Author’s Accepted Manuscript

Development of a 2-hour suicide prevention

program for medical staff including nurses and
medical residents: a two-center pilot trial

Yukako Nakagami, Hiroaki Kubo, Ryoko Katsuki,

Tomomichi Sakai, Genichi Sugihara, Chisako
Naito, Hiroyuki Oda, Kohei Hayakawa, Yuriko
Suzuki, Daisuke Fujisawa, Naoki Hashimoto, Keiji www.elsevier.com/locate/jad

Kobara, Tetsuji Cho, Hironori Kuga, Kiyoshi

Takao, Yoko Kawahara, Yumi Matsumura,
Toshiya Murai, Koichi Akashi, Shigenobu Kanba,
Kotaro Otsuka, Takahiro A. Kato

PII: S0165-0327(17)30724-3
DOI: http://dx.doi.org/10.1016/j.jad.2017.08.074
Reference: JAD9193
To appear in: Journal of Affective Disorders
Received date: 21 April 2017
Revised date: 26 July 2017
Accepted date: 27 August 2017
Cite this article as: Yukako Nakagami, Hiroaki Kubo, Ryoko Katsuki,
Tomomichi Sakai, Genichi Sugihara, Chisako Naito, Hiroyuki Oda, Kohei
Hayakawa, Yuriko Suzuki, Daisuke Fujisawa, Naoki Hashimoto, Keiji Kobara,
Tetsuji Cho, Hironori Kuga, Kiyoshi Takao, Yoko Kawahara, Yumi Matsumura,
Toshiya Murai, Koichi Akashi, Shigenobu Kanba, Kotaro Otsuka and Takahiro
A. Kato, Development of a 2-hour suicide prevention program for medical staff
including nurses and medical residents: a two-center pilot trial, Journal of
Affective Disorders, http://dx.doi.org/10.1016/j.jad.2017.08.074
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Development of a 2-hour suicide prevention program for medical staff including nurses

and medical residents: a two-center pilot trial

Yukako Nakagami, M.D. 1), Hiroaki Kubo, M.A. 2), Ryoko Katsuki, M.A. 2), Tomomichi
3) 1) 4),
Sakai, M.D. , Genichi Sugihara, M.D., Ph.D. , Chisako Naito, R.N., M.S.N.

Hiroyuki Oda, M.D. 3), Kohei Hayakawa, M.D. 2), Yuriko Suzuki, M.D.,M.P.H., Ph.D.
5)
, Daisuke Fujisawa, M.D., Ph.D. 6), Naoki Hashimoto M.D., Ph.D. 7), Keiji Kobara,

M.D. 8), Tetsuji Cho, M.D., Ph.D. 9), Hironori Kuga, M.D. 2), 10), Kiyoshi Takao, M.D. 2),
10)
, Yoko Kawahara, M.D. 6), Yumi Matsumura, M.D., Ph.D. 11)
, Toshiya Murai, M.D.,

Ph.D. 1), Koichi Akashi, M.D., Ph.D. 12), 13)

, Shigenobu Kanba, M.D., Ph.D. 2), Kotaro

Otsuka, M.D., Ph.D. 14), Takahiro A. Kato, M.D., Ph.D. 2) *

Affiliations:

1. Department of Psychiatry, Kyoto University Graduate School of Medicine,

Shogoin-Kawaharacho 54, Kyoto, 606-8507, Japan

2. Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu

University, Maidashi 3-1-1, Higashi-ku, Fukuoka 812-8582, Japan

3. Aso Iizuka Hispital, Iizuka, 3-83 Yoshio- machi, Iizuka, Fukuoka 820-0018, Japan

4. Integrated Clinical Education Center, Kyoto University Hospital, Patient Safety

Unit, Kyoto University Hospital, Shogoin-Kawaharacho 54, Kyoto, 606-8507, Japan

5. Department of Adult Mental Health, National Institute of Mental Health, National

Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo

187-8553, Japan

6. Department of Neuropsychiatry, Keio University School of Medicine, 35

 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan

7. Department of Psychiatry, Hokkaido University Graduate School of Medicine,

North 15, West 7, Sapporo 060-8638, Japan

8. Shimane Prefectural Counseling Center for Physical and Mental Health, 1741-3

Higashi-Tsuda-Cho, Matsue, Shimane 690-0011, Japan

9. Mie Prefectural Mental Medical Center, 1-12-1 Shiroyama, Tsu, Mie 514-0818,

Japan

10. Division of Clinical Research, National Hospital Organization, Hizen Psychiatric

Center, 160 Mitsu, Yoshinogari-cho, Kanzaki-gun, Saga 842-0192, Japan

11. Patient Safety Unit, Kyoto University Hospital, Shogoin-Kawaharacho 54, Kyoto,

606-8507, Japan

12. Clinical Education Center, Kyushu University Hospital, Kyushu University,

Maidashi 3-1-1, Higashi-ku, Fukuoka 812-8582, Japan

13. Department of Medicine and Biosystemic Science, Graduate School of Medical

Sciences, Kyushu University, Maidashi 3-1-1, Higashi-ku, Fukuoka 812-8582,

Japan

14. Department of Neuropsychiatry, School of Medicine, Iwate Medical University,

19-1 Uchimaru, Morioka, Iwate 020-8505, Japan

Contributors

T. A. Kato, K. Otsuka, Y. Suzuki, and D. Fujisawa contributed to the conception and

design.

