SUICIDE IS ASSOCIATED not only with primary psychiatric disorders such as depression1 but also with physical disorders, including cancer, HIV/AIDS, Huntington's disease, multiple sclerosis, peptic ulcer, renal disease, spinal cord injury, systemic lupus erythematosus and pain.2–4 Physical symptoms, such as headache, stomach ache and pain, often accompany depression and other psychiatric disorders, thus psychiatric patients with physical symptoms are initially likely to consult physicians rather than psychiatrists.5 Therefore, physicians' education for detecting depression/suicidality is strongly recommended and some trials have proved to contribute to the reduction of suicide rates.6–9 Such educating programs are urgently needed especially in Japan due to a continuously high suicide rate.10–12 Within the Japanese medical educational system, a suicide intervention program has not been formally conducted until now. Japanese medical students generally have only about 1 week's affiliation (clerkship) in psychiatry and virtually no training for suicide intervention takes place, in contrast with more than 1 month's psychiatry affiliation in Western countries.13,14 Immediately after graduating from medical schools and joining the residency program, most residents become doctors in charge of inpatients in each rotation ward, therefore their role is not only to examine patients' illness but also to establish rapport with patients. Hospitalization with medical illnesses is reported to increase the suicide risk.15 A recent national survey in Japan revealed that suicide occurred over the last 3 years in 66% of general/psychiatric hospitals with a psychiatric ward and in as many as 29% of general hospitals without a psychiatric ward.16 Therefore, medical residents, who contact patients daily and who eventually become general practitioners and physicians in each specialty field, seem to be the most appropriate candidates for a suicide intervention program effective to the utmost extent. As residents are very occupied and have a limited contact with people suffering from mental health problems, we developed a 2-hour brief suicide intervention program, partially based on the Mental Health First Aid (MHFA) program for the public,17–19 so that all residents can participate as effectively as possible within the limited time. This piloting and preliminary evaluation were deemed to be crucial first steps toward a possible larger effort to establish an effective brief suicide intervention program among medical residents.
Aim: Suicide is associated not only with primary psychiatric disorders but also with physical disorders. Physicians' education on suicide prevention contributes to reducing suicide. Therefore, medical residents, who contact patients daily and who eventually become primary physicians in each specialty, might be the most appropriate candidates for intervention. In this article, we introduce our newly developed suicide intervention program among medical residents.
Methods: We developed a 2-hour suicide intervention program among medical residents, based on the Mental Health First Aid (MHFA), which had originally been developed for the public. The program contains a 1-hour lecture and a 1-hour role-play session. As the first pilot trial, we conducted the program among 44 first-year medical residents at a university hospital and evaluated its effectiveness. Changes in confidence, attitudes and behavior toward suicidal people were evaluated using self-reported questionnaires before, immediately after, and 6 months after the program.
Results: Participants' confidence and attitudes significantly improved after the program. The total mean score (standard deviation) of the Suicide Intervention Response Inventory improved from 18.4 (2.0) before the intervention to 19.4 (2.0) immediately after the intervention. However, the effectiveness was limited after 6 months. In the course of 6 months, the participants learned to apply the MHFA principles in their daily clinical practice.
Conclusion: Our newly developed brief suicide intervention program demonstrating its effectiveness among medical residents should be modified in order to be more effective in the long term. The next trial with a control group ought to be conducted to evaluate our developed program.
Our training program is partly based on the MHFA program. The MHFA program has recently been established in Australia and proved to be effective for public mental health including suicide prevention.17–19 MHFA standard training course provides 12 hours of lectures and workshops focusing on the following five-step principles: (i) assess risk of suicide or harm, (ii) listen non-judgmentally, (iii) give reassurance and information, (iv) encourage a person to get appropriate professional help; and (v) encourage self-help strategies. MHFA aims not only to increase knowledge about mental health but also to help with acquiring the first aid skills. On the other hand, in the Japanese medical education system, lectures of psychiatry only enable medical students to increase their knowledge, while skill training is rarely provided. Therefore, the MHFA program especially the skill training part is considered to be particularly useful for the medical residents' training.
