Promoting suicide prevention : an evaluation of a programme for training trainers in psychiatric clinical work

The overall goal of this thesis is to evaluate a 200-hour academic postgraduate educational intervention programme in suicide prevention at Karolinska Institute developed and implemented by the Swedish National Centre for Suicide Research and Prevention of Mental Ill-Health (NASP). Twenty-nine key persons working in 11 psychiatric intervention clinics in Stockholm County took part in the programme. The question studied was whether participating in the programme enabled them to implement suicide-preventive activities in their clinics and to enhance their co-workers' knowledge, perception of clarity in work and positive attitudes towards attempted-suicide patients. Staff working in 11 psychiatric clinics in Stockholm County without participants in the programme served as controls. Opportunities for and obstacles to implementation of suicide-preventive activities after staff have taken part in the training-of-trainers programme are discussed.

Questionnaires were used before and after the implementation of suicide-preventive activities to assess their effects on co-workers of key persons taking part in the training-of-trainers programme. At baseline, a questionnaire was sent to a random sample of 1,724 mental- health professionals working in 11 intervention and 11 control clinics in Stockholm County. At follow-up, one and a half years after the end of the course, the same questionnaire was sent to the 1,0 10 staff members who had completed it at baseline, resulting in a panel of 617 respondents.

At baseline, fewer than half the staff working with suicide attempters on a regular basis in both intervention and control clinics considered themselves sufficiently trained for this work. At follow-up, knowledge as well as the confidence in work had improved significantly among staff working in intervention clinics (especially among assistant nurses and staff employed in clinics where extensive suicide-preventive activities were implemented), while no change was found for controls. Moreover, at follow-up staff working in intervention clinics reported significantly more clarity in work with attempted-suicide patients than staff in control clinics.

The impact of the programme on staff attitudes towards attempted-suicide patients was assessed by means of questionnaires that were found to be relevant and valid when measurement models proposed by other authors were cross-validated and new proposals tested using structural- equation modelling with LISREL. Assistant nurses in intervention clinics reported significantly more positive attitudes towards attempted-suicide patients and suicide prevention, after the intervention programme, than their counterparts in the control clinics.

Excess mortality due to suicide is reported among staff in mental healthcare. In this thesis, the reported prevalence of suicidal thoughts and suicide attempts among psychiatric staff was compared with that in the general population at baseline. Identical questions were addressed to these two groups in the same year. Lifetime prevalence of suicidal thoughts and suicide attempts, standardised by age and gender, was significantly higher among mental-health professionals than among the general population. No difference was found for past-year prevalence.

The training-of-trainers model appears to be an effective way to disseminate knowledge of suicide prevention from a few suicidologists to a small number of key persons and subsequently to a large number of their colleagues in mental healthcare.

List of scientific papers

I. Ramberg IL, Wasserman D (2000). Prevalence of reported suicidal behaviour in the general population and mental health-care staff. Psychol Med. 30(5): 1189-96.
https://pubmed.ncbi.nlm.nih.gov/12027053

II. Ramberg IL, Wasserman D (2003). The roles of knowledge and supervision in work with suicidal patients. Nordic Journal of Psychiatry. [Accepted]

III. Ramber IL, Wasserman D (2003). Benefits of implementing a training-of-trainers model to promote knowledge and clarity in work with psychiatric suicidal patients. Archives of Suicide Research. [Accepted]

IV. Aish AM, Ramberg IL, Wasserman D (2000). Measuring attitudes of mental health-care staff towards suicidal patients. Archives of Suicide Research. 6: 309-23.

V. Ramberg IL, Wasserman D (2003). Training-of-trainers programme in suicide prevention - enhancing assistant nurses positive attitudes towards suicide attempters. [Manuscript]

VI. Ramberg IL, Wasserman D (2003). Suicide-preventive activities in psychiatric care: evaluation of an educational programme in suicide prevention. Nordic Journal of Psychiatry. [Accepted]