General practitioners’ clinical expertise in managing suicidal young people: implications for continued education

A systematic review of suicide risk management strategies in primary care settings

Introduction and Objective

Suicide is a major public health concern. Recently, suicide rates have increased among traditionally low-risk groups (e.g., white, middle-aged males). Suicide risk assessments and prevention strategies should be tailored to specific at-risk populations. This systematic review examines suicide risk detection and management in primary care, focusing on treatments to reduce suicide rates and improve prevention efforts.

Methodology

A systematic review was conducted following PRISMA guidelines. Literature was collected and analyzed using Boolean operators with relevant keywords in databases (e.g., PubMed, Google Scholar, PsycINFO) to identify randomized and non-randomized studies focusing on suicide risk factors and management strategies in primary care, published in the past 10 years. The risk of bias 2.0 and Newcastle Ottawa scale was used to assess risk of bias, and data from moderate-quality studies were synthesized.

Results

Thirteen moderate-quality studies were reviewed. Key findings include the need for assessing modifiable risk factors like substance use and mental health. General practitioner (GP) engagement post-suicide attempt (SA) improves outcomes and reduces repeat SAs. Effective strategies include comprehensive risk assessments, collaborative treatment, and enhanced GP support. Barriers to effective suicide prevention include insufficient information, judgmental communication, lack of positive therapeutic relationships, and inadequate holistic assessments. These findings highlight the need for tailored suicide prevention strategies in primary care. However, the evidence sample size is small with reduced statistical power that limits generalizability. The included studies were also regional examinations, which restrict their broader relevance.

Discussion

Significant risk factors, barriers, and effective strategies for suicide prevention were identified. For children aged 12 or younger, preexisting psychiatric, developmental, or behavioral disorders, impulsive behaviors, aggressiveness, and significant stressful life events within the family were critical. For adults, loneliness, gaps in depression treatment, and social factors are significant. Barriers to suicide prevention included insufficient information, judgmental communication, lack of positive therapeutic relationships, inadequate holistic risk assessments, lack of individualized care, insufficient tangible support and resources, inconsistent follow-up procedures, variability in risk assessment, poor communication, stigma, and negative attitudes. Effective methods include the Postvention Assisting Bereaved by Suicide training program, continued education, comprehensive clinical assessments, individualized care, and community-based interventions like the SUPRANET program.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO, identifier CRD42024550904.

Examination of medical student and physician attitudes towards suicide reveals need for required training

The attitudes of healthcare providers towards suicidal patients are known to influence their motivation to treat patients during a suicidal crisis. Patients who attempted suicide are more likely to have recently visited a primary care provider who is not necessarily sufficiently trained in managing a suicidal patient rather than a mental health provider who is trained to do so. For those reasons, documenting medical students and physicians' attitudes towards suicide can help in the development of effective intervention training to prepare them to manage these types of patients. In this mini review, attitudes towards suicidal patients, the effectiveness of training on changing their attitudes are discussed. In summary, primary care providers are recognized as a top area where improvements can prevent suicides; providing proper suicide prevention training can effectively improve attitudes and quality of care for suicidal patients.

Raising Suicide in Medical Appointments-Barriers and Facilitators Experienced by Young Adults and GPs: A Mixed-Methods Systematic Review

The aim of this review was to understand the barriers and facilitators facing GPs and young adults in raising and addressing suicide in medical appointments. A mixed-methods systematic review was conducted of qualitative and quantitative studies. The focus was papers that explored barriers and facilitators experienced by young adults aged 18 to 26, and GPs working in primary care environments. Nine studies met the inclusion criteria. Four studies provided information on young adults' views, four on GPs, and one considered both GP and young adults' viewpoints. Nine barrier and seven facilitator themes were identified. Unique to this review was the recognition that young adults want GPs to initiate the conversation about suicide. They see this as a GP's responsibility. This review further confirmed that GPs lack the confidence and skills to assess suicide risk in young adults. Both findings combined could explain previous results for reduced identification of suicide risk in this cohort. GP training needs considerable focus on addressing skill deficiencies and improving GP confidence to assess suicide risk. However, introducing suicide risk screening in primary care for young adults should be a priority as this will overcome the need for young adults to voluntarily disclose thoughts of suicide.

Supporting general practitioners in the assessment and management of suicide risk in young people: an evaluation of an educational resource in primary care

Aim:

To conduct a local evaluation of the use of the educational resource: Suicide in Children and Young People: Tips for GPs, in practice and its impact on General Practitioners (GPs)’ clinical decision making.

