Teaching medical professionals about suicide prevention: what's missing?

The Prevention of Suicide in Older Military Veterans

Suicidal behavior among older military veterans is an important medical and social problem. The goal of this literature review is to discuss this underappreciated issue and identify suicide preventive interventions that can be utilized with the older military veteran population. Older veterans experience psychiatric, medical, and social problems associated with their age and/or military experience that can contribute to suicide risk. These problems include relationship losses through death or estrangement, depression, cognitive decline, loneliness, isolation, frailty, mobility issues, and chronic pain. Therefore, older veterans face a unique set of challenges. Suicide prevention in older veterans should take a multipronged approach which includes screening for suicidality, management of psychiatric and medical disorders, social assistance, safety planning, lethal means restriction, and involving family members in the veteran's healthcare. Family members should be included in the safety planning process when possible. Gatekeeper training programs can be utilized to train individuals who are working with older veterans to reduce suicides amongst this age group.

Suicide: An Overview for Clinicians

Most suicides have a diagnosable psychiatric disorder, most frequently, a mood disorder. Psychosocial issues and neurobiological abnormalities such as dysregulation in stress response systems contribute to suicidal behavior. All psychiatric patients need to be screened for the presence of suicidal ideation. Clinicians are expected to gather information about patient's clinical features and to formulate decisions about patient's dangerousness to self and the treatment plan. As psychiatric disorders are a major risk factor for suicide their pharmacologic and psychological treatment is of utmost importance to prevent suicide. Restriction of access to lethal means is important for suicide prevention.

Prevention of suicidal behavior in diabetes: the role of primary care

Studies in different countries suggest that the rates of suicide ideation, attempts and death are increased in patients with diabetes in comparison to the general population. Suicidal behavior in patients with diabetes is a significant but underappreciated problem. Elevated suicide risk in individuals with diabetes may be related to comorbid psychiatric disorders, particularly depression. Considerable evidence suggests a bidirectional relationship between diabetes and depression: individuals with diabetes are at elevated risk of developing depression and patients with depression are more likely to develop diabetes. Frequent comorbidity of diabetes and depression may be related to psychosocial and neurobiological factors. Other comorbid psychiatric conditions including anxiety and alcohol use disorders may also increase suicide risk in diabetes. Primary care physicians are likely the key to suicide prevention efforts in individuals with diabetes since they see almost half of individuals who die by suicide within 1 month of their suicide. The management of potentially suicidal patients with diabetes in primary care comprises six major components: management of diabetes and its complications, especially conditions associated with pain; diagnosis and treatment of comorbid psychiatric disorders; frequent assessment of suicide risk; restricting access to the means of suicide; specific treatments to reduce the predisposition to attempt suicide; and referral to psychiatric care. Suicide prevention in individuals with diabetes and other medical disorders is a difficult but critically important task.

Mental Health First Aid training and assessment in Australian medical, nursing and pharmacy curricula: a national perspective using content analysis

BACKGROUND

Suicide is among the leading causes of death among people aged 15 to 29 worldwide. Healthcare professionals interact with people at risk of suicide regularly, yet mental health and crisis first aid training is lacking in curricula. Mental Health First Aid (MHFA) training teaches crucial communication and crisis first aid skills and is increasingly recognised as integral to healthcare education. This study aimed to explore the extent of, as well as barriers and enablers to MHFA training delivery and assessment in Australian medical, nursing and pharmacy curricula.

METHODS

All accredited Australian medical, nursing and pharmacy program providers were identified through Australian Health Practitioner Regulation Agency and National Boards websites and invited to participate in a semi-structured interview. A purpose-designed interview guide explored if and how MHFA training was delivered and assessed in curricula, as well as perceptions of and barriers and enablers to MHFA training. Interview recordings were transcribed verbatim, allowing for deductive content analysis to compare MHFA training provision across programs.

RESULTS

Of 75 invited program providers, 36 (48%; 13 medical, 13 nursing and 10 pharmacy) participated, of which 15 representatives (42%; six medical, two nursing and six pharmacy) reported providing MHFA training to students. Differences in mandating training, year level of students completing training, type of training delivered and source of MHFA instructors were identified. Barriers to MHFA implementation included perceived adequacy of existing curricula, lack of funding and time, while facilitators included perceived benefit and availability of funding.

CONCLUSION

MHFA training is provided to more than one third of medical, nursing and pharmacy students in Australia. Increased funding may facilitate the integration of MHFA as a minimum standard of mental health training for future healthcare professionals. Further research exploring the effectiveness of MHFA in improving behaviours and its impact on patient outcomes is warranted.

TRIAL REGISTRATION

This study was approved by the University of Sydney Human Research Ethics Committee [Project number: 2020/087].

Exploring the impact of suicide care experiences and post-intervention supports sought among community pharmacists: a cross-sectional survey

BACKGROUND

There is a need to appropriately train, support and remunerate pharmacists for their expanding roles in mental healthcare. Pharmacists often care for people experiencing mental health crises, including suicidal thoughts and behaviours, but little is known about pharmacists' suicide care experiences.

