|Year : 2016 | Volume
| Issue : 2 | Page : 85-87
Suicidality and mood disorders: Gatekeepers' training and mental health first aid
Rajesh Sagar, Raman Deep Pattanayak
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||4-Nov-2016|
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sagar R, Pattanayak RD. Suicidality and mood disorders: Gatekeepers' training and mental health first aid. J Mental Health Hum Behav 2016;21:85-7
|How to cite this URL:|
Sagar R, Pattanayak RD. Suicidality and mood disorders: Gatekeepers' training and mental health first aid. J Mental Health Hum Behav [serial online] 2016 [cited 2017 Dec 14];21:85-7. Available from: http://www.jmhhb.org/text.asp?2016/21/2/85/193424
The world suicide prevention day was observed on September 10, 2016, with a theme of "connect, communicate, care." While suicide prevention includes multi-level interventions - individual, societal, environmental, organizational, and policy, in this editorial, we aim to discuss the need and scope of training gatekeepers (including school teachers, college teaching staff, nonmental health professionals, and police personnel) and members from community in suicide prevention and to reduce the risk of suicidality associated with mood disorders.
As per the World Health Organization (WHO) estimates, over a million people commit suicide each year - that translates to one person every 40 s and about 3000 per day. , Globally, suicides account for 50% of all violent deaths in men and 70% in women.  Over the past decades, the problem and burden of suicide are shifting more to the Asian regions. In India, on an average, more than 100,000 persons commit suicide per year as seen in 2004-2014 decadal period.  Official figures are much lower due to underreporting of suicide, social stigma, and legal implications, and suicidal attempts are at least 20 times more common than suicides. Over a year, one-third of attempters repeat the behavior and nearly 10% eventually commit suicide. ,, Further, available research from Asia and South India indicates that the younger age groups may have a 4-5-fold higher prevalence of completed suicide than the global average. 
Suicide is potentially a preventable public health problem. A large proportion of suicides do take place in the context or background of a mood disorder, which often remains under-recognized in the early phases.  The onset of suicidal ideation usually heralds a severe depressive episode, requiring an immediate medical help; however, in view of associated symptoms such as psychomotor retardation or severe hopelessness, the suffering person may not ask or present for medical help.
Here comes the role of the trained members from educational institutes/workplace and volunteers who may work in the community more closely and may also be in the position of "gatekeepers." The mental health fraternity has made efforts toward community awareness for the past decades; however, training of gatekeepers and making them "partners" in delivery of mental health care are likely to expand the workforce and resources in mental health.
In the field of suicide prevention, the term gatekeeper refers to individuals who have face-to-face contact with large numbers of community members as part of their usual routine or who are in a unique position to identify and help a person at risk.  They may be trained to identify and refer the person in need of treatment or supporting services as appropriate. In addition to the "designated" gatekeepers (e.g., health professionals), the "emergent" gatekeepers (e.g., teachers, university staff, police, fellow students) are of interest to the gatekeeper programs. These have often focused on training school teachers or even students to act as gatekeepers for their peers. , It also appears to be feasible as well as effective for training police officers and workplace colleagues.  The gatekeepers are a position which could be advantageous for early detection and intervention. Further, depression being a common "condition," there are several misconceptions associated with it, which are better addressed by a trained member of the community. The incidents pertaining to self-harm and suicide are oft covered by media - both print and web. In spite of suicide being a commonly reported event in media, unfortunately, it is witnessed in the aftermath of the suicide or suicidal attempt that the focus solely remains on one or more proximal event, often associated with blame, initiation of legal proceedings, and lack of focus on other possible factors associated with suicidality. This link between clinical depression and onset of suicidal ideations - which is a frequent clinical encounter for those who work in the field of mental health - unfortunately, remains overlooked in the community. The lack of information and/or presence of several myths and misconceptions about psychiatric illnesses often lead to a "wall of resistance" to acknowledge the link - especially after the completion of the suicide. That is precisely why it is important to focus on this link "before-hand" rather than in the "aftermath" of suicide. There is a need to halt the progression of the undetected mood disorders, preventing at least a proportion, if not all, of the suicides.
The families of patients with a long-standing diagnosis of severe mood disorders may be better equipped to identify the mood symptoms or suicidal ideations, as opposed to the first episode or hitherto undiagnosed cases. For the first-episode individuals, the behavioral changes, even if identified, may at times be "rationalized" or "normalized" by those close to the patients. Suicidality may not be thought of as a medical or psychiatric issue, which may not be the case. All actively suicidal persons require a proper assessment and management.
