|Year : 2021 | Volume
| Issue : 2 | Page : 217-223
Effectiveness of gatekeepers' training for suicide prevention program among medical professionals and medical undergraduate students of a medical college from Western India
Rutvin Patel1, Ritambhara Mehta2, Kamlesh Dave2, Pradhyuman Chaudhary3
1 Consultant Psychiatrist, Surat, Gujarat, India
2 Department of Psychiatry, Government Medical College, Surat, Gujarat, India
3 Department of Psychiatry, GMERS Medical College and Hospital, Sola, Ahmedabad, Gujarat, India
|Date of Submission||16-Feb-2021|
|Date of Acceptance||20-Jun-2021|
|Date of Web Publication||06-Oct-2021|
Dr. Pradhyuman Chaudhary
Department of Psychiatry, GMERS Medical College and Civil Hospital, 225, Sola Gam Road, beside High Court, Shenbhai Nagar,Sola, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
| 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
|How to cite this article:|
Patel R, Mehta R, Dave K, Chaudhary P. Effectiveness of gatekeepers' training for suicide prevention program among medical professionals and medical undergraduate students of a medical college from Western India. Ind Psychiatry J 2021;30:217-23
|How to cite this URL:|
Patel R, Mehta R, Dave K, Chaudhary P. Effectiveness of gatekeepers' training for suicide prevention program among medical professionals and medical undergraduate students of a medical college from Western India. Ind Psychiatry J [serial online] 2021 [cited 2022 May 22];30:217-23. Available from: https://www.industrialpsychiatry.org/text.asp?2021/30/2/217/327588
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., The global prevalence of depression among medical students was recently estimated to be 28.0%, according to a meta-analysis of 77 studies. 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). 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. 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. 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. College students are more likely to seek support and share suicidal thoughts with peers than adults. However, adolescents fail to share the intentions of a suicidal peer with others more than 75% of the time. 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.,
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., Hence, it is unsurprising that medical students have been found to show a significantly higher prevalence of depressive symptoms than the general population. 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. 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. 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.
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.” Gatekeeper training programs teach community members to identify signs of depression and other behaviors that put individuals at heightened risk for suicide. Improvement in suicide-related knowledge and self-efficacy is a convincing outcome of the gatekeeper training.
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). 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. 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|| |
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].
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].
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 |
Click here to view
|Table 2: Medical students' knowledge about warning signs, risk factors, and protective factors |
Click here to view
Posttraining comparison of knowledge in both the groups is shown in [Table 3] and graphical of the same is shown in [Figure 1] and [Figure 2].
|Table 3: Comparison of general knowledge of medical teachers and medical students |
Click here to view
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 |
Click here to view
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 [Table 5] and [Table 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 |
Click here to view
|Table 6: Medical students' changes in self-appraisal of knowledge and skill |
Click here to view
|Table 7: Comparison of self-appraisal of skills of medical teachers and medical students |
Click here to view
| 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.,, 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.,,,,,,, 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.,
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.
| 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,, increase in awareness of depression and destigamtization of help seeking behavior of participant to prevent suicide., This impact was observed in general population, specifically in medical students' and clinicians.
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Stone DM, Crosby AE. Suicide prevention. Am J Lifestyle Med 2014;8:404-20.
APA; Rihmer Z, Belsö N, Kiss K. Strategies for suicide prevention. Curr Opin Psychiatry 2002;15:83-7.
Puthran R, Zhang MW, Tam WW, Ho RC. Prevalence of depression amongst medical students: A meta-analysis. Med Educ 2016;50:456-68.
Chahal S, Nadda A, Govil N, Gupta N, Nadda D, Goel K, et al. Suicide deaths among medical students, residents and physicians in India spanning a decade (2010-2019): An exploratory study using on line news portals and Google database [published online ahead of print, 2021 Apr 27]. Int J Soc Psychiatry. 2021;207640211011365.
Laitman BM, Muller D. Medical student deaths by suicide: The importance of transparency. Acad Med 2019;94:466-8.
Center C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H, et al
. Confronting depression and suicide in physicians: A consensus statement. JAMA 2003;289:3161-6.
Drum DJ, Brownson C, Burton Denmark A, Smith SE. New data on the nature of suicidal crises in college students: Shifting the paradigm. Prof Psychol 2009;40:213-22.
Klimes-Dougan B, Klingbeil DA, Meller SJ. The impact of universal suicide-prevention programs on the help-seeking attitudes and behaviors of youths. Crisis 2013;34:82-97.
Furr SR, Westefeld JS, McConnell GN, Jenkins JM. Suicide and depression among college students: A decade later. Prof Psychol 2001;32:97-100.
Gallagher RP, Zhang B, Taylor R. National Survey of Counselingcenter Directors. Alexandria, VA: International Association of Counseling Services; 2004.
Rosenthal JM, Okie S. White coat, mood indigo – Depression in medical school. N Engl J Med 2005;353:1085-8.
Adams J. Straining to describe and tackle stress in medical students. Med Educ 2004;38:463-4.
