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ORIGINAL ARTICLE
Year : 2018  |  Volume : 27  |  Issue : 1  |  Page : 115-123  Table of Contents     

A novel approach to suicide prevention – Educating when it matters


1 Department of Psychiatry, Gujarat Medical Education and Research Society Medical College, Gotri, Vadodara, India
2 Department of Community Medicine, Gujarat Medical Education and Research Society Medical College, Gotri, Vadodara, India
3 Department of Psychiatry, Smt N H L Municipal Medical College, Ahmedabad, Gujarat, India

Date of Web Publication15-Oct-2018

Correspondence Address:
Dr. Paragkumar Chavda
Department of Community Medicine, Gujarat Medical Education and Research Society Medical College, Gotri - 390 021, Vadodara
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipj.ipj_10_18

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   Abstract 


Background: Looking at the burden of suicide, there is a dire need for medical schools to incorporate suicide prevention training. Effective communication helps in early detection and management of suicidal behavior. Medical students can act as a GATEKEEPER if they receive adequate training. Methodology: This was an educational intervention study done at tertiary care teaching hospital to assess the knowledge and attitude of medical students toward depression and suicide and to impart and assess communication skills for suicide prevention in one of the four batches of students in 4th semester. Pretest was conducted to assess knowledge and attitude toward depression and suicide, followed by training using interactive lectures, demonstration of interview, and hands-on training with patients and role-plays. The posttest and objective structured clinical examination (OSCE) were administered for skill assessment. Feedback was taken regarding this intervention. Results: The mean marks of the pre- and post-test were 8.96 (8.3–9.6) and 14.58 (13.8–15.3), respectively, out of 25. The difference was statistically significant (t = 13.24, P ≤ 0.0001) which suggests improvement in knowledge. We found mixed responses in attitude statements showing limited change. Mean obtained marks on OSCE examination out of 66 was 42.7. Among various components of OSCE, students scored high on rapport building. The most useful components of trainings were role-play, OSCE, and interaction with patients as per their feedback. Conclusion: The intervention was found effective in increasing knowledge, changing attitude, and enhancing communication skills of medical students toward suicide prevention. Training of communication skills for suicide prevention in depressed person should be given to every medical student as suggested by feedback.

Keywords: Communication skills, depression, medical students, suicide prevention


How to cite this article:
Desai ND, Chavda P, Shah SH, Shah N, Shah SN, Sharma E. A novel approach to suicide prevention – Educating when it matters. Ind Psychiatry J 2018;27:115-23

How to cite this URL:
Desai ND, Chavda P, Shah SH, Shah N, Shah SN, Sharma E. A novel approach to suicide prevention – Educating when it matters. Ind Psychiatry J [serial online] 2018 [cited 2018 Dec 13];27:115-23. Available from: http://www.industrialpsychiatry.org/text.asp?2018/27/1/115/243303



Suicide and that too in the adolescents and young adults is an emerging global issue. It is more so in the lower- and middle-income countries and the same is reflected in India. Globally, one-year period prevalence of major depression is in range of 5%–6% of the population with a lifetime prevalence estimate at 11%–15%.[1] The young adults, postpartum women, and elderly form the vulnerable group for depression worldwide. Suicide accounts for overall 1.4% of all deaths worldwide, but there is a great variation in the proportion of suicide as cause of death across different age groups. Among young adults (15–29 years of age), suicide is the second leading cause of death.[2] This is especially so among the Southeast Asian countries. Considering the increasing burden, the World Health Organization has declared the theme for World Health Day 2017 on Depression with the slogan “Depression: Let's Talk.”[3] In India, community-based studies on depression are few and suggest a point prevalence ranging from 1% to 7% with a rising trend over the years.[4] Currently, the reported suicide rate in India is 11.5/1 lakh population with a rising trend.[5]

