Abstract
Introduction:
Suicide risk among Indigenous populations is a multifaceted phenomenon, influenced by biological, psychological, and social factors at the individual level, as well as cultural, political, and economic issues at the family and community level. The global prevalence of depression among medical students was recently estimated to be 28.0 % according to a meta-analysis of 77 studies. In the field of suicide prevention, the term gatekeeper refers to “individuals in a community who have face-to-face contact with large numbers of community members as part of their usual routine.” They may be trained to “identify persons at risk of suicide and refer them to treatment or supporting services as appropriate”. In our study we aimed to improved attitude and knowledge in gatekeeper to improve detection and referral of individuals who are at risk of suicide.
Methods and Material:
We adapted an evidence-based gatekeeper training into a two-hour, multi-modal and interactive event for medical professional and undergraduate students. Then we evaluated the intervention compared to free-recall knowledge and attitudes questions were examined before and after participation in a student and faculty gatekeeper training program. Focus groups with students enriched interpretation of quantitative results.
Statistical analysis used:
Knowledge, attitudes, and skills of both students and teachers were analyzed by Mann–Whitney U-test. Comparison of knowledge, attitudes, and skills between both groups was analyzed by Wilcoxon signed-rank test.
Results:
Undergraduate students developed more positive attitude for suicidal behavior where faculties developed more confident in their skill after training sessions.
Conclusion:
brief gatekeeper training found effective in improving knowledge about suicide. Also, increasing participants' accuracy to identify warning signs, risk factors and protective factors about suicide.
Keywords: Gatekeeper training, medical professional, medical students, suicide prevention
Suicide risk among various populations can be attributed to multiple factors, including biological, psychological, and social factors at an individual level, as well as cultural, political, and economic factors at family and community level.[1,2] The global prevalence of depression among medical students was recently estimated to be 28.0%, according to a meta-analysis of 77 studies.[3] As per the India's National Crime Records Bureau – which reports an official suicide rate based on police reports, estimated 1,34,516 suicides in the country during 2018 showing an increase of 3.6% in comparison to 2017 and the rate of suicides has increased by 0.3 during 2018 over 2017. 7.6% (10,159 victims out of 134,516) of total suicides reported were done by students. 14.3% of total suicides committed by students were reported in Maharashtra (1448 suicides) followed by 9.4% in Tamil Nadu (953 suicides), 8.5% in Madhya Pradesh (862 suicides), 7.4% in Karnataka (755 suicides), and 6.0% in West Bengal (609 suicides).[4] A recent study from India found that 358 deaths due to suicide were reported among medical students (125), residents (105), and physicians (128) between 2010 and 2019.[5] A recent study from the United States of America calculated a prevalence of 6.19 suicides/100,000 students during a period of 10 years.[6] Medical students and physicians too are not exempt from stigma associated with mental health problems. This creates a barrier to help-seeking. Addressing these issues will make them better able to confront depression and suicidality and identify the same in their colleagues.[7] College students are more likely to seek support and share suicidal thoughts with peers than adults.[8] However, adolescents fail to share the intentions of a suicidal peer with others more than 75% of the time.[9] Data regarding suicidal ideation and attempts suggest that only a minority of students who attempt or complete suicide have sought counseling before the suicidal crisis.[10,11]
Completing medical education involves a lot of commitment and exposure to stressful situations, which has an impact on physical, mental, and emotional planes. Few common stressors identified by the researchers are long duty hours, heavy workload, and financial burden of academics.[12,13] Hence, it is unsurprising that medical students have been found to show a significantly higher prevalence of depressive symptoms than the general population.[14] Another study has suggested that although the rate of depression among students entering medical school is similar to that among other people of similar ages, the prevalence increases disproportionately over the course of medical schooling.[15] Depression among medical students deserves special attention; it not only affects students' lives in terms of academic performance, dropout, and professional development but may also have repercussions on patient care in the long run as depressed and anxious medical students have been reported to be more cynical, less empathetic, and less willing to care for chronically ill patients.[16] Physicians are an at-risk profession for suicide, with a global Standardized Mortality Ratios (SMR) of 1.44 (95 confidence interval 1.16, 1.72). There is an important heterogeneity between studies with women being particularly at risk compared to male physicians.[17]
In the field of suicide prevention, the term gatekeeper refers to “individuals in a community who have face-to-face contact with large numbers of community members as part of their usual routine.” They may be trained to “identify persons at risk of suicide and refer them to treatment or supporting services as appropriate.”[18] Gatekeeper training programs teach community members to identify signs of depression and other behaviors that put individuals at heightened risk for suicide.[19] Improvement in suicide-related knowledge and self-efficacy is a convincing outcome of the gatekeeper training.[20]
Most of the studies that tested suicide gatekeeper programs with college students found increase in declarative and perceived suicide knowledge from pretraining to posttraining, though declarative knowledge appeared to diminish at longer follow-ups (3–5 months).[21] However, studies have not examined the effect of gatekeeper training on individual identification or referral of students at-risk for suicide, in particular. Further, gatekeeper trainings were implemented primarily with those in leadership or staff positions, with one exception.[21] The purpose of this study was to assess change or impact of training on attitudes and knowledge in gatekeepers, which can improve detection, communication, and referral of medical college students at risk for suicide to help. Using an open pilot trial design, it was hypothesized that our 3-h peer gatekeeper suicide prevention training would be associated with improvements in suicide-related knowledge, rates of identification of suicidal peers, and rates of referral of suicidal peers.
