Effectiveness of Gatekeeper Training and the Implementation of Evidence Based Practice Guidelines for General Practitioners in the Prevention of Suicidal Behaviour: a Controlled Study

Many people who are suicidal (thoughts, plans, attempts) do not seek treatment. A survey (Bruffaerts, 2011, conducted among 21 nationally representative samples, n=55.302), showed that 44% of people with suicidal thoughts do not receive treatment. Low perceived need was the most important reason for not seeking help (45%). Most important barriers to seeking help were attitudinal (54% of suicidal respondents): a preference for self-reliance, believing spontaneous recovery will occur without treatment, thinking the problem is not that severe, believing the treatment will not be effective, and fear of stigma. Individuals with higher education and income have higher odds to seek treatment. It is clear that suicidality impedes help seeking. One can even state that the inclination not to seek help is one of the core symptoms of the suicidal syndrome (Kerkhof, 2010). "Suicidal thoughts typically are transient in nature, those experiening a suicidal crisis may simply try to ride it out until the crisis abates" (Bruffaerts et al, 2011). People experiencing suicidal thoughts typically feel pessimistic and hopeless and so may not have positive expectations thet treatment will help them. Shame and fear of stigma may even lead suicidal individuals to reject any form of help. Persuading suicidal individuals to contact a GP and to accept referral to mental health care are therefore important first steps in the prevention of suicide. Although suicidal individuals may feel reluctant to reveal their suicidal ideation, they are generally happy to reveal their despair when invited to by a trusted person, and to accept initiatives from others. Careful questioning after suicidal despair appears to be appreciated and may open doors for further treatment. Consumers report high satisfaction with the gatekeeper skill, competence, and comfort with the subject of suicide after QPR training. In the Netherlands 1,400- 1,600 people commit suicide (CBS) annually, around 100,000 attempt suicide (Trimbos, 2006, 2011), around 14.000 of them contact the emergency department (Kerkhof et al, 2007, RIVM, 2008) and 462,500 suffer from suicidal ideation (Trimbos, 2006, 2011). The corresponding disease burden equals 231,000 disability adjusted life years (DALYs) (RIVM, 2011). The proposed study envisions the evaluation of an intervention which is directed at the various health care professionals (general practitioners and community facilitators) who may act as gatekeepers in early recognition of suicidality, persuasion and referral of at risk people in the community This project addresses three questions in three studies: 1. Is gatekeeper training effective in enhancing relevant skills? 2. Does the intervention impact on rates of (attempted) suicides at regional level? 3. Is the intervention cost-effective relative to routine medical care? 1. For the intervention we will make use of the implementation of the new Dutch Evidence Based Practice Guidelines (Van Hemert et al, 2011) and the QPR method (Question, Persuade, Refer) pioneered by Knox et al (2003) in an approach toward large-scale suicide prevention. A skills training program for the gatekeepers will be offered in the experimental regions Amsterdam and Friesland. The training is designed to enhance knowledge and skills to cope with suicidality in GP's and gatekeepers by improving the recognition of 'at risk' people, offering consultation on how to engage with suicidal persons, persuade, and make appropriate referrals to the specialised health care. The effectiveness of the gatekeeper training will be evaluated in a randomised clinical trial in two parallel groups, one experimental where the trainees receive the gatekeeper training and one to serve as a control condition where aspirant trainees will be waitlisted. 2. It is hypothesized that in the experimental regions the suicide rates and the rates of attempted suicide will drop. Therefore the key-outcome will be the numbers of registered suicide attempts and completed suicides. These data can be collated from hospital records or directly from Statistics Netherlands (CBS). The data will allow pre-intervention and post-intervention comparisons within hospitals, thus eliminating possible biases stemming from registration artefacts within hospitals. 3. For the last research question on the cost-effectiveness of the intervention we will make use of CBS registration of suicides while attempted suicides will be extracted from the data files of the emergency wards of general hospitals. The costs of offering the intervention at regional level will be computed and combined with the outcome data to model the incremental cost-effectiveness of the intervention relative to care as usual. If this gatekeeper and GP training would lead to a 25% reduction ath the local level, implementation on a national scale would translate into 3,000-4,000 fewer suicide attempts treated in hospitals annually, and 350-375 fewer suicides.