Adolescent Suicide

Suicide Interventions

Physician Education Programs

Background

The majority of individuals who commit suicide have prior history of mental health problems. Unfortunately, many physicians are unskilled in diagnosing mental health disorders and managing them correctly. One approach, then, to decreasing the rate of youth suicide is to train physicians to diagnose and manage mental health problems better. Another is to improve the care of those presenting to hospitals with attempts.


Review of physician education programs:

Author

Aoun, 1999

Study design and target population

Rural Western Australia. 208 individuals who had attempted suicide (37%) or at risk of suicide (63%).

Before-after ecological design.

Intervention

Suicide prevention counselor, hospital protocol of best practices for suicide attemptors, professional and community education.

Outcomes

Re-admissions for attempts.

Results

The proportion of patients who were re-admitted for attempts decreased from 11.1% in the pre-intervention period to 3.6% in the study period. This is a 68% reduction.

Study quality and conclusions

Weak study design.

Only about 5% were <15%; 133% were 15-24 years.



Author

Van Heeringen, et al, 1995

Study design and target population

Randomized controlled trial of 516 suicide attemptors >15 years old treated in the ED in Belgium.

Intervention

Nurse home visits to improve compliance with outpatient care.

Outcomes

(1) Self-reported suicidal behavior 1 year later.

(2) Compliance with OPD care.

Results

Adjusted for gender, marital status, and history of attempted suicide, odds of non-compliance Int vs. control was .68 (95% CI.44, .89).

Odds of non-fatal suicide attempt was.58 (95% CI .30, 1.15) and for fatal was 1.05 (95% CI .34, 3.33)

Study quality and conclusions

Well done study, although there was a 24% lost to follow-up rate. This is tertiary prevention.



Author

Rihmer, Rutz, and Pihlgren, 1995

Study design and target population

Before-after study

General practitioners in Gotland, Suicide (Population 60,000)

Intervention

Two day training program for GPs on diagnosis and management of depression.

Outcomes

Proportion of suicide victims with depression before and after the intervention

Results

Before the intervention, the proportion of victims who were depressed was 42%; 2.5 years after the intervention it was 12% (OR=0.18, 0.02-1.09) and 9.5 years after the intervention it was 16% (OR=0.25, 0.09-0.74).

Study quality and conclusions

Before and after study without other control group is a weak study design. The outcome is only indirectly related to the appropriate outcome measure which is the rate of suicide.



Author

Rutz et al., 1989

Study design and target population

Before-after study with comparison of Gotland to Sweden as a whole. 

Intervention

Two day training program for GPs on diagnosis and management of depression in 1983-4.

Outcomes

Suicide rate in Gotland and whole of Sweden, 1982-1985

Results

Rate of suicide in Gotland decreased from 19.7 to 7.1 per 100,000 (reduction of 64%) compared to decrease from 25.5 to 24.8 (3%) in Sweden as a whole.

Examined as a 4 year floating average 1969-1985, there was a significant difference between Gotland and Sweden as a whole only in 1985.

Study quality and conclusions

There was a significant drop in Gotland after the introduction of the program, which was not seen elsewhere. However, since this was an ecological study, and was done in only one community, it is not certain that the program was responsible for the large effect.

Summary of physician education programs

The only data on these programs comes from the group in Sweden. Their earlier study appears to indicate an effect of the program on the suicide rate in Gotland compared to the rest of Sweden. However, conclusions about this intervention are severely limited by the fact that the only evaluation is an ecological one.

The one study on nurse home visiting to increase compliance with outpatient care was a good randomized controlled trial and it did find an effect. Given that this was done in another country with a different health care system, it bears repeating.

The study of interventions to improve care in the hospital to decrease recidivism is a very weak design and no conclusions can be drawn.

Recommendations on physician education programs

At present, this interventions to train physicians and to improve outpatient compliance look appealing and promising but lack of adequate data limit the ability to recommend them without further study.

Recommendations for future research

Physician education needs to be evaluated, preferably with an RCT, examining the impact of the program on suicide attempts. The data on physician behavior change are now mature enough to recommend strategies which could be used to insure that the program does change physician behavior; what needs to be tested is whether such behavior change results in decreases in suicide attempts and completion.