The studies in primary health-care settings in India have reported a prevalence of depression as high as 20%–40% among all outpatient attendees.[4] A large proportion of these patients also remain undiagnosed. Studies also indicate that most of those who attempt suicide have seen a primary care physician in the past 1 month. Doctors are the potential gatekeepers who will have contact with high-risk patients. In this scenario, it is very important for every doctor to have the basic training in how to deal with patients who are in distress and express death wishes; this unfortunately is not a part of standard curriculum. Preventing suicide can depend on the ability of caregiver to make judgments about a person's suicide risk status, and for that effective communication skill that incorporate empathy, compassion, and nonjudgmental listening are important. The earlier studies have also recommended a need for capacity building of primary care workforce on detection of depression in primary care settings.[6] Looking at the rising burden of these diseases and limited number of trained psychiatrists available in India, the involvement of primary care physician appears to be an important strategy for prevention of depression and suicide at population level.[7] In this direction, recently, there have been suggestions for increasing the exposure to psychiatry within the undergraduate medical curriculum.[8]

In the current scenario, psychiatry forms a very small part of the curriculum and the teaching-learning is largely didactic.[9] The undergraduate medical students are often at a loss and feel uncomfortable and underconfident in dealing with patients who are in distress and who express suicidal thoughts. Further, due to the academic stress of studying in medicine, many of these medical undergraduate students themselves are also at increased risk of depression.[10],[11] Thus, there is a need for skill-based training of undergraduate students in suicide prevention. The proposed training intervention aims to improve the attitude of the trainee doctors toward suicide and equip them with necessary skills for communicating with depressed suicidal persons and offering the correct guidance and help to their peers and patients. The objective of this research was to assess the effectiveness of a training intervention on communication skills for suicide prevention among undergraduate medical students.


   Methodology Top


Study design

This was an educational intervention study among undergraduate medical students.

Approval from the Institutional Human Ethics Committee was taken before the start of the study. Written Informed consent was obtained from the students. All of the 32 students posted in this batch volunteered to participate in this training.

General setting

The study was conducted in department of psychiatry of a medical college from Western part of India with annual intake of 150 undergraduate medical students. In this college, psychiatry training includes a 2-week clinical posting during the 4th semester, 20 h of didactic lectures during the 6th semester, and 2-week posting in psychiatry during internship.

Intervention

A specially designed training intervention was designed and administered.

Pretest was administered on the first day of the clinical posting that included the knowledge and attitude assessment.

The special training intervention was administered over 4 days in the middle of clinical posting. Day 1 focused on depression, day 2 on suicide prevention, and day 3 and 4 focused on relevant role-plays. Prior written permission from indoor patients was taken to demonstrate an interview and be examined by students during intervention.

Posttest same as pretest and objective structured clinical examination (OSCE) were conducted 1-day before the last day of clinical posting for knowledge, attitude, and skill assessment.

Specially designed intervention is highlighted below:

Day 1: Focus on depression (total time: 3 h)

  1. One hour interactive lecture on depression
  2. Demonstration of an interview with a depressed indoor patient by a faculty member
  3. Selected volunteer student's interaction with the patient in the presence of a faculty member followed by feedback and suggestions.


Day 2: Focus on suicide prevention (total time: 3 h)

  1. One hour interactive lecture on suicide including suicide risk assessment
  2. Demonstration of interview with depressed suicidal indoor patient by a faculty member
  3. Selected volunteer student's interaction with the patient in the presence of a faculty member followed by feedback and suggestions.


Day 3 and 4: Role-plays (total time: 6 h)

Clinical case vignettes about patients presenting with varying degrees of severity of clinical depression were prepared and reviewed by independent subject experts. The students were asked to volunteer to take the role of either a patient or a doctor. Those choosing the patient's role were randomly assigned a clinical case vignette. A total of 9 role-plays were conducted in the presence of a faculty member who provided necessary comments and clarifications to enhance the learning experience of the students based on their comments after role-play.