T. A. Kato, H. Kubo, K. Otsuka, Y. Suzuki, D. Fujisawa, N. Hashimoto, K. Kobara, T.

Cho, H. Kuga, K. Takao, and Y. Kawahara contributed to the development of

intervention program.

T. A. Kato, H. Kubo, Y. Nakagami, T. Sakai, G. Sugihara, C. Naito, and H. Oda were

responsible for protocol of the study.

Y. Nakagami, T. A. Kato, H. Kubo, R. Katsuki, and K. Hayakawa contributed to the data

checking, analysis and interpretation of data.

Y. Nakagami and T. A. Kato drafted the article, and Matsumura, T. Murai, K. Akashi, S.

and Kanba, and K. Otsuka revised it critically for important intellectual content.

All the authors provided final approval of the version to be published.

*Correspondence To:

Takahiro A. Kato, M.D., PhD. (Associate Professor)

Department of Neuropsychiatry, Graduate School of Medical Sciences, Kyushu

University, Kyushu University

Address: Maidashi 3-1-1, Higashi-ku, Fukuoka 812-8582, Japan

Phone: +81-92-642-5627, Fax: +81-92-642-5644

E-mail address: takahiro@npsych.med.kyushu-u.ac.jp

Conflicts of Interest:

All the authors have no conflicts to declare.

Source of Funding:

This work was supported by a Grant-in-Aid for Scientific Research on (1) The Japan

Agency for Medical Research and Development (AMED)

(Syogaisya-Taisaku-Sogo-Kenkyu-Kaihatsu-Jigyo to T.A.K.), and (2) KAKENHI - the

Japan Society for the Promotion of Science (25461781 to K.O.).

Abstract (235 words):

Background: Suicide is a crucial global health concern and effective suicide prevention

has long been warranted. Mental illness, especially depression is the highest risk factor

of suicide. Suicidal risk is increased in people not only with mental illness but also with

physical illnesses, thus medical staff caring for physically-ill patients are also required

to manage people with suicidal risk. In the present study, we evaluated our newly

developed suicide intervention program among medical staff.

Methods: We developed a 2-hour suicide intervention program for medical staff, based

on the Mental Health First Aid (MHFA), which had originally been developed for the

general population. We conducted this program for 74 medical staff members from 2

hospitals. Changes in knowledge, perceived skills, and confidence in early intervention

of depression and suicide-prevention were evaluated using self-reported questionnaires

at 3 points; pre-program, immediately after the program, and 1 month after program.

Results: This suicide prevention program had significant effects on improving perceived

skills and confidence especially among nurses and medical residents. These significant

effects lasted even 1 month after the program.

Limitations: Design was a single-arm study with relatively small sample size and

short-term follow up.

Conclusions: The present study suggests that the major target of this effective program

is nurses and medical residents. Future research is required to validate the effects of the

program with control groups, and also to assess long-term effectiveness and actual

reduction in suicide rates.

Key words:
suicide prevention, depression, mental health first aid (MHFA), medical staff, nurse,

medical resident

Abbreviations:

MHFA, Mental Health First Aid; AMED, The Japan Agency for Medical Research and

Development; STORM, Skills-Based Training on Risk Management; CTR, Clinical

Trials Registry; PHQ, Patient Health Questionnaire; MTD, Modern Type Depression.
<Main Manuscript (3180 words)>

Introduction

Suicide accounts for over 800,000 deaths per year, which translates to 1.4% of all deaths

worldwide according to the World Health Organization (WHO) (World Health

Organization, 2014). As such, suicide is a crucial global health concern and effective

suicide prevention has long been warranted. In Japan, the annual number of suicide

victims was in excess of 30,000 from 1998 until very recently (approximately more than

20 per 10,000). In 2007, the Cabinet Office released the ‘General Principles of Suicide

Prevention Policy’, and promoted the establishment of systems for suicide prevention,

and a standard package of programs for suicide prevention (Nakanishi et al., 2015).

Suicidal risk increases by various physical illnesses such as cancer,

cardiovascular disease, multiple sclerosis, and peptic ulcer (Hawkins et al., 2016;

Hawton and van Heeringen, 2009; Lewis et al., 2017). In Japan, one of the most

common causative factors for suicide is health problems (Inoue et al., 2015). Among

patients admitted to general hospital, the suicide rate is approximately 3 times higher

than in the general population (Dhossche et al., 2001). Approximately 70% of people

who die by suicide are in contact with a general practitioner within the last month of

their lives (Andersen et al., 2000). Thus, medical staff caring for physically ill patients

are required to identify people with high suicide risk, and to provide an initial response.

Indeed, professionals in the general public health sector, including physicians, nurses,

and emergency care staff, are defined as a key player in the WHO suicide prevention

strategy (World Health Organization, 2012).

Based on the above evidence, suicide prevention programs for primary care
staff, especially for physicians, have previously been developed in various countries. In

Northern Ireland, a 150-minute educational program for general practitioners improved

knowledge of depression and its management (Kelly, 1998). In Canada, physicians

receiving a 3-hour case-based educational session had increased referrals to

psychiatrists and other mental health professionals (Worrall et al., 1999). Furthermore,

in Sweden, two 2-day programs which was offered to general practitioners succeeded in

reducing suicide rates by 60% (Rutz, 2001). A meta-analysis also indicated that suicide

prevention delivered by general practitioners decreased relative risk of suicide deaths by

0.78 (Milner et al., 2017). In addition to physicians, nurses and medical residents are

key players in suicide prevention due to their close contact with patients (Berlim et al.,

2007; Gilbody et al., 2003). However, nurses and residents often lack educational

training related to suicide prevention (Bolster et al., 2015; Kato et al., 2010), and

therefore tend to experience communication barriers in suicide management. For

example, some nurses fear that they might say something wrong, and remain silent

(Valente, 2011).