Our training program was developed through a multistage process. In the first stage, experienced Japanese psychiatrists (TAK, YS, RS, DF, KU, NH and KO) took the actual MHFA course in November 2007. Next, the original MHFA program was translated into Japanese and modified for the Japanese context by the permission of the providers of the MHFA (Professor AF Jorm and Ms BA Kitchener of ORYGEN Research Center, Melbourne). The program was modified to suit the Japanese social settings and the Japanese medical residents who have some knowledge of psychiatry and limited time to join any other training than their present specialty. The content of the modified 2-hour training is shown in Table 1. The 1-hour lecture focused on suicide risk assessment, management skills as well as the epidemiology of suicide in Japan, especially the important fact that the majority of depressive patients tend to visit physicians instead of psychiatrists.5 During the 1-hour role-play session, participating residents watched a specifically prepared 10-min demonstration of interviews of actors playing roles of a suicidal patient with two types of physicians (one physician is over confident and straightforward, while another is sympathetic and considerate) and one nurse. The role setting was that the patient complaining about insomnia called the nurse. The patient had been told that her diagnosis was stomach ulcer by the doctor in charge on the previous day. The nurse summoned two doctors and each of them responded to the patient in a different way. Their responses represented both good and bad ways to respond toward a suicidal patient (detail in Appendix I). After the demonstration, a 15-min lecture and discussion evaluating the physicians' attitudes followed. Next, the participants played the role of physicians, while receiving feedback from supervisors. Finally Q&A time concluded the program.
|Lecture session (60 min)|
|A) Lecture improving knowledge of depression and suicide (30 min)|
|1) People with depression tend to express somatic symptoms and they are more likely to visit physicians rather than psychiatrists.|
|2) Risk factors of depression and suicide, especially physical illness.|
|3) Many persons who committed suicide had had depression.|
|4) Therefore, early detection of depression in primary care setting is of great importance.|
|B) Introductory lecture of suicide intervention skill (30 min)|
|Instuctors who took the MHFA training course in Melbourne taught suicide intervention skills, which was modified from the original MHFA principle to medical bedside setting.|
|Five-step principles of the MHFA|
|1) Assess risk of suicide or harm|
|2) Listen non-judgmentally|
|3) Give reassurance and information|
|4) Encourage a person to get appropriate professional help|
|5) Encourage self-help strategies|
|Role play session (60 min)|
|1) Demonstration (10 min)|
|Participating medical residents watched a specifically prepared 10-min demonstration of interviews of actors playing roles of a suicidal patient with two types of physicians (detail in Appendix I).|
|2) Small lecture and discussion evaluating the physicians' attitudes (15 min)|
|3) Role play by participants (25 min)|
|The participants played the role of physicians, while receiving feedback from supervisors.|
|4) Final Q & A time (10 min)|
The program consisted of a 1-hour lecture and a 1-hour role-play session, which was held during the orientation seminar for new employees of Kyushu University Hospital. A total of 44 first-year medical residents starting to work at Kyushu University Hospital (21 male, 23 female) who have just graduated from medical school and were just about to enter real clinical settings and who had not planned to join in any psychiatric rotation in their first year were approached to participate in this study. Of 44, all gave informed consent in writing and orally to the authors responsible for this study and they took our program in April 2008. All the study procedures were approved by the Ethical Committee of Kyushu University.
Comparative self-administered assessments were made three times: before and immediately after the intervention (pre-test and post-test) and 6 months after the intervention (follow-up).
Participants' basic information
Participants' age, gender, intended specialty in medicine, and past experience of mental health problems (oneself, family or close persons) were collected at pre-test.
Participants' basic information and their evaluation of the program
Participants' subjective evaluation regarding the effectiveness of the training program was rated on a simple five-point scale: 1 = extremely effective, 5 = not effective at all.