Background:

This Royal College of General Practitioners (RCGP) resource was developed to support GPs in the assessment and management of suicide risk in young people.

Method:

The dissemination of the educational resource took place over a nine month period (February 2018–October 2018) across two Clinical Commissioning Groups in West Midlands. Subsequently, a survey questionnaire on GPs’ experiences of using the resource was sent to GPs in both Clinical Commissioning Groups (CCGs).

Findings:

Sixty-two GPs completed the survey: 21% reported that they had used the resource; most commonly for: (1) information; (2) assessing a young person; and (3) signposting themselves and young people to relevant resources. Five out of thirteen GPs (38.5%), who responded to the question about whether the resource had an impact on their clinical decision making, reported that it did; four (30.7%) responded that it did not; and four (30.7%) did not answer this question. Twenty out of thirty-two GPs (62.5%) agreed that suicide prevention training should be part of their NHS revalidation cycle. The generalizability of the findings is limited by the small sample size and possible response and social desirability bias. The survey questionnaire was not validated. Despite the limitations, this work can be useful in informing a future large-scale evaluation of the RCGP online resource to identify barriers and facilitators to its implementation.

Are Clinicians Confident in the Risk Assessment of Suicide?: A Systematic Literature Review

Suicide reduction is recognized as a vital focus for mental health clinicians. Clinician confidence to undertake suicide risk assessment, though poorly understood, appears related to job performance, though overconfidence has also been evident in clinical practice. A systematic literature search was undertaken on PSYCinfo and MEDLINE using the terms: suicide risk assessment, confidence, clinician. Of 192 papers identified, 10 articles were deemed pertinent. These for the most part suggested clinician confidence above the 50% chance level though statistical evidence was lacking for all but two. The literature fails to provide sufficient and objective evidence of the impact of clinician confidence in practice. Recommendations are provided for future research.

Working with Young People at Risk of Suicidal Behaviour and Self-Harm: A Qualitative Study of Australian General Practitioners' Perspectives

General Practitioners (GPs) play a crucial role in the identification and support of young people at risk of suicidal behaviour and self-harm; however, no studies have explored GPs' perspectives, approaches, challenges, and resource needs when working with this cohort in an Australian setting. This was a qualitative study where fifteen GPs (Mage = 45.25 years) from multiple clinics in Western Australia took part in semi-structured interviews, and data were analysed thematically. Seven main themes were identified: (1) working with young people has its unique challenges; (2) screening and assessment tools can help to manage uncertainty and discomfort; (3) going beyond tools-the dialogue and relationship are most important; (4) there are limits to what we can offer in the time available; (5) the service access and referral pathways lack clarity and coordination; (6) the provision of mental health support should not fall on GPs alone; and (7) more comprehensive training in suicide and self-harm is needed. The findings highlight a number of opportunities to enhance care and better assist GPs working with young people who present with suicidal behaviour and self-harm, including considerations for conducting assessments, targeted resources such as training, and system and service improvements.

General practitioners' training and their attitudes towards young people who self-harm: A cross-sectional survey

AIM

Self-harm is common among adolescents and young adults and carries increased risk of suicide and other negative outcomes, yet only a small proportion will seek professional help. General practitioners (GPs) are a potentially valuable source of help as most young people visit their GP regularly for other reasons. The primary aim of this research was to explore GPs' empathy and attitudes towards young people who self-harm and how these are related to GP specialist training.

METHOD

GPs completed questionnaires regarding their training, levels of empathy, perceived knowledge and attitudes towards young people who self-harm. The cross-sectional design included a random sample of 178 GPs and 47 GPs-in-training in the Republic of Ireland. Bootstrapped mediation analysis using structural equation modelling (SEM) was applied to explore the pattern of relationships among GP-training, empathy, perceived knowledge of self-harm and attitudes towards youth who self-harm.

RESULTS

The SEM results revealed that the model had a very good fit to the data. Empathy was the strongest predictor of attitudes towards self-harm even if GPs had received youth mental health training and fully mediated the effect of youth mental health training on perceived knowledge of self-harm. Specialized training in self-harm was a stronger predictor of perceived knowledge than empathy but had no association with negative attitudes.

CONCLUSIONS

The findings emphasize positive outcomes associated with GP training and highlight potential differences in the effects associated with specific vs general training in youth mental health. These differences may be used to inform the design and implementation of continuing professional development.