Thus, development of educational programs for not only physicians but also

nurses and medical residents is warranted to help patients at risk of suicide. In 2002, the

United Kingdom adopted a national suicide prevention strategy, and a suicide

prevention program called “Skills-Based Training on Risk Management (STORM)”

played an important role. After STORM training, which is usually completed in 1 to 2

days, medical staff including nurses and junior physicians had an improved attitude

toward suicidal people (Gask et al., 2006).

Due to time constraints common among medical staff which often constitute a

barrier in taking these programs (Chan et al., 2009; Magruder et al., 2015), shorter
educational programs are warranted. We previously developed a pilot 2-hour suicide

intervention program for medical residents (Kato et al., 2010), partially based on the

Mental Health First Aid (MHFA) (Kitchener and Jorm, 2002, 2006). MHFA is originally

developed as an 12-hour educational course that teaches participants (mainly, citizens)

how to identify, understand and respond to signs of mental illnesses, which gives

participants the skills needed to reach out and provide initial help and support to

someone who may be developing a mental health or experiencing a crisis. Five-step

principles of the MHFA (3rd version) are as follows: Step 1) Approach the person,

assess and assist with any crisis; Step 2) Listen non-judgmentally; Step 3) Give support

and information; Step 4) Encourage the person to get appropriate professional help;

Step 5) Encourage other support (Kitchener et al., 2013). As the main content of our

2-hour educational program, we have limited our focus on assessing and managing

people with depression, because the most prevalent disorder of those who die by suicide

is major depression (Botega et al., 2007; Hawton and van Heeringen, 2009; Rutz, 2001),

and depressed suicidal patients are cost-effective targets for suicide prevention

intervention (de Beurs et al., 2015a). This first pilot program was conducted among 44

new medical residents at a university hospital in 2008, and improved participants’

confidence in management of suicidal people (Kato et al., 2010). However, a

multi-center trial of this first pilot program has shown that the effectiveness of this

program was limited (Suzuki et al., 2014). Thereafter, we have conducted a process of

revising the educational program by modifying the lecture content and role-play

materials and have just completed development of the latest version of this program,

which can be applied for different types of staff including nurses, residents, and

physicians at the same time. In the present study, we conducted this updated program
among nurses, residents, and physicians in two hospitals (independently), and evaluated

its effectiveness on each professional group.

Methods

This study was approved by the ethics committees of Kyoto University and Kyushu

University, and was registered at the UMIN Clinical Trials Registry (UMIN-CTR)

(UMIN000018768 & UMIN000020133). We developed a modified training program on

suicide prevention, and examined its effect on medical staff as a single arm pilot study

in 2 general hospitals in Japan, namely, Kyoto university hospital (Site A) and Aso

Iizuka hospital (Site B; one of Kyushu University affiliated hospitals). In each hospital,

all the participants were recruited through official announcements such as e-mail and

posters. Participants in both hospitals received the same 2-hour program, consisting of

lectures and a role-play session. Participants answered self-rated questionnaires 3 times;

pre-program, post-program, and 1 month after the program. All the questionnaires were

anonymous, nonintrusive, and completed in privacy. All research subjects were

informed that participation was completely voluntary, return of the questionnaire

implied consent, and that results of questionnaires would be used for research purposes.

Program development

The original 12-hour MHFA program was established for non-health professionals in

Australia, composed of lectures and workshops, and has improved (1) knowledge of

mental health, (2) stigma of mental illnesses and (3) assistance approach toward people

with mental problems (Hadlaczky et al., 2014; Kitchener and Jorm, 2002). Based on the

12-hour MHFA program, we previously developed a 2-hour educational program for

medical residents especially focusing on dealing with patients with depression and

suicidal risk (Kato et al., 2010; Suzuki et al., 2014). Thereafter, in order to improve the
training program, round table discussions were conducted with organizers, facilitators,

and participants. Applying these outcomes, we further modified the program for medical

staff, including nurses, residents and physicians. Three major modifications are as

follows:

First, we updated the lecture content. Depressive symptoms such as insomnia

and loss of appetite are frequently observed during the course of depression even in the

early phase, thus such physical symptoms are possible signs of depression. We

encouraged participants to ask such symptoms first before asking mental symptoms

(Fujieda et al., 2017). We suggested to utilize checklists of depression such as Patient

Health Questionnaire (PHQ)-9. PHQ-9 is a 9-item measure of depressive symptoms,

developed by Kroenke et al. (Kroenke et al., 2001) and translated into Japanese

(Muramatsu et al., 2007). Item-9 of the PHQ-9 is also useful to assess suicidal risk

because item-9 directly relates to suicidal ideation (Simon et al., 2013). We focused on

Japan’s specific cultural, social, and biological factors related to depression and suicide

(Hayashi et al., 2015; Kanehara et al., 2015; Mostafazadeh-Bora et al., 2016;

Shirakawa, 2017). A novel form of depression, called “modern type depression (MTD)”

was added due to the increasing number of MTD patients among Japanese youth (Kato

et al., 2016; Kato and Kanba, 2016; Kato et al., 2011a; Kato et al., 2011b).

Second, we used video to demonstrate both inadequate and ideal ways of

listening and responding to a depressive patient.

