Research paperEffectiveness of General Practitioner training to improve suicide awareness and knowledge and skills towards depression
Introduction
According to the World Health Organization, worldwide over 800,000 people die by suicide every year (WHO, 2014). About 90% of all suicides occur in the context of psychiatric disorders, with depression being the most prominent risk factor (Hegerl et al., 2009; Mann et al., 2005; Yoshimasu et al., 2008). Commonly, persons who died by suicide had contact with healthcare services in the year before their death, with higher rates of contact for primary care providers than for mental health services (Luoma et al., 2002).
It has repeatedly been reported however that about half of patients with depression in primary care are not diagnosed as such and hence do not receive adequate treatment (Cepoiu et al., 2008, Fernandez et al., 2007). Reported barriers to the detection and adequate treatment of depression include patient-related factors such as vague somatic complaints, co-morbidity, lack of insight and reluctance to psychiatric diagnosis or medication treatment (Richards et al., 2004, Simon et al., 2004, Telford et al., 2002). In addition, several General Practitioner (GP) related factors have been reported to hinder adequate depression management such as limited knowledge of depression, unease to inquire about psychosocial issues, and negative attitudes towards depression (Richards et al., 2004).
Assessment of suicide risk receives even less attention by GPs. When suicide completers or attempters contact their GP in the period preceding their attempt, suicidal thoughts or behaviors are addressed in only a small minority (Houston et al., 2003, Luoma et al., 2002, Marquet et al., 2005, Richards et al., 2004). In only 3% of those who died by suicide, the GPs’ patient record reports about suicide risk (Houston et al., 2003). When the GP is consulted after a suicide attempt, suicidal thoughts and risk of future attempts are explored in only half of the cases (Richards et al., 2004). Suicide warning signs may not be blatant enough to arouse the GP's concern, as suicidal people ask for help in indirect and ambivalent ways (Schulberg et al., 2004). The majority of GPs lack sufficient knowledge about suicide and perceive themselves as poorly skilled in dealing with suicidal patients (Aoun, 1999, Hawgood et al., 2008, Palmieri et al., 2008). GPs should become more sensitive to subtle suicide warning signs and take the lead in making such issues debatable (Bennewith et al., 2002; Marquet et al., 2005).
Unfortunately, formal training in suicide prevention is absent for most graduate programs of medicine and the large majority of GPs have not undertaken postgraduate training in this area (Bajaj et al., 2008, Hawgood et al., 2008, Palmieri et al., 2008). Training programs for GPs aiming to improve their capacity to detect and treat depression and suicide risk are one of the few evidence-based strategies in the field of suicide prevention and therefore widely recognized as worthwhile and highly recommended (Hegerl et al., 2006, Hegerl et al., 2009, Kaplan et al., 2001; Mann et al., 2005; Miret et al., 2013; Zalsman et al., 2016; WHO, 2012).
In the last decades, several studies evaluating the effectiveness of education programs for GPs showed promising results, with trainings producing increased knowledge and self-efficacy, more favorable attitudes towards depression, improved detection and treatment practices, and increased use of non-medical treatment of depression (Gerrity et al., 2001, van Os et al., 2002). Moreover, intensive GP training has been found to improve patient outcomes and to reduce suicides rates (Henriksson and Isacsson, 2006, Rutz, 2001, van Os et al., 2004). Few studies, however, have been conducted within an international perspective and hardly any study demonstrated the effects of GP training in the longer term.
The current study draws upon data of the Optimizing Suicide Prevention Programs and their Implementation in Europe (OSPI-Europe), a large scale European research project (7th Framework Program of the EU) that ran from 2008 till 2013. The overall aim of the project was to evaluate the effectiveness of a multilevel suicide prevention program. One of the levels of the program concerns the training of GPs’ suicide awareness and knowledge and skills towards depression in four different regions in Europe (Hegerl et al., 2009). The evaluation of this activity, which relies on a single group pre-post research design, is the main focus of the current paper. The present study aims to examine: (1) whether the GPs’ attitudes towards depression and suicide prevention, and confidence to deal with suicide and depression improve after following an education program; and (2) whether the newly acquired competencies are maintained after three to six months follow-up.
Section snippets
Participants
As part of the OSPI-Europe multilevel intervention, a standardized training program about depression and suicide was provided to 304 GPs in four OSPI-Europe intervention regions: Amadora (Portugal), Leipzig (Germany), Limerick (Ireland), and Miskolc (Hungary). In Ireland, a large number of GPs received the OSPI-Europe training program (n = 96) however due to limited capacity no evaluation could be conducted of the participating GPs.
Intervention
The content of the training program provided participants with
Response rate
Across the three intervention countries, baseline data were collected from 208 GPs who attended training. Immediately after training the response rate reached 91.8%, while at three to six months follow-up 55.8% of GPs responded on the questionnaires.
Participants’ characteristics
Table 1 presents the characteristics of the GPs who participated in the study. Most of the participating GPs were female, older than 45 years, with more than 20 years of experience. The number of participating GPs slightly differed across countries
Summary
Prior to training, GPs had several stigmatizing attitudes towards depression and its treatment, as was measured with the DAQ. The majority of GPs perceived depression as a natural part of being old, a way that people with poor stamina deal with life difficulties, and a characteristic that is not amenable to change. Moreover, GPs showed little optimism about the treatment of depression. They were convinced that there is little to be offered to those depressed patients who do not respond to what
Acknowledgments
The authors wish to thank Claire Coffey, researcher at the National Suicide Research Foundation, University College Cork, who contributed to the implementation of this study in Ireland as well as Katrin Gottlebe, Nadine Sonnabend and Anita Maehner, who were involved in the project and training program in Germany. We further wish to thank all GPs who participated in the OSPI-Europe training sessions and took time to complete the questionnaires as well as all trainers involved in the OSPI-Europe
Funding
The OSPI-Europe project has received funding from the European Community's Seventh Framework Program (FP7/2007–2013) under grant agreement no 223138.
Ethical approval
The OSPI-Europe research project is executed in accordance with the principles laid down in the Helsinki Declaration (2000). The research protocol was approved by the ethics commissions of all participating countries.
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