SUBJECTS AND METHODS
Participants
Twenty medical students and 15 medical teachers from Government Medical College, Surat city, Gujarat state, participated in the study. Participants were selected from the Psychological Help and Guidance Center for Suicide Prevention Committee of College after obtaining their willingness to participate in the study.
Semi-structured pro forma including attitude and knowledge questionnaire was filled by participants before gatekeepers' suicide prevention training program. It covered multiple areas of myths and facts, identifying emotional and behavioral problems, attitudes and beliefs, steps to take after identifying a suicidal person, communication skills in medical students with emphasis on depression and suicide, and roles and responsibility of a gatekeeper.
An evidence-based gatekeepers' training was organized for medical professionals and undergraduate students of 3-h duration. Interactive lectures were held on myths and facts about suicide, identifying emotional and behavioral problems in suicidal person, attitudes and beliefs about suicide, identifying a suicidal person, and communication skills. All the sessions included group activity and question–answer period at the end. Communication skills were demonstrated by role-plays. Effectiveness of workshop was assessed in the same areas with postassessment at the end of the workshop.
All the statistical analyses were conducted in SPSS 20 (IBM Corp, Armonk, NY). The Shapiro–Wilk test was used to examine whether or not each subscale score had a normal distribution. Mann–Whitney U-test was used to compare the mean scores of independent categorical variables, and all variables were entered by a stepwise method if significant at the P < 0.05 level. Knowledge, attitudes, and skills of both students and teachers were analyzed by Mann–Whitney U-test. Comparison of knowledge, attitudes, and skills between both groups was analyzed by Wilcoxon signed-rank test.
RESULTS
Description of study population characteristic
Out of the total 35 participants, 20 were medical students and 15 were medical teachers. Fifteen medical teachers were in the age group of 30–51 years, with the mean age of 38 ± 7 years. Medical teachers were having experience from 2 to 20 years. Mean years of experience was 9.7 ± 6 years. There were 20 medical students in the age group of 18–22 years, with the mean age of 19.7 ± 0.98 years.
Description about knowledge about suicide
Before training, medical teachers scored more on general knowledge about suicide as compared to medical students. After training, overall knowledge improved in almost half the statements in each group (significant at P < 0.05).
Posttest evaluation revealed that medical students developed better knowledge regarding myths and facts surrounding suicide, including about the relationship of drugs/alcohol with suicide, about role of removal of instruments in preventing suicide, suicides occurring in nondepressed individuals, and help-seeking in suicide. They showed improvement in their beliefs that people who talk about suicide do not kill themselves and people who are suicidal always want to die (P = 0.046, 0.62, 0.01, 0.04, and 0.01) [Figure 1].
Figure 1.
Medical students’ general knowledge about suicide
Medical teachers demonstrated improved knowledge in posttraining assessment about higher degree of completed suicide in men, suicidal acts in psychotic illness, object removal for suicide prevention, and change in their beliefs regarding suddenness of suicide and that those who talk about suicide do not die (P = 0.002, 0.02, 0.02, 0.005, and 0.04) [Figure 2].
Figure 2.
Medical teachers’ general knowledge about suicide
Medical teachers' knowledge about warning signs, risk factors, and protective factors improved after training, as shown in Table 1. They were statistically significant at P < 0.01, <0.05, and <0.05, respectively. In medical students, knowledge about warning signs and risk factors improved after training as shown in Table 2. They were statistically significant at P < 0.01 and <0.05, respectively. Knowledge about protective factors in medical students was increased as compared to the baseline, but the score was not significant.
Table 1.