Tarchi L, Moretti M, Osculati AM, Politi P, Damiani S. The hippocratic risk: Epidemiology of suicide in a sample of medical undergraduates. Psychiatr Q 2021;92:715-20.
Yusoff MS, Mat Pa MN, Esa AR, Abdul Rahim AF. Mental health of medical students before and during medical education: A prospective study. J Taibah Univ Med Sci 2013;8:86-92.
Yusoff MS, Abdul Rahim AF, Baba AA, Ismail SB, Mat Pa MN, Esa AR. The impact of medical education on psychological health of students: A cohort study. Psychol Health Med 2013;18:420-30.
Dutheil F, Aubert C, Pereira B, Dambrun M, Moustafa F, Mermillod M, et al
. Suicide among physicians and health-care workers: A systematic review and meta-analysis. PLoS One 2019;14:e0226361.
Office of the Surgeon General (US); National Action Alliance for Suicide Prevention (US). 2012 National Strategy for Suicide Prevention: Goals and Objectives for Action: A Report of the U.S. Surgeon General and of the National Action Alliance for Suicide Prevention. Washington (DC): US Department of Health and Human Services (US); 2012. Available from: https://www.ncbi.nlm.nih.gov/books/NBK109917/
. [updated 2016 Apr 18; cited 2021 Feb 15].
Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, et al
. Suicide prevention strategies: A systematic review. JAMA 2005;294:2064-74.
Cwik MF, Tingey L, Wilkinson R, Goklish N, Larzelere-Hinton F, Barlow A. Suicide prevention gatekeeper training: Can they advance prevention in Indian country? Arch Suicide Res 2016;20:402-11.
Indelicato NA, Mirsu-Paun A, Griffin WD. Outcomes of a suicide prevention gatekeeper training on a university campus. J Coll Stud Dev 2011;52:350-63.
Cross W, Matthieu MM, Lezine D, Knox KL. Does a brief suicide prevention gatekeeper training program enhance observed skills? Crisis 2010;31:149-59.
Taub DJ, Servaty-Seib HL, Miles N, Lee JY, Morris CA, Prieto-Welch SL, et al
. The impact of gatekeeper training for suicide prevention on university resident assistants. J Coll Couns 2013;16:64-78.
Cimini MD, Rivero EM, Bernier JE, Stanley JA, Murray AD, Anderson DA, et al
. Implementing an audience-specific small-group gatekeeper training program to respond to suicide risk among college students: A case study. J Am Coll Health 2014;62:92-100.
Rallis BA, Esposito-Smythers C, Disabato DJ, Mehlenbeck RS, Kaplan S, Geer L, et al
. A brief peer gatekeeper suicide prevention training: Results of an open pilot trial. J Clin Psychol 2018;74:1106-16.
Nasir BF, Hides L, Kisely S, Ranmuthugala G, Nicholson GC, Black E, et al
. The need for a culturally-tailored gatekeeper training intervention program in preventing suicide among Indigenous peoples: A systematic review. BMC Psychiatry 2016;16:357.
Silva C, Smith AR, Dodd DR, Covington DW, Joiner TE. Suicide-related knowledge and confidence among behavioral health care staff in seven states. Psychiatr Serv 2016;67:1240-5.
Bean G, Baber KM. Connect: An effective community-based youth suicide prevention program. Suicide Life Threat Behav 2011;41:87-97.
Teo AR, Andrea SB, Sakakibara R, Motohara S, Matthieu MM, Fetters MD. Brief gatekeeper training for suicide prevention in an ethnic minority population: A controlled intervention. BMC Psychiatry 2016;16:211.
Smith-Millman M, Bernstein L, Link N, Hoover S, Lever N. Effectiveness of an online suicide prevention program for college faculty and students J Am Coll Health. 2020;1-8.
Stuart C, Waalen JK, Haelstromm E. Many helping hearts: An evaluation of peer gatekeeper training in suicide risk assessment. Death Stud 2003;27:321-33.
Nebhinani N, Kuppili PP, Mamta 3rd
, Paul K. Effectiveness of brief educational training on medical students' attitude toward suicide prevention. J Neurosci Rural Pract 2020;11:609-15.
King KA, Smith J. Project SOAR: A training program to increase school counselors' knowledge and confidence regarding suicide prevention and intervention. J Sch Health 2000;70:402-7.
Cheng J, Kumar S, Nelson E, Harris T, Coverdale J. A national survey of medical student suicides. Acad Psychiatry 2014;38:542-6.
Hawgood JL, Krysinska KE, Ide N, De Leo D. Is suicide prevention properly taught in medical schools? Med Teach 2008;30:287-95.
Yousuf S, Beh PS, Wong PW. Attitudes towards suicide following an undergraduate suicide prevention module: Experience of medical students in Hong Kong. Hong Kong Med J 2013;19:377-85.
Moutier C, Norcross W, Jong P, Norman M, Kirby B, McGuire T, et al
. The suicide prevention and depression awareness program at the University of California, San Diego School of Medicine. Acad Med 2012;87:320-6.
Reynolds CF 3rd
, Clayton PJ. Commentary: Out of the silence: Confronting depression in medical students and residents. Acad Med 2009;84:159-60.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]