Intervention evaluation

The evaluation was done by administering a newly developed knowledge and attitude questionnaire and the OSCE station material which were validated by two external subject experts who were not part of the study in the following manner:

  1. Knowledge assessment: Done using a 25 mark paper consisting of essay type questions (5 mark) and objective questions in the form of true/false (10 mark) and multiple-choice question (MCQ) items (10 marks). The same questionnaire was used before and after the intervention
  2. Attitude assessment: Done using 20-item questionnaire where each item was to be rated on a 3-point Likert scale and filled anonymously. The statements were taken from three validated scales, that is, revised depression attitude questionnaire; Suicide Opinion Questionnaire and Attitude Toward Suicide Prevention Scale relevant to the aim of the study [12],[13],[14]
  3. Skills assessment: Done using a six-station OSCE. Three procedure stations and three question stations were developed for OSCE. The materials developed for the OSCE were “simulated patient's scenarios” and “checklists for the observers.” Case scenarios' scripts were created based on real clinical cases and incorporated details including patient's background, chief complaints, guidance on facial expression and eye-to-eye contact, and sample responses to possible questions. Paramedical staff members of the department of psychiatry with at least 5-year experience of working in the department were chosen to serve as simulated patients. The chosen staff underwent a 2-h training on role-playing as simulated patients for the OSCE stations. This training was declared completed only when all the trainer faculty unanimously reached a consensus that the performance by the simulated patients was satisfactory. The students were observed on these stations by the subject expert (faculty from the department). The checklist developed for the observers rated each activity on 3-point scale – done accurately, done partially, and not done.


Station 1, 3, and 5 were simulated patient stations carrying 20 marks each. Station 2, 4, and 6 were question stations on the diagnosis and management of patient scenarios of the preceding stations, carrying 2 marks each. Details are shown in [Table 1].
Table 1: Objective structured clinical examination station details

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The students were informed that the score on the knowledge assessment and OSCE examination would not be counted toward their internal assessment. The scores of OSCE were shared along with scoring sheets with students for their self-assessment at the end of OSCE exercise.

Feedback on this intervention was taken from participating students and faculty. Feedback from students was taken at two levels – for role-play and for the complete intervention. Feedback related to their level of comfort in role-play as patient or as interviewer on a Likert scale was taken for their roles, respectively, from the 9 pairs of student volunteers for role-play at the end of the day. In the feedback form, open-ended questions were also included to capture students' reflection on their experience in role-play. Overall feedback on the training intervention was obtained from all the students on a semi-structured proforma after the posttest. Feedback was also obtained from four faculty members who participated in the training intervention.

Data analysis

The quantitative data were entered in Microsoft Excel Worksheet and analyzed in SPSS 17.0 (IBM Corp., Armonk, New York, USA). Student's t-test was used for statistical significance. The qualitative data obtained in the form of students' reflective feedback were processed manually by thematic analysis.


   Results Top


This section presents the details of the learning of the students in the domains of knowledge, attitude, and skills and feedback from students and faculty on the training intervention. The demographic details of the participating students are presented in [Table 2].
Table 2: Demographic details of the participating students (n=32)

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Knowledge assessment

[Table 3] shows the pre- and post-test scores on the knowledge assessment of students. The posttest marks were significantly higher compared to pretest marks. The mean obtained marks for essay type questions were 0.2 and 2.7 out of a total of 5 in pre- and post-test, respectively. For MCQs, the difference was more with the mean obtained pretest marks at 2.7 and posttest marks at 4.3 out of 10. For true/false questions, there was little difference with pretest mean marks at 6.1 and posttest marks at 7.6 out of 10. On other variables of interest, namely, gender, religion, domicile, present stay, or type of family, there was no statistically significant difference.
Table 3: Comparison of pre- and post-test scores on assessment of knowledge of students

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Attitude assessment

[Table 4] shows comparison of the responses of students on pre- and post-intervention attitude assessment.
Table 4: Comparison of pre- and post-intervention responses on attitude assessment

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For some of the concepts, there was already a favorable attitude from beginning which was reflected in pretest. Most students opined that suicide prevention is their responsibility, they can prevent suicide even when a person has made up a strong mind for the act, there are warning signals preceding suicide, some religious beliefs have a helpful role in suicide prevention, even the young people may have stressors strong enough leading them to suicidal ideation, and it is their business to prevent suicide and hence if approached they should intervene in a person's life to prevent a possible suicide attempt. Most students differed from the idea of suicide clinics for painless suicide from the beginning.