Suicide Intervention Response Inventory
To evaluate the effectiveness of the program, the management skills for people with suicidality were assessed using Suicide Intervention Response Inventory (SIRI) as a main outcome. SIRI is one of the most internationally acceptable and validated test assessing the respondent's ability to select an appropriate response to a series of clinical scenario in which the patients presents with potential self-harm.20,21 In the present study, the SIRI score was calculated based on the original version of SIRI (SIRI-1). Briefly, each of 25 excerpts from counseling sessions begins with an expression by the client concerning some aspect of the situation he or she faces, followed by two possible helper responses to the client's remark. For example, item 1 is as follows: Client: I decided to call in tonight because I really feel like I might do something to myself. I've been thinking about suicide. Helper A: You say you're suicidal, but what is it that's really bothering you? Helper B: Can you tell me more about your suicidal feelings? Raters should choose which response is appropriate. Regarding item 1, the more appropriate response by the client proves to be helper B. The correct response is rated 1, while an incorrect response is rated 0. The total of all ratings was then measured and analyzed.
Participants' attitudes and behavior change toward people with mental health problems
Participants' confidence about their ability to support people with mental health problems was rated on a five-point scale: 1 = very confident, 5 = not confident at all. The actual contact of people with mental health problems at and outside of the work during the last 6 months was reported. Their degree of help provided toward such people was evaluated with 4-point Likert scale: 4 = very much supported. In addition, participants' social distance toward depressive patients was evaluated using a case vignette of one depressive patient, which was previously employed in Australian and Japanese public surveys and the detail methodology has been described previously.22
Participants' health condition
Participants' physical and mental health condition was evaluated by the SF-8 Japanese version.23
Clinical outcome measurement
Actual clinical intervention times and methods (i.e. whether the risk of suicide was checked) were self-reported by participants 6 months later, following the MHFA five principles and asked whether the cases were referred to professional experts of mental health such as psychiatrists.
Before making the comparison of the score at different time points, the distribution of the score was ascertained if it fits to the statistical assumption. Paired t-test, multivariate repetitive analysis (Bonferroni), and other design-based statistics were used with Stata 10.2, with the significant level at 0.05.
Basic characteristics of participants
All 44 participants completed the program and the assessments both before and immediately after the program. A majority the participants rated the lecture and the role-play session positively (quite helpful or extremely helpful): the positive rating being 38 (88.4%) for the lecture session, 40 (93.0%) for the role-play session. Out of 44 participants, 37 completed the follow-up assessments 6 months later and they were the subjects of the following analysis (response rate: 84.1%). The basic characteristics of study participants (n = 44) and completers (n = 37) were described in Table 2. There were no differences between the study participants and completers. Notably, among the completers, only one resident intended to choose psychiatry as one's future specialty and 30 (81.1%) of them intended to choose internal medicine or surgery in the future. Eight completers (21.6%) have experienced mental health problems themselves, and 12 (32.4%) of them had someone in their family members or close others with mental health problems.
|Study participants (n = 44)||Completers (n = 37)||P-value|
|Age||Mean (SD)||26.3 (4.3)||26.1 (4.1)||0.442|
|Experience of mental health problems|
Suicide Intervention Response Inventory
In terms of the clinical management skills for people with depression and/or suicidality, the score of the SIRI was evaluated as a main outcome (Table 3). One participant was excluded from the analysis due to inappropriate response (n = 36). The total score of SIRI improved immediately after the intervention, while the improved score did not remain until 6 months after. However, when we look at the score of individual items, items 11, 12 and 21 have continued to be significantly improved. On the other hand, items 7 and 18 have significantly decreased during 6 months' residency training.
