role modeling, sports celebrities, school-based intervention, mental health help-seeking
MeSH terms
Help-Seeking Behavior, Suicide Prevention, Adolescent, Australia, Mental Disorders, Humans, Male, School Health Services, Schools, Students, Program Evaluation, Cluster Analysis, Intention, Social Stigma, Suicidal Ideation

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