The change seen due to the intervention can be described as – more number of students posttest were comfortable in talking with depressed person, were aware that suicide happens with warning, and were found to be aware that the possibility of a person repeating a suicide attempt is high. Negligible number of students in posttest felt that people have a right to take their own lives as against one-third students in pretest.

There was not much change in some components – many students even in the posttest felt that depression and suicide are caused by a weakened willpower and most suicide attempts are impulsive in nature, many felt that there may be situations where suicide may be a reasonable solution, many agreed that they would feel ashamed of a suicide attempt by a family member, and many students could still not differentiate between a transient emotional distress and depression.

Thus, unlike knowledge scores, the expected change in attitudes toward depression and suicide did not occur completely. This finding indicates that changing attitudes are not as easy as giving knowledge.

Skills assessment

The skills assessment was done using OSCE as a posttest after completing the training intervention. Each OSCE skill station carried 20 marks with the subsequent question station of 2 marks. Thus, we clubbed together the marks from procedure and related question station for ease of understanding. The observation checklist on procedure station was divided into four main components, namely, rapport building and empathy, depression assessment, suicide risk assessment, and overall approach. [Figure 1] presents the mean marks obtained by students on the three stations that ranged from 13.3 to 14.7 out of 22. Overall mean obtained marks were 42.7 out of 66. Among various components of OSCE, students scored high on rapport building. We also analyzed if having taken part in the role-play affected their performance in the OSCE. There was no statistically significant difference in mean OSCE score among those who took part in role-play and those who did not.
Figure 1: Box and whisker chart on score obtained by students on objective structured clinical examination assessment (n = 32) mean is represented by middle value, boxes are 1 standard deviation on either side of mean, and whiskers are minimum and maximum values

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Feedback from students

Feedback from students who participated in role-play

We conducted a total of 9 role-plays with 9 doctor–patient dyads. [Figure 2] displays the quantitative part of the feedback. The students who played the role of patient found themselves more comfortable playing their roles, performing in the group and being evaluated. However, two of them mentioned that it was uncomfortable since the interview forced them to reveal personal information. Two students also mentioned that the interviewer failed to show empathy while many appreciated the nonjudgmental attitude and patient listening by the interviewer as depicted in the following narratives:
Figure 2: Feedback from the students who acted in role-play (n = 18)

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“At last, when as a patient I had a doctor to listen to me I felt comfortable, as patient has someone to talk to.”

“As a patient, I was not that comfortable talking to the person in front of me everything about my problem and my life…… on the other hand felt relieved and felt assured that someone is there to listen to me quietly without judging me”

A larger proportion of students from the interviewer group found themselves uncomfortable during the role-play as can be seen from [Figure 2]. They expressed varied feelings about the role-play which included the need for studying more about depression and suicide, importance of listening and communication skills, and ensuring to take the history of suicidal ideation with depressed patient. Some of their responses in their own words:

“The purpose of this activity (is) fulfilled for me as it helped me get an idea of how to actually prepare myself, although I think it would have been a lot better if I had studied more on subject. Actually playing a role gives you an idea of the suffering, so it inspired me to study more and be well informed.”

“It was quite difficult to do role of doctor. I was very nervous…………. but in between the role-play I went blank as I didn't know what to ask. I was so nervous that I didn't ask patient's name and if she is having ideas about suicide. Overall there was a lot to learn from role-play. It was very good experience.”

“It was kind of awkward performing in front of class plus knowing that the patient is a dummy patient. So it was hard to show empathy knowing that sufferings were fake. If it would have been real patient the concern and empathy would have come with flow.”