"I'm just a long history of people rejecting referrals" experiences of young people who fell through the gap between child and adult mental health services

The paediatric-adult split in mental health care necessitates young people to make a transition between services when they reach the upper end of child and adolescent mental health services (CAMHS). However, we know that this transition is often poor, and not all young people who require ongoing support are able to continue care in adult mental health services (AMHS). These young people are said to have fallen through the gap between services. This research aimed to explore the reasons why young people fall through the gap between CAMHS and AMHS, and what effect this has had on them and their families. Narrative interviews were conducted with 15 young people and 15 parents, representing 19 unique transition stories. Themes were identified collaboratively using thematic analysis. Reasons for falling through the gap were grouped into systemic problems and problems with the quality of care received. Effects of falling through the gap were grouped into separate themes for young people (feeling abandoned; struggling to manage without continued care; problems with medication) and parents (emotional impact of care ending; parents taking an active role in the young person's care). To our knowledge, this is the first qualitative study that has focused only on the experiences of young people who have fallen through the gap between services. This research adds novel findings to existing literature regarding barriers to transition and the effects of discontinuity of care.

Staff awareness of suicide and self-harm risk in healthcare settings: A mixed-methods systematic review

BACKGROUND

Suicide risk screening in healthcare settings plays a significant role in suicide prevention. Healthcare staff who are poorly informed about self-harm and suicide risk are less likely to identify and subsequently screen at-risk individuals. This mixed-method systematic review aimed to appraise and synthesise evidence from studies that explored and promoted healthcare staff's knowledge and awareness of suicide and self-harm risk in healthcare settings.

METHODS

Electronic databases (CINAHL, MEDLINE, APA PsycInfo, APA PsycARTICLES, Psychology and behavioural Science Collection, ERIC, and SocINDEX), the Cochrane Library, and various grey literature databases were searched for relevant studies. The level of evidence and methodological quality of the included studies were assessed.

RESULTS

Eighteen empirical studies were included. Levels of knowledge about suicide and self-harm risk varied significantly across the reviewed studies. Face-to-face group training and educational programmes, digital or online educational programmes, and an educational poster campaign were amongst the strategies used to promote awareness of suicide and self-harm risk, with the majority marginally succeeding in doing so.

LIMITATIONS

The reviewed studies were heterogeneous in terms of design, interventions, and outcome measures which made it difficult to make comparisons. The overall level of scientific evidence was classified as being relatively low. The lack of blinding and lack of a control group were amongst the limitations for experimental studies.

CONCLUSIONS

Long-term, routine face-to-face group training programmes should be established to educate healthcare staff about suicide risk across all professions and in specific patient groups.

The social life of self-harm in general practice

Research engaging qualitatively with clinical practitioners' understanding of, and response to, self-harm has been limited. Self-harm offers a particularly compelling case through which to examine the enduring challenges faced by practitioners in treating patients whose presenting symptoms are not clearly biomedical in nature. In this paper, we present an analysis of 30 General Practitioners' (GPs') accounts of treating patients who had self-harmed. Our analysis demonstrates the complex ways in which GPs seek to make sense of self-harm. Illustrated through three common 'types' of patients (the 'good girl', the 'problem patient' and the 'out of the blue'), we show how GPs grapple with ideas of 'social' and 'psychological' causes of self-harm. We argue that these tensions emerge in different ways according to the social identities of patients, with accounts shaped by local contexts, including access to specialist services, as well as by cultural understandings regarding the legitimacy of self-harming behaviour. We suggest that studying the social life of self-harm in general practice extends a sociological analysis of self-harm more widely, as well as contributing to sociological theorisation on the doctor-patient relationship.

Systematic Review and Quality Appraisal of Practice Guidelines for Self-Harm in Children and Adolescents

This study aimed to systematically identify and appraise clinical practice guidelines (CPGs) relating to the assessment and management of suicide risk and self-harm in children and adolescents. Our research question is as follows: For young people (under 18 years old) presenting to clinical care with suicide ideation or a history of self-harm, what is the quality of up-to-date CPGs? Using the PRISMA format, we systematically identified CPGs meeting our inclusion and exclusion criteria. Subsequently, two independent raters conducted appraisals of the eligible CPGs using the Appraisal of Guidelines for Research and Evaluation II instrument. CPGs were then classified as "poor quality," "minimum quality," and "high quality" using operationally defined criteria developed a priori. We identified 10 eligible CPGs published or renewed between 2005 and May 2017. Only the long-term management of self-harm CPGs produced by the National Institute for Health and Care Excellence met "high-quality" criteria. Despite multiple options of CPGs published to choose from, only one was identified as "high quality," where bias is adequately minimized. Clinicians are advised to direct resources to implementing the "high-quality" CPG.