Medical teachers’ knowledge about warning signs, risk factors, and protective factors
| Before training | After training | t | P | |
|---|---|---|---|---|
| Warning signs | ||||
| Crying, anger outbursts, reckless behavior | 7 | 24 | −3.508 | 0.002 |
| Threatening to hurt or kill themselves, abnormal anxiety, or agitation | ||||
| Mood changes, withdrawal from family and friends | ||||
| Increased use of alcohol or other drugs, giving away possessions | ||||
| Expressing feelings of hopelessness, being trapped with no way out and no reason for living, sleeplessness | ||||
| Feeling isolated and that no one understands you | ||||
| Risk factors | ||||
| Mental illness, one or more prior suicidal attempt | 12 | 24 | −2.500 | 0.021 |
| Loss of significant relationship, alcohol and drug abuse, living in isolation, living with chronic pain and disability, financial crisis | ||||
| Protective factors | ||||
| Learning to live and chronic pain and managing good physical and mental health | 12 | 24 | −2.169 | 0.042 |
| Financial security, staying connected to community | ||||
| Having a significant relationship with another person | ||||
| Developing personal skill and resilience; talking to someone for help |
Table 2.
Medical students’ knowledge about warning signs, risk factors, and protective factors
| Before training | After training | t | P | |
|---|---|---|---|---|
| Warning signs | ||||
| Crying, anger outbursts, reckless behavior | 7 | 20 | −4.35 | 0.000 |
| Threatening to hurt or kill themselves, abnormal anxiety, or agitation | ||||
| Mood changes, withdrawal from family and friends | ||||
| Increased use of alcohol or other drugs, giving away possessions | ||||
| Expressing feelings of hopelessness, being trapped with no way out and no reason for living, sleeplessness | ||||
| Feeling isolated and that no one understands you | ||||
| Risk factors | ||||
| Mental illness, one or more prior suicidal attempt | 14 | 20 | −2.51 | 0.021 |
| Loss of significant relationship, alcohol and drug abuse, living in isolation, living with chronic pain and disability, financial crisis | ||||
| Protective factors | ||||
| Learning to live and chronic pain and managing good physical and mental health | 13 | 20 | −1.71 | 0.104 |
| Financial security, staying connected to community | ||||
| Having a significant relationship with another person | ||||
| Developing personal skill and resilience; talking to someone for help |
Posttraining comparison of knowledge in both the groups is shown in Table 3 and graphical of the same is shown in Figures 1 and 2.
Table 3.
Comparison of general knowledge of medical teachers and medical students
| Questions | Faculty | Student |
|---|---|---|
| More men than women complete suicide | 0.002 | 0.059 |
| Grieving after suicide is different than after other kinds of death | 0.317 | 0.085 |
| Suicide is always the act of a mentally ill or psychotic person | 0.025 | 1.00 |
| There is no relationship between drugs/alcohol and suicide | 0.083 | 0.046 |
| There are one or two causes or motives that explain most suicides | 0.564 | 0.157 |
| Removing the means of suicide (e.g., removal of acidic/kerosene, sharp objects, insecticides) would prevent many suicides | 0.020 | 0.002 |
| Suicide tendencies are always inherited and always suicide runs in families | 0.567 | 0.317 |
| Everyone who commits suicide is depressed | 0.157 | 0.014 |
| People who make plans to commit suicide keep their thoughts to themselves and the suicide occur without warning | 0.005 | 0.004 |
| People who talk about suicide do not kill themselves | 0.046 | 0.414 |
| People who are suicidal always want to die | 1.000 | 0.014 |
Data were analyzed by Wilcoxon signed-rank test
Medical students had more positive attitude than medical teachers in the posttraining assessment. However, the attitude was significantly improved in both the groups as compared to pretraining [Table 4].
Table 4.
Comparison of attitudes of medical teachers and medical students
| Questions | Teachers | Students |
|---|---|---|
| In most situations, individuals and organizations should not intervene when a person is suicidal | 0.096 | 0.739 |
| Once someone decides to take their life, it is hard to change their mind | 0.206 | 0.035 |
| The main goal of suicidal acts precipitated by interpersonal conflict is to punish or threaten others | 0.038 | 0.957 |
| Suicidal behavior is not predictable | 0.007 | 0.012 |
| Talking about suicide-related issues with an individual does not precipitate suicidal behavior | 0.643 | 0.368 |
Data were analyzed by Wilcoxon signed-rank test
Description about change in self-appraisal of knowledge and skills
Both groups had improved scores in “changes in self-appraisal of knowledge and skills” after training, as shown in Tables 5 and 6. They were statistically significant at P ≤ 0.01. Changes in self-appraisal of knowledge and skills improved for all taught domains in both groups after training. Posttraining comparison about changes in self-appraisal of knowledge and skills in both groups is shown in Table 7.
Table 5.