Overall, they felt that before this series of the role-plays, they were uncomfortable talking to patients with depression. They also feared that they may say something which may increase the patient's stress. With this series of role-plays, they found themselves more comfortable. They also appreciated the role of nonverbal communication. One student mentioned,

“We were as good as a layman for interviewing such patients when we started this term, now at least we know something. This is unlike medicine term where at the end of the term we are confident that we can take history from the patient.”

At the end of the role-play, the number of students fully satisfied with their performance in role-play was more in the patients' group as compared to the interviewers' group. Majority also felt that they required some more clarity for participating in role-plays.

Overall feedback from students at the end of training

This overall feedback was obtained from all students participating in this training. [Table 5] displays the quantitative part of the feedback. The most useful components of training as per their perspective were role-play (n = 20), OSCE (n = 9), interacting with patients (n = 4), and lecture on suicide (n = 1). Here are verbatim responses from a couple of students.
Table 5: Overall feedback from students regarding the intervention

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“The act of role-playing was enjoyable as it not only made us more aware of risk of suicide among depressed patients and how to deal effectively but also made us more empathetic toward them.”

“It helps us learn how to communicate with patient. We learned from role-play about how to react to patients and how to question the patient.”

We also asked the students' suggestions for further improvement in this training intervention. Four students mentioned to include more interaction with real patients. One student suggested including videos. The other students who made suggestions for improvement in their own words;

“We gave appropriate focus on the Counselling part, but if we had more time, I would have loved to learn more aspects also.”

“Yes, during role-play I acted as patient. I would also like to be doctor but it's not possible due to lack of time”

All students expressed that this should be made as routine in teaching. They expressed that the role-play helped them to learn the communication skills and improved their confidence.

Feedback from the faculty

About the training

All the faculty members involved in the project suggested that this should be implemented in future batches. They felt that the skill-oriented training (role-plays and OSCE) was the strength of this intervention. The limitations mentioned were that it is a time-consuming task to address a moderately large batch size of approximately 30 students in clinical posting using this intervention.

Objective structured clinical examination

The feedback from the faculty suggested that the OSCE examination was well organized, it was in alignment with the learning objectives, the scores provide a true measure of the clinical skill of student, and that it eliminates the chance of bias in examination.


   Discussion Top


We implemented a skill-based training on recognition of depression and suicide risk assessment among a small group of undergraduate medical students in Western part of India. Worldwide, there is an increasing focus on psychiatry curricula for undergraduate students. The mental health issues have risen rapidly and formed a large part of the disease burden in the West. In UK, the academia has also responded to this new challenge by incorporating changes in their curricula.[15] Studies from Australia and Asia-Pacific also suggest that there is need to address inadequacies in teaching of depression and suicide in undergraduate curriculum.[16],[17] With rapid change in lifestyle, we see similar movement of the epidemic curve in South Asian counties now. However, our medical school curricula are yet to adequately address this new challenge.[7] A survey in Australia among medical schools, students, and general practitioners has suggested the need for more structured and hands-on component on suicide prevention in medical curriculum.[18] Similarly, in India also the suggestions for improving the psychiatry education has been made at multiple levels; increasing duration of exposure to psychiatry, making the teaching more skill based and focusing more on the primary care psychiatry. The Vision 2015 document of Medical Council of India (MCI) stresses on the revised curriculum to be more skill and competency based. It has identified 5 roles of an Indian Medical Graduate, one of which is the role of a good communicator.[19] The revised version of graduate medical education regulations from MCI has clarified the new vision of MCI in detail. It includes “the ability of medical graduate to assess the risk of suicide and manage appropriately” as one of the six core competencies under the department of psychiatry.[20]

As discussed earlier, the need to focus on the undergraduate psychiatry curriculum is vital as it prepares the future basic doctor in dealing with the issues such as depression and suicidal risk. Not only that depression is a substantial proportion of the outpatient clientele in primary care settings but the primary care physicians in such settings also have an unmet need for training to deal with such cases. A study from the USA shows that although the primary care physicians perceive the severity of the depression correctly, they are hesitant to perform suicide risk assessment.[21]