An Electronic Clinical Decision Support System for the Assessment and Management of Suicidality in Primary Care: Protocol for a Mixed-Methods Study

Background

Suicide is a global public health concern, but it is preventable. Increased contact with primary care before the suicide or attempted suicide raises opportunities for intervention and prevention. However, suicide assessment and management are areas that many general practitioners (GPs) find particularly challenging. Previous research has indicated significant variability in how GPs understand, operationalize, and assess suicide risk, which subsequently has an impact on clinical decision making. Clinical decision support systems (CDSS) have been widely implemented across different health care settings, including primary care to support practitioners in clinical decision making. A CDSS may reduce inconsistencies in the identification, assessment, and management of suicide risk by GPs by guiding them through the consultation and generating a risk assessment plan that can be shared with a service user or with specialized mental health services.

Objective

Our aim is to co-develop and test with end users (eg, GPs, primary care attendees, mental health professionals) an electronic clinical decision support system (e-CDSS) to support GPs in the identification, assessment, and management of suicidality in primary care.

Methods

Ours is an ongoing embedded mixed-methods study with four phases: (1) qualitative interviews with GPs to explore their views on the content, format, and use of the e-CDSS, as well as consultation with two service-user advisory groups (people aged ≤25 and people aged ≥25) to inform the content of the e-CDSS including phrasing of items and clarity; (2) participatory co-production workshops with GPs, service users, and clinical experts in suicidality to determine the content and format of the e-CDDS; gain consensus of the relevance of items; establish content validity and identify pathways to implementation, using the Consolidated Framework for Implementation Research; (3) building the e-CDSS so that it guides the GP through a consultation; and (4) usability testing of the e-CDSS with GPs and service users in one primary care practice involving a nonlive and a live stage.

Results

The study was funded for four years, to take place between 2015 and 2019, and is currently completing phase 4 data collection. The first results are expected to be submitted for publication in June 2019. The findings will enable us to evaluate the feasibility, acceptability, and usability of a suicide-specific, electronic, guided decision support system in primary care.

Conclusions

This study will be the first to explore the feasibility, acceptability, and usability of an electronic, guided decision support system for use in primary care consultations for the improved assessment and management of suicidality.

International Registered Report Identifier (IRRID)

RR1-10.2196/11135

What Works in Youth Suicide Prevention? A Systematic Review and Meta-Analysis

BACKGROUND

Young people require specific attention when it comes to suicide prevention, however efforts need to be based on robust evidence.

METHODS

We conducted a systematic review and meta-analysis of all studies examining the impact of interventions that were specifically designed to reduce suicide-related behavior in young people.

FINDINGS

Ninety-nine studies were identified, of which 52 were conducted in clinical settings, 31 in educational or workplace settings, and 15 in community settings. Around half were randomized controlled trials. Large scale interventions delivered in both clinical and educational settings appear to reduce self-harm and suicidal ideation post-intervention, and to a lesser extent at follow-up. In community settings, multi-faceted, place-based approaches seem to have an impact. Study quality was limited.

INTERPRETATION

Overall whilst the number and range of studies is encouraging, gaps exist. Few studies were conducted in low-middle income countries or with demographic populations known to be at increased risk. Similarly, there was a lack of studies conducted in primary care, universities and workplaces. However, we identified that specific youth suicide-prevention interventions can reduce self-harm and suicidal ideation; these types of intervention need testing in high-quality studies.

Suicide Prevention Training: Policies for Health Care Professionals Across the United States as of October 2017

OBJECTIVES

To identify and compare state policies for suicide prevention training among health care professionals across the United States and benchmark state plan updates against national recommendations set by the surgeon general and the National Action Alliance for Suicide Prevention in 2012.

METHODS

We searched state legislation databases to identify policies, which we described and characterized by date of adoption, target audience, and duration and frequency of the training. We used descriptive statistics to summarize state-by-state variation in suicide education policies.

RESULTS

In the United States, as of October 9, 2017, 10 (20%) states had passed legislation mandating health care professionals complete suicide prevention training, and 7 (14%) had policies encouraging training. The content and scope of policies varied substantially. Most states (n = 43) had a state suicide prevention plan that had been revised since 2012, but 7 lacked an updated plan.

CONCLUSIONS

Considerable variation in suicide prevention training for health care professionals exists across the United States. There is a need for consistent polices in suicide prevention training across the nation to better equip health care providers to address the needs of patients who may be at risk for suicide.