Attitudes change of participants
Changes of participants' attitudes toward people with mental health problems and participants' health conditions were evaluated (Table 4). Participants' confidence in clinical management skills significantly improved immediately after the intervention, and the score remained high after 6 months while not statistically significant. On the other hand, social distance toward people with mental health problems significantly widened after 6 months. In addition, participants' mental health condition after 6 months significantly deteriorated when compared to the starting point of their residency training.
|Confidence in clinical management in general (range: 1–5)§|
|Degree of help provided to people with mental health problems (range: 1–4)|
|Social distance with a person with mental health problems (case vignette)|
|Health condition (SF-8)||2.7||0.6||3.0*||0.5||−3.07||0.004|
Although it was difficult to evaluate its relevance to their clinical situation, participants were asked to report their behaviors in accordance with the MHFA principle at their real clinical settings. The experienced number of actual clinical interventional behaviors during the 6 months after the program was self-reported. Of 37 completers, 22 reported 41 clinical contacts of people with probable depression/suicidality, ranging from 0 to 6 cases per resident. Following the MHFA principle, 26 cases were assessed in terms of their risk of suicide or harm, among them six cases were directly asked about their suicidal idea (principle 1: assess risk of suicide or harm). Almost all cases were approached by the participants with the MHFA principles 2 (listen non-judgmentally) and 3 (give reassurance and information). Regarding the MHFA principle 4 (encourage a person to get appropriate professional help), 39 cases were consulted with senior doctors, and 32 cases were encouraged to take advice from mental health professionals. The actual number of referral cases was 19 to the Department of Psychiatry, three to the Department of Psychosomatics, and three to faculties outside of the University Hospital, respectively.
This is the first report to develop and evaluate a brief suicide intervention program, which was conducted among first-year medical residents. Our survey using self-administered assessments demonstrated the effective improvement in their confidence and attitudes toward people with mental health problems immediately after the program. In addition, the MHFA principles taught during the program seem to be applied in their real clinical settings.
Previously, several educational intervention programs for general practitioners (GPs) or physicians in suicide prevention have been reported, beginning with the Gotland Study.6 In the UK, the STORM Project, which is a brief educational intervention for front-line health professionals in contact with suicidal patients aiming to improve the assessment and management of suicide, raised the confidence of the participants in suicide intervention.24 However the STORM Project may not be sufficient to reduce the population suicide rate.25 On the other hand, a reduction in frequency of suicidal acts was reported in Nuremberg during the 2-year regional intervention26 and a 5-year GP-based regional intervention has recently been reported to result in a greater decline in suicide rates compared with the surrounding region and national rates.7 Moreover, a Japanese community-based program of improved depression management in the elderly population in a rural village reported a reduction in suicide rates compared with prior rates in the village.27 However, educational interventions targeting GPs do not always work. Thompson et al. reported that educating GPs about depression treatment guidelines did not improve the rates of correct diagnosis of depression and treatment response.28 Thus, increased recognition of suicidal ideation or depression does not necessarily improve the outcome, and it is therefore important to measure the impact on treatment practice.7 Despite the fact that our study is limited in this regard, we measured the clinical outcome. Actually, in our study, participants' behavior toward patients with mental problems seems to produce the appropriate outcome according to the given MHFA principles.
Despite the fact that there only exist very few internationally acceptable and validated tests assessing the respondent's ability toward people with potential self-harm and suicide, SIRI is one of the most widely used tests. The SIRI has been adopted by more than 100 suicide and crisis intervention centers throughout North America for use in volunteer screening and evaluation of paraprofessional training programs.21 In our study, items 7 and 18 significantly decreased during 6 months' training. [Item 7 – Client: I really need help . . . It's just . . . [voice breaks: silence]. Helper A: It must be hard for you to talk about what's bothering you. Helper B: Go on, I'm here to listen to you talk. More appropriate response is A. Item 18 – Client: I have a gun pointed at my head right now, and if you don't help me, I'm going to pull the trigger! Helper A: You seem to be somewhat upset. Helper B: I want you to put down the gun so we can talk. More appropriate response is B.20,21] Evaluating a better response in both items seems quite difficult even to us, Japanese psychiatrists. This difficulty might be due to a difference in suicide method and suicidal intervention approach between Japan and the Western countries. It is reported that the idea of the suicidal process as a continuous and smooth evolution from thoughts to plans and attempts of suicide needs to be further investigated as it seems to be dependent on the cultural setting.29,30 Therefore, evaluation methods including sociocultural factors should be developed for a more precise skill assessment of suicidal persons.