Third, we increased and modified actual examples of communicating with

people with mental problems. Behavioral rehearsals and interview skills have important

effects on suicide prevention training (Cross et al., 2010; Palmieri et al., 2008), and this

revised program focused on practicing in actual suicide prevention interview skills

using role-plays (details in Table1). In developing the program, we utilized Japan’s

public research financial support from the Japan Agency for Medical Research and

Development (AMED), following the General Principles of Suicide Prevention Policy.

Measurements

Evaluation of changes in knowledge, skills, and positive attitudes such as confidence is

the optimal measurement in developing suicide prevention training (Duffy and Ryan,

2004). Thus, we used the following measurements to evaluate these 3 important

elements (knowledge-skill-attitude).

Knowledge

10 yes-or-no questions to evaluate knowledge of suicide prevention including;

knowledge of the causes of depression; suicide ideation; symptoms or signs of people

with depression and/or suicide ideation; general principles based on the MHFA suicide

prevention strategy such as approaching the person, assessing and assisting with any

crisis, and giving support and information.

Confidence

The confidence level in management of people with depression and with suicidal risk

was evaluated by 6 questions based on the MHFA strategy; 1) approaching a person

with symptoms of depression, 2) listening non-judgmentally, 3) conveying the

possibility of clinical depression, 4) giving support and information, 5) asking “suicidal

thoughts”, 6) encouraging the obtention of appropriate professional help. Participants

answered these 6 questions on a five point Likert scale, ranging from 1 (not confident at

all) to 5 (very confident) at all three time points.

Perceived skill

To evaluate self-perception of practical skills in early intervention of depression and

suicide-prevention in clinical settings, we developed original questionnaires using a

case vignette. The case of a 30-year-old patient called “Ms. M” at a participant’s facility,

with complaints of weight loss, insomnia, and sadness was presented as follows:

Ms. M is a 30-year-old office worker who is a patient at the medical facility

where you are employed. Formally a bright and sociable person she enters your

office with a gloomy expression. On the medical questionnaire she has only

written ‘difficulty sleeping for a month’ but when you weight her you discover

that she has lost 5kg. During the consultation she mentions that she has had

difficulty sleeping, is drowsy during the day, can’t concentrate on work and is

making mistakes, has no appetite, is not enjoying her food and is sometimes

suddenly overcome with sadness for no apparent reason.

You (respondent) consider Ms M’s current condition concerning.

Imagine you are in charge of Ms M. Would you deal with Ms M in the following

way or not?

As shown above, participants (respondents) imagined they themselves were in charge of

Ms. M, and answered the possibility of performing 8 questioned behaviors; each

question was originally developed to evaluate perceived skills for early intervention of
depression and suicide-prevention based on the MHFA strategy (Each question is shown

in Table 5 and Table S3A&B). The possibility of each behavior was rated using

5-grades indicating 0 (absolutely no), 1 (probably not), 2 (don’t know), 3 (probably

yes), 4 (absolutely yes).

Statistics

All analyses were undertaken using IBM SPSS 23 Advanced Statistics for Mac OS.

Results of knowledge, perceived skill, and confidence level were compared at

pre-program, post-program and 1 month after the program. Shapiro-Wilk test was used

to evaluate the normality of data, and revealed non-normal distribution. A one-way

repeated measures analysis of variance (ANOVA) is known to be reasonably accurate

even with non-normal distribution data (Plichta and Garzon, 2009), thus we used

ANOVA to identify any significant difference over time. Post hoc comparison tests were

performed in order to compare the data of pre-program, post-program and 1 month after

the program, when an analysis of variance model indicated a significant difference. The

value of p<0.017 using the Bonferroni correction for multiple comparisons was

considered indicative of statistical significance.

Results

Participants

In total, 74 participants (42 nurses, 20 residents, and 12 physicians) completed the

program and answered the 3-time points self-rated questionnaires both at Kyoto

University hospital (n=30) and Aso Iizuka hospital (n=44). Three-quarters of

participants (n=56; 76%) had no work experience in psychiatric departments. The basic

characteristics of participants were shown in Table 2. The following results are mainly

described based on the combined data of two hospitals.

Knowledge

Knowledge of suicide prevention was evaluated by 10 yes-or-no questions. The results

were demonstrated in Table 3 and Table S1A&B. Among nurses, better results were

found both at post program and 1 month after the program than that at pre-program.

Among medical residents and physicians, a high pre-program knowledge score was

observed and no statistically significant difference between 3 points was found.

Confidence

Self-confidence toward people in depressive/suicidal states based on the MHFA was

assessed in 6 areas. Changes of participants' confidence at 3 points were evaluated

(Table 4 and Table S2A&B). Confidence in all 6 areas had significant differences

between 3 points in nurses and residents. Nurses’ confidence in all 6 areas was

significantly improved even 1 month after the program. Residents’ confidence in all 6

areas was significantly improved after the program, and in 5 areas (except “listening

non-judgmentally”), revealed lasting improvement after 1 month.

In physicians, confidence in only one area “listening non-judgmentally”, revealed

differences between 3 points, showing significant improvement even 1 month after the

program.