AIM

This cross-sectional study aimed to explore the impact of professional experiences with people at risk of suicide and support accessed, among community pharmacists.

METHOD

A survey exploring pharmacists' experiences with people at risk of suicide and post-intervention support-seeking was disseminated through Australian and Canadian professional associations, conferences and social media (June 2016-May 2017). Quantitative data were analysed using Chi-squared, Fisher's exact and independent t-tests, where appropriate. Qualitative data exploring the impact of these experiences were thematically analysed, and reasons for not seeking help post-intervention were identified.

RESULTS

Among 378 respondents, 84% had encountered patients at risk of suicide and 28% had lost patients to suicide. Some were negatively affected personally and/or professionally (11%), of which 88% did not seek professional support, mainly due to uncertainty about available services. Pharmacists were significantly more negatively affected if they had a personal mental health diagnosis (p = 0.017) and previous suicide care experiences (p = 0.001). Qualitative themes included: expanding knowledge and skills, role limitation and emotional impact and response.

CONCLUSION

A large proportion of pharmacists have interacted with suicidal patients and are impacted by these experiences, yet few seek help due to lack of awareness and access. There is a need to recognize pharmacists' roles in suicide care, and develop pharmacist-specific post-intervention support.

Pharmacists' attitudes, interest, and perceived skills regarding suicide prevention

Introduction

Pharmacists have been called upon to be involved in suicide prevention efforts, but little is known regarding their attitudes, interest, and perceived skills in the area.

Methods

The study was a voluntary, anonymous survey of pharmacists who attended a large end-of-year continuing education program sponsored by a school of pharmacy. The survey included the Attitudes to Suicide Prevention (ASP) Scale, items concerning interest in suicide prevention, and items from the suicide skills section of the Suicide Knowledge and Skills Questionnaire.

Results

The survey was completed by 227/297 (76.4%) pharmacists. The percentage of participants who expressed interest in direct involvement, indirect involvement, and receiving training in suicide prevention were 25%, 46%, and 56%, respectively. The mean total score on the ASP was 32.2 ± 5.5. Approximately 4% to 8% of participants agreed that they had the requisite training, skills, or support/supervision to engage and assist suicidal patients, and 22% agreed to feeling comfortable asking their patients direct and open questions about suicide. The ASP scores and items relating to perceived skills were correlated with interest in direct involvement in suicide prevention.

Discussion

There were some positive findings, but overall, the pharmacists who participated in this survey felt unprepared to be frontline clinicians in suicide prevention efforts. Further studies should be conducted to determine if these findings are generally reflective of the broader pharmacy community. If the profession is to have a serious role in suicide prevention, then adequate suicide prevention training for pharmacy students and pharmacists may be necessary.

Profile of suicide attempts and risk factors among psychiatric patients: A case-control study

BACKGROUND

Suicidal behaviour remains challenging for clinicians to predict, with few established risk factors and warning signs among psychiatric patients.

AIM

We aimed to describe characteristics and identify risk factors for suicide attempts among patients with psychiatric disorders.

METHODS

Multivariable logistic regression analysis, adjusted for clinically important confounders, was employed to determine risk factors for suicide attempts within a psychiatric patient population.

RESULTS

The case (n = 146) and control groups (n = 104) did not differ significantly with regards to sociodemographic characteristics. The majority of the participants who had attempted suicide did so with high intent to die, and expected to die without medical intervention. The primary method of attempt was pharmaceutical overdose among the case participants (73.3%). Results showed impulsivity (odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.03-1.30) and borderline personality symptoms (OR = 1.07, 95% CI = 1.01-1.13) were significantly associated with attempted suicide.

CONCLUSIONS

Our findings indicate that known sociodemographic risk factors for suicide may not apply within psychiatric populations. Prevention strategies for suicidal behaviour in psychiatric patients may be effective, including limited access to means for suicide attempts (i.e. excess pharmaceutical drugs) and target screening for high-risk personality and impulsivity traits.

Longitudinal measurement invariance of the Beck Scale for Suicide Ideation

In mental health care, both clinical and scientific decisions are based on within-subject comparisons of test scores on the same self-report questionnaire at different points in time. To establish the validity of test score comparisons over time, longitudinal measurement invariance should be established. The current study tested whether the 19 item Beck Scale for Suicide Ideation (BSS) is measurement invariant (MI) over time. As the first five items of the scale are often used to screen for the presence of suicidal thoughts, we also tested a model consisting of only the first five items. Psychiatric in- and out-patients (n=475) completed the questionnaire upon admission and after 3 months. By means of confirmatory factor analysis (CFA) we tested whether the parameters of a single factor model were equal over time. All fit indices indicated that both the 19-item questionnaire and the five-item screener were measurement invariant over time. This means that changes in test-scores over time can be attributed to true changes in the construct of interest. These findings legitimate the use of the 19 item scale and the five-item screener in longitudinal assessments.