Effectiveness of our program was limited after 6 months. Participants' confidence and attitudes toward suicidal people significantly improved immediately after the program, while the attitude change has not continued 6 months later. Participants' social distance toward people with mental health problems significantly worsened 6 months later compared to the starting point of their residency training. Despite the report that quality of life (QoL) was improved among the Australian public people who took the MHFA course,31 in our study the mental health condition of participants worsened in the course of 6 months. A severe stress in the course of medical residency training is considered to induce their psychological distress and tends to induce burnout.32,33 Therefore, such working conditions might have resulted in the worsened score of QoL and social distance toward patients with mental problems. Concerning the SIRI score, the improved score did not last for 6 months, which may have been due to the above-mentioned stressful condition.
There are some limitations to our study. First, the sample size is small with no control group. Evaluation of attitudes toward suicide intervention was limited due to a lack of well-validated measurements. Evaluation of suicide prevention was limited since the actual decrease in suicide rates could not be measured. Participants' stress in the process of medical residency training might have influenced the outcomes. Finally, self-reported questionnaires might not reflect participants' actual attitudes and outcomes.
To conclude, the first trial of our brief suicide intervention program showed the effectiveness after the intervention, while the effectiveness was limited 6 months later. Our newly developed brief suicide intervention program should therefore be modified in order to be more effective in the long term. The next trial with a control group ought to be conducted to evaluate our developed program. We believe that after our program is modified and widely adopted, each participant who eventually becomes a GP or a physician in a particular specialty can be expected to intervene toward patients with suicidality, which may contribute to the reduction of suicide.
The present study was supported by a grant-in-aid from the Japan Society for the Promotion of Science (JSPS) to KO. We thank Professor AF Jorm and Ms BA Kitchener of the ORYGEN Research Center for their useful advice, Ms M Otsuka of Iwate Medical University for her assistance, and the Japan Young Psychiatrists Organization (JYPO) for promoting our research activity.
DECLARATION OF INTEREST
All authors declare that they have no conflicts of interest.
Casting: Patient A, Doctor B, Doctor C, Nurse D, Patient's husband
Scenario as follows:
[Scene 1: Nurse Station at a general ward of internal medicine with Doctor B, Doctor C and Nurse.]
Nurse: Hi, Doctors, Ms. A doesn't seem to sleep well after she was told about her medical condition the day before yesterday. I gave her some sleeping pills, but every time I make rounds I can hear that she is awake in the night. Besides that, she seems to have a poor appetite.
Doctor B: Is that so? I just told her that she had only a stomach ulcer, which would be cured by the endoscopy. It should be OK, shouldn't it?
Doctor C: But I heard that the other patients in A's room worried about how she had changed. They saw her apologizing to her family pitifully. She used to be a cheerful person before.
Nurse: Even though there was no problem when the otolaryngologist examined her, she keeps calling us and complains about her headache and dizziness.
[Scene 2: in A's room. When Doctors and a nurse entered, Ms. A was having conversation with her husband.]
Dr. C: Ms. A, how are you today?
A: Doctor, recently, I really don't know . . .
Nurse: Ms. A, recently, you've been telling us about your headache and dizziness, haven't you?
A: Yes, I do have strong headaches, I feel dizzy and I can't sleep well . . .
Dr. B: Ms. A, there wasn't anything wrong with you when we examined you. You have nothing to worry about.
Dr. C: I see that you have headaches. What kind of pain is it?
A: I feel very dizzy and have throbbing headaches; I can't sleep and eat at all.