Perceived skills

Self-perception of practical skills was evaluated by a questionnaire with an original case

vignette (Table 5 and Table S3A&B). The questionnaire on skills in early intervention

of depression and suicide-prevention based on the MHFA were divided into eight parts,

as described above. In nurses, almost all skills were significantly improved at

post-program and/or 1 month after the program. In residents, skills of “asking mental

symptoms”, “asking suicidal thoughts” and “telling probability of mental illness” (these

skills are based on the MHFA strategy of “Assess and assist with any crisis” and

“Giving support and information”), were improved significantly at post-program, and

especially one skill, “telling probability of mental illness”, showed statistically

significant improvement even 1 month after. Among physicians, one skill, “telling

probability of mental illness” improved significantly, at post-program, and 1 month

after.

Previous clinical experience in psychiatry may affect the present outcomes. Thus, we

performed subgroup analysis using the data of nurses with “work experience in

psychiatric department” (n=6) and without “work experience in psychiatric department”

(n=34). The data of residents and physicians were omitted from the sub-group analysis,

because of the small number of participants. At the pre-program stage, the group

without work experience showed lower confidence scores in some aspects, compared to
nurses with work experience. Just after the program, and 1 month after the program,

these scores were improved, having similar mean scores to nurses with work experience

(Table S4).

Discussion

This is the first report evaluating a MHFA-based brief suicide intervention program for

medical staff including nurses. We have revealed that the program significantly

improved self-perception of skills and confidence especially among nurses and medical

residents, with improvements lasting even 1 month after the program. Among

physicians, improvement in perceived skills and confidence was limited. In nurses,

knowledge of suicide prevention was increased even 1 month after the program.

Shorter duration of programs is often vital for the attendance of busy medical

staff, and such shorter programs can be easily conducted and popularized. The present

study demonstrated that our 2-hour program had a positive impact on participants’ skills

and confidence, and is much shorter than numerous programs previously reported. In

the United Kingdom, for example, an 8-hour training program for non-psychiatrically

trained staff such as primary care nurses and emergency room nurses, improved skills of

suicide risk assessment and management (Morriss et al., 1999). An 18-hour education

program in Hong Kong, and a 6-hour program in Brazil also revealed positive changes

in nurses’ attitude, awareness, and competency related to suicide prevention (Botega et

al., 2007; Chan et al., 2009). In the United States, gatekeeper training for nurses, which

includes 6 to 8 hours of online training, improved knowledge and attitude about suicide

(Bolster et al., 2015). Compared to the above-mentioned programs, we believe that our
developed program have a merit of shorter time duration (just 2 hours). On the other

hand, in the United States, a study among nursing students indicated the effectiveness of

a 90-min gatekeeper-training program for suicide prevention entitled

Question-Persuade-Refer (Pullen et al., 2016). Furthermore, in Taiwan, a randomized

controlled study revealed the effectiveness of a 90-min gatekeeper suicide-awareness

program (Tsai et al., 2011). We have summarized the outlines of the above programs

and our developed programs in Table 6. In order to spread our program to busier

medical staff, further research is needed as to whether our program can be modified

with much shorter duration and more effective outcomes.

Regardless of the different durations of suicide prevention programs, two types

of content are suggested to be important; the interview skills to detect suicidal intent

(Palmieri et al., 2008), and behavioral rehearsals (Cross et al., 2010). Our program

includes the above two items, which may be attributable to the positive effects even for

such a brief 2-hour course. Furthermore, we used video to demonstrate ideal behaviors.

Recently, such digital techniques, including online training, have been reported effective

(de Beurs et al., 2015b; Ghoncheh et al., 2016; Magruder et al., 2015). Proper use of

digital techniques improves accessibility and flexibility of suicide prevention training,

which would lead to more effective suicide prevention.

In the present study, effects of our program lasted for one month, which is

consistent with previous reports. Long-term effects of our newly developed suicide

prevention programs remain uncertain, and repetition of training which links training to

actual experience may be needed based on previous studies of other programs (Gask et

al., 2006; Isaac et al., 2009; Rutz et al., 1992). In addition, effects can last long if

participants use new skills regularly (Bowman et al., 1992). Based on these facts,
repeated participation in our program along with clinical experiences may be important

for achieving long lasting suicide prevention.

Nurses usually spend the longest time with patients, thus they are in a prime

position for suicide prevention (Berlim et al., 2007; Bolster et al., 2015; Gilbody et al.,

2003). On the other hand, nurses lack skills and confidence needed for suicide

prevention, as our results and previous studies indicated (Bolster et al., 2015; Valente,

2011). The same is the case with medical residents, as they also spend much time with

patients, while they often lack experiences, skills and positive attitudes toward suicide

prevention. Numerous previous reports also supported the importance and effectiveness

of targeting nurses and medical residents (Bolster et al., 2015; Botega et al., 2007; Chan

et al., 2009; Gask et al., 2006; Kato et al., 2010; Morriss et al., 1999; Tsai et al., 2011).

Thus, we believe that nurses and medical residents are the most important targets for

suicide prevention training with tools including our program.

Limitations

There are several limitations in our study. First, our study was a single-arm study, and a

randomized controlled trial is required to reduce biases. For example, there may be

selection bias in our study; all the participants were recruited voluntarily, and the

positive effect of our program may be attributable to their own motivation. Thus,

caution is required in generalizing our findings to medical staff lacking interest in

suicide prevention and/or depression. Second, the sample size was relatively small. To

reduce the impact of these limitations and enhance the validity of the present study, we

conducted this educational program at two independent hospitals. Third, self-reported

questionnaires may not reflect real attitudes/behaviors. Fourth, we do not have

long-term follow-up data. Larger and long-term follow-up randomized controlled trials

would be required to clarify effects of our program more precisely. In addition, actual

behavioral changes such as a decrease in suicide rates and an increase in psychiatric

referral rates should be evaluated.