Lake traces the roots of failure of the primary care physician in identification of suicide risk in the undergraduate psychiatry curriculum. He argues that since primary care physician has limited time available with them for the mental health assessment of their patients, the medical school should also train the students in ultra-short interviews for depression and suicide risk.[22]

There is a need to focus on the training methodology used for psychiatric teaching. In our training intervention, we used lectures, demonstration of interviews with real patients, and role-plays. We could achieve substantial improvement in the knowledge scores and good improvement in attitude and skills. A study from Hong Kong that used movie, discussions, and skill-based training to students showed good effect in attitudes and a confidence in dealing with issues related to suicide.[23] A study from Zimbabwe used simulation-based teaching on depression. Unlike our intervention, they trained psychiatric nursing staff to play as simulated patients. They reported increased confidence of students in assessing and managing depression.[24] Serial role-playing to teach complex tasks such as suicide risk assessment has been described in literature.[25] We invited students themselves to play the role of patient as well as a doctor in our study. In our study, not only in pretest but also in posttest only a small proportion of students reported to be comfortable assessing someone for suicide risk. The reason for this may be that in pretest they were unaware about how to assess a patient for suicide risk, while in the posttest they realized that suicide risk assessment is challenging task which calls for considerable amount of communication skill.

The reason for limited change in the attitude may be because of the limited time the students spend in psychiatry. We need to explore the ways to address this issue of attitude change. A study of impact of psychiatry posting on attitudes toward mental illnesses and psychiatry among students shows positive change in attitude toward psychiatry but not much change in attitude toward mental illnesses.[26] A randomized trial from China compared lecture and lecture + self-directed learning on knowledge and attitude toward depression among medical undergraduates. They found lasting change in knowledge and attitude in self-directed learning group.[27] The reason for this could be that they used the medical humanities exercises extensively. A study from Oman medical school suggested that the clinical vignettes used should be adapted for local use. They observed that Omani students' perceptions were different for the same vignettes compared to students from the USA. Thus, there is a need for the development of culture-specific clinical case vignettes.[28] Hence, in this study, we ensured to develop our own clinical case vignettes for role-plays and OSCE stations rather than using prepared vignettes available from other sources.

Finally, there has also been innovations in teaching suicidal risk assessment by innovative methods. Foster et al. have demonstrated feasibility and effectiveness of an interactive virtual patient for teaching suicide risk assessment to medical students.[29] Such an exercise was beyond the scope for a limited resource setting like ours.


   Conclusion Top


Overall, this training intervention on depression and suicide risk assessment for undergraduate medical students was successful in increasing the knowledge of students on the topic. There was improvement in attitude of the students, yet there is the scope of improving it further. The role-plays and OSCE gave students hands-on opportunity at interviewing a patient with depression. The students found the training to be useful. They appreciated the role-play and OSCE the most among all interventions. They wanted that this training be given more time and continued for subsequent batches. The faculty also accepted the merits of this new way of teaching and wanted to incorporate it in routine teaching.

Limitations

The major limitation of the study was that it was conducted in a small sample and in a limited period. This was due to feasibility issues as the authors wanted to first understand the changes that can be brought about by such an exercise. The intervention is also time-consuming and will be a major limitation when done on a larger scale.

In our intervention, we wanted to locally develop videos for helping students learn the psychiatric interview but that could not be completed because of the limited availability of time. While there are successful attempts at use of already available movies for helping students learn about suicide and its prevention,[30] we intend to use them in future batches of this training. Another limitation of our intervention was that we could not provide opportunity to each student in role-play during the teaching sessions. However, each student underwent OSCE assessment with feedback.

Acknowledgment

This research was part of the Advance Course in Medical Education from MCI Nodal Center at Smt N H L Municipal Medical College, Ahmedabad for the first author. The author wishes to acknowledge the contributions made by all the nodal center faculty and participants that helped immensely to improve the quality of this research project. We also thank Dr. Ankit Patel and Dr. Dhrupan Patel, Junior Residents from Department of Psychiatry for their support during the project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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