Dr. C: Oh, really? I'm sorry to hear that.
Nurse: If you have any other worries, please tell us.
A: I . . . well . . . er . . . here, I can't say . . .
Dr. C: Well, as I'm your doctor in charge, would you please tell me? I would certainly keep it a secret.
A: Thank you, well, later could I confide only to you?
Dr. C: Of course.
Dr. B: (In a loud voice, angrily) Wait a minute, please. The most important thing for us is to think what is best for you. Let us all consider your treatment and find the best solution.
A's husband: Doctor, my wife has always been cheerful but over the last three days she keeps apologizing, “I'm sorry it's because I didn't go for a check-up for a long time . . . It's all my own fault that I became ill.”
A: I'm the one to blame. I've caused so much trouble to my family . . . I'm sorry . . .
Dr. B: Ms. A, you are very lucky to have such a nice and caring family, they came all the way to see you. You should face your illness bravely also for the sake of your family.
A: It's very hard for my family . . . the treatment costs a lot . . . someone like me isn't worth such treatment and money . . . especially as I'm not able to work anymore . . .
Dr. B: (interrupting A) So, you're worried about money, aren't you? I can understand that. All the patients are like that. But you don't need to worry because you have your nice family. It's not a big problem at all.
Dr. C: (Soothingly) Ms. A, you feel that you're causing trouble to your family, don't you? That must be hard, I suppose.
A's husband: I've been telling her that there's no need to worry about money, but she doesn't seem to understand in the slightest. I tried to get her to go for a walk to change her mood, however she keeps refusing.
Dr. B: Ms. A, your family cares about you in this way, so you should do your best to get better, shouldn't you?
A: I'm sorry . . . that's why I'm worthless . . .
Dr. C: Ms. A, it seems to me you may be thinking that it's not worth living, is that right?
A: Just like that . . . well . . . I've been a burden to my family . . .
Dr. C: Have you ever thought about disappearing or dying?
A: . . . (nodding without uttering anything) . . .
Dr. B: What a terrible thing to say!! Our hospital is supposed to do all we can to help all our patients.
Nurse: (reproving Dr. B) Doctor!
Dr. B: (embarrassed) So, do you want us to send you to the psychiatric ward?
A: . . . (lapsed into silence) . . .
Dr. C: Ms. A, have you ever had any concrete idea or plan of suicide?
A: Sometimes I think, ‘If I jumped out of this window, I would be free from all this pain.’ Yesterday, I thought, ‘I could hang myself if I put a rope on that rail.’ . . . But I realize I shouldn't be thinking like that . . .
Dr. C: That is painful, isn't it? You must feel really distressed to be thinking about dying.
A: . . . (crying)
Dr. C: Ms. A, thank you for telling us.
A: Doctors, Nurse, don't tell anyone about this, please. If people knew that I am having such dreadful thoughts . . .
Dr. C: (Slowly with emphasis) Ms. A, listen carefully, please. You are feeling really depressed right now. This feeling is, however, completely different from what your natural condition is, isn't it?
A: That is . . .
Dr. C: You are experiencing depression now. It is a medical symptom and because of it, I think, you are feeling sad, blame yourself and feel like dying.
A: Do I have depression?
Dr. C: I think there's such possibility. There are now many remedies for depression. You can get much better than how you feel now. In this hospital we also have specialists who treat the mind, they are doctors specialized in psychiatry and psychosomatic medicine.
A: (with surprise) Psychiatry and psychosomatic medicine?
Dr. C: Yes, that's right. We want you to get well again. I can introduce you to a kind psychiatrist, so won't you come to see him with your family tomorrow?
A: . . . Well, yes.
Dr. B: Well, but this is not something that we can do at our Department.
Dr. C: First of all, today I'll give you medicine so that you can sleep well. Don't worry too much, please, and have a good rest today. Should you have any anxiety, you can call our staff. And please promise me that you won't definitely do anything rash.