Conclusion

In sum, the present study revealed the effectiveness of our newly developed 2-hour

suicide intervention program on nurses, residents, and physicians. Especially among

nurses and residents, the effectiveness was prominent, and improvement of confidence

and perceived skills remained one month after. For assessing long-term effectiveness,

further research is needed. This pilot study would be a crucial first step toward

developing more effective suicide intervention programs among medical staff. We

believe that our program improves the skills of medical staff to identify people with

high suicide risk, and provide an initial response, which will contribute to the reduction

of the suicide rate.

Acknowledgment:

The authors express gratitude to the following mentors and colleagues; Professor

Anthony Jorm and Ms. Betty Kitchener for their mentorship in Mental Health First Aid

program; Dr. Ryoko Sato, Dr. Kumi Aoyama-Uehara, Mr. Makoto Kamisaki, Ms.

Mayumi Otsuka, Ms. Hiromi Urata of Mental Health First Aid Japan (MHFA-J:

http://mhfa.jp) and Japan Young Psychiatrists Organization (JYPO:

http://www.jypo.org/), for providing us suggestion on the research activities.

Table 1. Brief suicide intervention program for medical staff (120 min in total)

I. Lecture session (50 min)

A) Lecture improving knowledge of depression and suicide (25 min)

Highlights:

1) At the beginning, participants watched a short video, which demonstrates an

inadequate way of listening, in order to elicit participant interest.

2) The high suicide rate in Japan, especially among physically ill patients was

presented.

3) A strong relationship between suicide, depression and physical illnesses was

emphasized.

4) Participants learned risk factors and signs of suicide and depression, and the

importance of identifying and managing people at increased suicide risk.

B) Introductory lecture on suicide intervention skills (25 min)

Instructors who took the MHFA training course in Melbourne taught suicide

intervention skills, which was modified to medical bedside settings.

Five-step principles of the MHFA (3rd version)

Step 1) Approach the person, assess and assist with any crisis

Step 2) Listen non-judgmentally

Step 3) Give support and information

Step 4) Encourage the person to get appropriate professional help

Step 5) Encourage other support

II. Role play session (70 min)

1) Role play in listening skills (20 min)

A pair of participants played a listener and a speaker in turn, in order to acquire skills

needed for listening non-judgmentally.

2) Demonstrating (15 min)

Participants watched an 8-minute video, in which a nurse and a medical doctor respond

to a depressive patient ideally using the five-step principles of the MHFA, followed by

small lecture and discussion.

3) Role play in a clinical setting (25 min)

Using a medical scenario, participants played the role of a medical staff and a patient

alternately, followed by evaluation and discussion.

4) Final Q&A time (10 min)

Table 2. Demographic data

Site A & B（ Kyoto Univ. hosp & Aso Iizuka hosp. ）

Nurses Residents Physicians

n=42 n=20 n=12

Sex (observed cases)

Male, n 6 10 8

Female, n 36 10 4

Age (observed cases)

Mean (S.D.) 38.74 (10.15) 26.35 (1.23) 36.58 (9.75)

Experience in psychiatry and/or psychosomatic medicine

Psychiatry, n 7 7 2
Psychosomatic medicine, n 0 0 0

Neither, n 34 13 9

Unknown, n 1 0 1
Table 3. Knowledge of suicide prevention
p-value
1-month Significance
Site A & B Pre Post (Repeated
later (ANOVA)
ANOVA)
Nurses (n=42) Mean 7.98 9.33 9.05 < 0.001 Pre < Post, Pre < 1-month later

SD 1.37 0.75 0.76

Residents (n=18) Mean 8.83 9.56 9.17 0.048 ――

SD 1.04 0.62 0.79

Physicians (n=11) Mean 8.82 9.55 9.55 0.062 ――

SD 0.75 0.69 0.69

All Participants (n=71) Mean 8.32 9.42 9.15 < 0.001 Pre < Post, Pre < 1-month later

SD 1.27 0.71 0.77 Post > 1-month later

ANOVA= analysis of variance

Table 4. Confidence level in management of people with depression and with
suicidal risk
p-value
1-month Significance
Site A & B Pre Post (Repeated
later (ANOVA)
ANOVA)
1. Are you confident to voice and initiate the support of a person with symptoms of depression? ( Approaching the person with

symptoms of depression )

Nurses (n=42) Mean 1.14 2.24 2.05 < 0.001 Pre < Post, Pre < 1-month later

SD 0.65 0.62 0.70

Residents (n=20) Mean 1.65 2.55 2.20 < 0.001 Pre < Post, Pre < 1-month later

SD 1.04 0.69 0.83

Physicians (n=11) Mean 2.73 3.00 3.09 0.342 ――

SD 1.10 1.00 0.83

All Participants (n=73) Mean 1.52 2.44 2.25 < 0.001 Pre < Post, Pre < 1-month later,

SD 1.00 0.75 0.83 Post > 1-month later

2. Are you confident that you are able to listen to a person with symptoms of depression at their own pace? ( Listening

non-judgmentally )

Nurses (41) Mean 1.63 2.44 2.27 < 0.001 Pre < Post, Pre < 1-month later

SD 0.66 0.67 0.71

Residents (20) Mean 2.00 2.55 2.35 0.024 Pre < Post

SD 1.03 0.60 0.81

Physicians (11) Mean 2.27 2.91 2.82 0.005 Pre < Post, Pre < 1-month later

SD 1.01 1.04 1.08

All Participants (72) Mean 1.83 2.54 2.38 < 0.001 Pre < Post, Pre < 1-month later