WHO has also taken up a somewhat-related theme of psychological or Mental Health First Aid (MHFA) for the Mental Health Day, 2016.  This involves training of laypersons to detect the common mental health problems, provide basic support, and link to the mental help (look, listen, link). Internationally, the training and resources for MHFA are being provided by several agencies and organizations - akin to the concept of "physical first aid," basic life support and cardiopulmonary resuscitation training which is regularly imparted to community members. , At a community level, there is a room for improvement and expansion of the range of mental health first aid responses among people; for example, a large-scale national survey of 3998 adults (using case vignette approach) in Australia found that respondents could come up less often with some of the desirable responses, e.g. to assess the problem or risk of harm, to give or seek information. 
What should be the evidence-based components and formats of such trainings for suicidality? There should be a strong component of knowledge, including common signs and symptoms of mood disorders, early warning signs, effective help seeking, and mental health resources in addition to attitudinal aspects and intervention behavior, including enhancing self-efficacy to intervene.  A study by Cross et al.  found that QPR - question, persuade, and refer - training plus a standardized role-play exercise helped participants practice gatekeeping skills (such as the ability to ask directly about suicide, persuade the at-risk individual to accept help, and refer appropriately) both after the training and 6 weeks later.
The RAND corporation has developed a conceptual model of gatekeeping - which is consistent with Bandura's social cognitive theory, which posits the interactions between personal and environmental factors to influence the learning of new behavior.  In this context, the individual factors which may influence a person's decision to intervene for a suicidal person include (a) knowledge about suicide, (b) beliefs and attitudes about prevention, (c) stigma, and (d) self-efficacy to intervene.  Evidence suggests that these factors can be effectively targeted through the gatekeeper training. For example, Signs of Suicide Prevention Program (SOS) is a universal, school-based gatekeeper training designed for middle-school (ages 11-13) or high-school (ages 13-17) students who incorporate suicide awareness with a brief screening for depression and other risk factors associated with suicidal behavior. The didactic component of the program is based on the action steps ACT - acknowledge, care, and tell (a responsible adult). Three months after the intervention, students who received training had significantly higher declarative knowledge about depression and suicide than those in the control group.  Recently, these findings were replicated and extended using a more rigorous design, whereby it was found that the exposure to the SOS program resulted in greater knowledge of depression and suicide and more favorable attitudes toward (a) intervening with peers and (b) getting help for themselves. In addition, the high-risk SOS participants, those with a lifetime history of suicide attempt, themselves were less likely to report suicidality in the 3 months, following the training compared to lower-risk participants. 
Research evidence is available to establish that gatekeeper training can improve knowledge, beliefs/attitudes, self-efficacy, and reluctance to intervene. The transfer of knowledge, beliefs, and skills learned in training to actual intervention behavior is, however, largely unstudied. Large-scale cohort studies in military personnel and physicians have reported promising results with a significant reduction in suicidal ideation, suicide attempts, and deaths by suicide.  There is, however, need for more randomized controlled trials in the field. It has been seen that the posttraining interventions may be more effective if they include the some of the important themes such as a social network-connecting with other gatekeepers, continued learning, community outreach, reminders-ongoing communication, and enhancing previous training. 
Where and how to begin? Before one begins, there is a need to analyze and assess several of these factors. First of all, it is important to know about the community per se - their mental health perceived/felt needs, sensitivities, prevalence of mental health problems, existing services, etc. Next prudent step would be to identify the stakeholders in the community, which may include community leaders, local religious/leadership, police and security personnel, civic organizations, hospitals, and educational institutes. Next would be to assess and anticipate the logistic and pragmatic aspects of conducting the programs to gatekeeper trainings, including the resistance if any which may be faced from prevalent social, cultural aspects. Another crucial step would be to find the partners to collaborate and support. The toolkit for mental health aid/gatekeeper training in detection of depression and its warning signs of severity and suicidality should be formulated using the available evidence-supported components, after linguistic and cultural adaptations for better acceptability. Finally, in order for above to work, there needs to be policy support for conducting the training for gatekeepers for mental health issues, including for depression and suicidality, at a larger scale. The targets need to be set to cover a minimum percent or proportion of population, which can thereafter assist in a gradual dissemination of knowledge and skills to other people for early identification and help seeking. For example, in Australia, over 1% of general population has received the gatekeeper training. 
In recent years, the focus is increasing shifting toward the generation of evidence in the settings from low- and middle-income countries, including Sri Lanka and India. A study by Colucci et al.  aimed to develop guidelines for India on how a member of the public should provide MHFA to a suicidal person, in consultation with some of the Indian mental health clinicians using Delphi consensus. Of a total of 168 items generated, 71 met the consensus criterion and translated. However, there is a huge need to have a larger consensus among Indian experts on gatekeeper training/mental first aid, with inclusion of more widely representative expert panels, from various states and mental health fields, and users.
To conclude, there is an immense, potential role of training gatekeepers who are often in a unique position to detect the early signs of clinical depression, identifying the warning signs and risk for suicidality. They are also important stakeholders and we need to create opportunities to make them effective "partners" in mental health care by training them in early identification, mental first aid, and support and refer/link to a mental professional.
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