Medical teachers’ changes in self-appraisal of knowledge and skills
| Median difference | P | |
|---|---|---|
| Question Knowledge | ||
| Knowing facts about suicide | 1 | 0.005 |
| Knowing suicide warning signs | 2 | 0.001 |
| How to ask someone who may be suicidal | 2 | 0.000 |
| Persuading someone to get help | 1 | 0.002 |
| How to get help for someone who may be suicidal | 1 | 0.005 |
| Information about local resources for help with suicide | 2 | 0.003 |
| Please rate your general understanding about suicide and suicide prevention | 2 | 0.019 |
| Question - Skills | ||
| I am confident in my ability to successfully assess suicidal person | 1 | 0.001 |
| I am confident in my ability to successfully help suicidal person | 1 | 0.001 |
| I am hesitant to ask someone if he or she is suicidal | −1 | 0.009 |
| I must honor my promise to keep secret that someone I know is going to suicide | 0 | 0.038 |
Data were analyzed by MannWhitney U-test
Table 6.
Medical students’ changes in self-appraisal of knowledge and skill
| Median difference | P | |
|---|---|---|
| Question - Knowledge | ||
| Knowing facts about suicide | 1 | 0.000 |
| Knowing suicide warning signs | 1 | 0.000 |
| How to ask someone who may be suicidal | 1 | 0.002 |
| Persuading someone to get help | 0 | 0.154 |
| How to get help for someone who may be suicidal | 2 | 0.001 |
| Information about local resources for help with suicide | 1 | 0.001 |
| Please rate your general understanding about suicide and suicide prevention | 2 | 0.000 |
| Question - Skills | ||
| I am confident in my ability to successfully assess suicidal person | 0 | 0.001 |
| I am confident in my ability to successfully help suicidal person | 0 | 0.005 |
| I am hesitant to ask someone if he or she is suicidal | −0.5 | 0.035 |
| I must honor my promise to keep secret that someone I know is going to suicide | −1.0 | 0.005 |
Data were analyzed by MannWhitney U-test
Table 7.
Comparison of self-appraisal of skills of medical teachers and medical students
| Questions | Medical teachers | Medical student |
|---|---|---|
| I am confident in my ability to successfully assess suicidal person | 0.001 | 0.001 |
| I am confident in my ability to successfully help suicidal person | 0.001 | 0.248 |
| I am hesitant to ask someone if he or she is suicidal | 0.009 | 0.428 |
| I must honor my promise to keep secret that someone I know is going to suicide | 0.038 | 0.005 |
Data were analyzed by Wilcoxon signed-rank test
DISCUSSION
This study involved a preliminary investigation of the effectiveness of a gatekeeper training program in medical professionals and medical students. We begin by summarizing the results of the main effects of gatekeeper training including tests of moderators and mediators of training impact. First, gatekeeper training had a greater impact on increasing participants' general information about suicide. Secondly, post training knowledge was noted to improve. Participant's accuracy to identify warning signs, risk factors and protective factors of suicide, as well as participants with lowest appraisals showed improved appraisals post behavior training. Third, overall attitudes and self-appraisal skills of both students and teachers showed positive change. Fourth, medical students developed more helpful attitudes toward suicidal behavior, whereas medical teachers perceived themselves as more confident in their skills after the training session.
Though widely used, the effect of gatekeeper trainings for suicide prevention on the medical professionals and students' population is not well studied in India. Existing evidence suggests that the gatekeeper trainings administered to faculty, staff, and students in leadership/educator roles (e.g. resident assistant, peer educators) on college campuses are associated with increases in declarative as well as self-perceived knowledge about suicide and the ability to make adequate referrals.[22,23,24] Several studies supported our finding that gatekeeper training for adults in community setting increases their knowledge of youth specific risk factors for suicide, their intentions, and perceived efficacy.[20,21,25,26,27,28,29,30] Present study also indicated improvement in overall knowledge as well as knowledge about warning signs, risk factors, and protective factors as compared to pretraining status. In addition, there was significant improvement in positive attitudes toward suicide intervention following training, a finding which is supported by two previous studies.[31,32]
In the current study, self-efficacy was found to have improved after training. This result was supported by one study, which found that the number of years since receiving training affected one's self-efficacy to intervene. It was found that those who had attended suicide training within the past 3 years were more likely to report self-efficacy to intervene than those who had completed training longer than 3 years prior.[33]
CONCLUSION
This study provides brief gatekeeper training found effective in improving knowledge about suicide. It also increased participant's accuracy to identify warning signs, risk factors and protective factors about suicide. Studies assessing suicide prevention curricula and interventions aimed at raising mental health literacy levels confirmed[34,35,36] increase in awareness of depression and destigamtization of help seeking behavior of participant to prevent suicide.[37,38] This impact was observed in general population, specifically in medical students' and clinicians.
Future directions
Continued research is needed as to how knowledge, beliefs, and self-efficacy are related to both gatekeepers' intervention behavior and changes in suicide rates. Research should examine the components and features of gatekeepers' trainings that yield the most promising effects.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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