SD 0.86 0.73 0.81

3. Are you confident to directly convey the possibility of clinical depression to a person with depressive symptoms? ( Conveying

the possibility of clinical depression )

Nurses (42) Mean 0.88 2.05 2.12 < 0.001 Pre < Post, Pre < 1-month later

SD 0.77 0.76 0.74

Residents (20) Mean 1.20 2.35 2.25 < 0.001 Pre < Post, Pre < 1-month later

SD 0.83 0.88 0.72

Physicians (11) Mean 2.45 3.09 3.18 0.022 ――

SD 1.29 1.04 0.75

All Participants (73) Mean 1.21 2.29 2.32 < 0.001 Pre < Post, Pre < 1-month later

SD 1.03 0.90 0.81

4. Are you confident to provide information regarding depression to a person with depressive symptoms? ( Giving support

and information )

Nurses (42) Mean 0.95 2.33 2.19 < 0.001 Pre < Post, Pre < 1-month later

SD 0.76 0.85 0.67

Residents (20) Mean 1.65 2.70 2.40 < 0.001 Pre < Post, Pre < 1-month later

SD 0.99 0.92 0.94

Physicians (11) Mean 3.00 3.18 3.27 0.492 ――

SD 1.10 0.75 0.79

All Participants (73) Mean 1.45 2.56 2.41 < 0.001 Pre < Post, Pre < 1-month later

SD 1.13 0.90 0.85

5. Are you confident to directly ask a person with depressive symptoms whether they have suicidal thoughts? ( Asking
“suicidal thoughts” )

Nurses (42) Mean 1.10 2.02 2.10 < 0.001 Pre < Post, Pre < 1-month later

SD 0.79 0.84 0.79

Residents (20) Mean 2.00 2.85 2.30 0.001 Pre < Post, Post > 1-month later

SD 1.03 0.81 0.66

Physicians (11) Mean 3.09 3.27 3.09 0.650 ――

SD 1.22 0.79 0.94

All Participants (73) Mean 1.64 2.44 2.30 < 0.001 Pre < Post, Pre < 1-month later

SD 1.17 0.96 0.84

6. Are you confident to directly recommend the support by experts to a person with depressive symptoms? ( Encouraging the

obtention of appropriate professional help )

Nurses (42) Mean 1.76 2.50 2.48 < 0.001 Pre < Post, Pre < 1-month later

SD 0.85 0.83 0.74

Residents (20) Mean 2.05 2.90 2.65 < 0.001 Pre < Post, Pre < 1-month later

SD 0.94 0.64 0.81

Physicians (11) Mean 3.18 3.36 3.09 0.486 ――

SD 1.25 0.67 1.04

All Participants (73) Mean 2.05 2.74 2.62 < 0.001 Pre < Post, Pre < 1-month later

SD 1.05 0.82 0.83

Table 5. Self-perception of practical skills of suicide prevention
(Responses to a clinical case vignette setting)
p-value
1-month Significance
Site A & B Pre Post (Repeated
later (ANOVA)
ANOVA)
1. Do you ask M about her worries even if she doesn't mention any? [ Approach the person ]

Nurses (n=42) Mean 3.02 3.50 3.24 0.016 Pre < Post

SD 0.95 0.63 0.93

Residents (n=20) Mean 3.25 3.30 3.15 0.677 ――

SD 0.64 0.66 0.88

Physicians (n=11) Mean 3.55 3.64 3.55 0.735 ――

SD 0.69 0.50 0.52

All Participants (n=73) Mean 3.16 3.47 3.26 0.019 Pre < Post

SD 0.85 0.63 0.87

2. Do you ask M about her mental symptoms even if she doesn't mention any? [ Assess and assist with any crisis ]

Nurses (42) Mean 2.31 3.38 3.12 < 0.001 Pre < Post, Pre < 1-month later

SD 0.98 0.70 0.99

Residents (20) Mean 2.60 3.35 3.15 0.023 Pre < Post

SD 1.10 0.59 0.93

Physicians (11) Mean 3.09 3.45 3.27 0.494 ――

SD 1.04 0.69 1.01

All Participants (73) Mean 2.51 3.38 3.15 < 0.001 Pre < Post, Pre < 1-month later

SD 1.04 0.66 0.97

3. Do you convey sympathetic words regarding any psychological pain M is feeling? [ Listen non-judgmentally ]

Nurses (42) Mean 3.21 3.64 3.45 < 0.001 Pre < Post

SD 0.61 0.48 0.63

Residents (20) Mean 3.35 3.50 3.45 0.715 ――

SD 0.81 0.51 0.69

Physicians (11) Mean 3.64 3.73 3.73 0.297 ――

SD 0.50 0.47 0.47

All Participants (73) Mean 3.32 3.62 3.49 0.001 Pre < Post

SD 0.66 0.49 0.63

4. When you consider that there is a ‘high probability of some kind of mental illness’ do you convey this directly to M?

[ Give support and information ]

Nurses (42) Mean 1.62 3.29 3.26 < 0.001 Pre < Post, Pre < 1-month later

SD 0.99 0.60 0.59

Residents (20) Mean 2.50 3.45 3.20 0.002 Pre < Post, Pre < 1-month later

SD 1.10 0.60 0.70

Physicians (11) Mean 2.73 3.55 3.64 0.002 Pre < Post, Pre < 1-month later

SD 1.01 0.69 0.50

All Participants (73) Mean 2.03 3.37 3.30 < 0.001 Pre < Post, Pre < 1-month later

SD 1.12 0.61 0.62

5. Do you ask M if she has ‘suicidal thoughts’? [ Assess and assist with any crisis ]

Nurses (42) Mean 1.60 3.29 3.26 < 0.001 Pre < Post, Pre < 1-month later

SD 1.11 0.67 0.73

Residents (20) Mean 2.85 3.65 3.40 0.017 Pre < Post

SD 1.31 0.49 0.68

Physicians (11) Mean 3.55 3.64 3.27 0.266 ――

SD 0.82 0.92 1.01

All Participants (73) Mean 2.23 3.44 3.30 < 0.001 Pre < Post, Pre < 1-month later

SD 1.36 0.69 0.76

6. When M tells you that she has ‘suicidal thoughts’, do you firstly ask her the reason? [ Assess and assist with any crisis

( This question is not an appropriate behavior ) ]

Nurses (42) Mean 2.55 2.31 2.93 0.013 ――

SD 0.15 0.20 0.13

Residents (20) Mean 3.15 2.20 2.80 0.058 ――

SD 1.09 1.51 1.06

Physicians (11) Mean 3.18 2.36 2.64 0.218 ――

SD 1.33 1.63 1.43

All Participants (73) Mean 2.81 2.29 2.85 0.003 Pre > Post, Post < 1-month later

SD 1.10 1.39 1.01

7. Do you directly provide M with information that will facilitate a consultation by psychiatric or psychosomatic experts?

[ Give support and information ]

Nurses (42) Mean 2.64 3.50 3.36 < 0.001 Pre < Post, Pre < 1-month later

SD 0.88 0.59 0.53

Residents (20) Mean 3.25 3.35 3.45 0.642 ――

 SD 0.79 0.81 0.60

Physicians (11) Mean 3.45 3.82 3.73 0.038 ――

SD 0.69 0.40 0.47

All Participants (73) Mean 2.93 3.51 3.44 < 0.001 Pre < Post, Pre < 1-month later

SD 0.89 0.65 0.55

8. Do you directly recommend that M visit a psychiatric or psychosomatic department? [ Encourage the person to get

appropriate professional help ]

Nurses (42) Mean 2.26 3.21 3.14 < 0.001 Pre < Post, Pre < 1-month later

SD 1.08 0.72 0.65

Residents (20) Mean 2.90 3.30 3.40 0.231 ――

SD 1.25 0.80 0.94

Physicians (11) Mean 3.18 3.73 3.55 0.102 ――

SD 0.87 0.47 0.52

All Participants (73) Mean 2.58 3.32 3.11 < 0.001 Pre < Post, Pre < 1-month later

SD 1.15 0.72 1.12

Table 6. Summary of educational programs for suicide prevention and early intervention of depression
Author,
Country Target Duration Main outcome Program characteristics
Year
Kelly, Northern Improvement in knowledge of
General practitioners 2.5 hr Depression awareness seminar
1998 Ireland depression and its management
Worrall et Increased referrals to psychiatrists and
Canada Family physicians 3 hr Case based educational session
al., 1999 other mental health professionals
the four 2
Morriss et Non-psychiatrically trained staff including primary care Improved skills of suicide risk Interview skills training, using role play
United hour
al., 1999 nurses assessment and management with modeling and video feedback
Kingdom (8 hours)
twice
Rutz,
Sweden General medical practitioners 2-days Reduced suicide rates by 60% Educational and treatment program
2001
( 4 days)
the Skills-Based Training on Risk
Gask et usually 1 Positive changes in attitudes and
United Mental health care workers including nurses and doctors Management (STORM)
al., 2006 to 2 days confidence
Kingdom
Botega et
Brazil Nurses personnel working at a general hospital 6 hr Positive changes in attitudes Training program on suicide prevention
al., 2007;
Positive changes in awareness, and
Chan et Hong Education program on suicide prevention
Registered nurses 18 hr competency related to suicide
al., 2009 Kong based on reflective learning principle
prevention
Improved awareness of suicide warning
Tsai et al.,
Taiwan Nurses from a general hospital 1.5 hr and willingness to refer patients for A gatekeeper suicide-awareness program
2011
professional counseling
Kato et
Improved confidence and attitude,
al., 2010 Based on Mental Health First Aid
Japan Medical residents 2 hr although RCT did not reveal the
Suzuki et (MHFA)
significance of this effect
al., 2014
the
Bolster et Improved knowledge and attitude about Question-Persuade-Refer (QPR) for
United Nurses 6 to 8 hr
al., 2015 suicide Nurses
States
Pullen et the Increase in the understanding and Question-Persuade-Refer (QPR)
First-semester senior nursing students 1.5 hr
al., 2016 United comfort level with suicide prevention. Gatekeeper Training for Suicide
 States Prevention

Nakagami
et al.,
Medical staff Improved knowledge, skill, and Based on Mental Health First Aid
2017 Japan 2 hr
(nurse, resident, physician) confidence. (MHFA)
This
report
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Highlights:

 We developed a 2-hour suicide intervention program for medical staff, based on

the Mental Health First Aid (MHFA).

 This newly developed suicide prevention program significantly improved

perceived skills and confidence especially among nurses and medical residents.

 Futher validation with control groups is required to assess long-term

effectiveness and actual reduction in suicide rates.