Introduction

Suicide is associated with a significant global burden; approximately 78% of suicides occur in lower and middle-income group countries, and it is commonly associated with psychiatric illnesses.1 There has been an alarming increase in the rates of suicide among students in India, from 5.5% of total suicides in 2010 to 7.6% in 2018.2 3 Patient-related factors such as poor help-seeking, stigma, and healthcare-related factors such as lack of skills in managing suicidal patients are some important barriers to prevention of suicide.4 Doctors play a pivotal role in the management of suicide attempters as well as the prevention of suicide. However, a significant proportion of doctors hold an unfavorable attitude toward suicide. Limited focus on suicide in the medical curriculum, stigma, and deficit in skills leading to decreased confidence are some of the reasons purported to be responsible for the negative beliefs about suicide.5 6

It was found that health personnel in Australia who had exposure to suicide prevention had a significantly better attitude toward suicide prevention.7 In Japan, it was found that a positive attitude toward suicide prevention and reduced critical comments about suicide was associated with higher clinical experience.8 A study on final-year medical students from Haryana found that almost two-thirds of the respondents had poor awareness about suicide, and only half had a favorable attitude toward suicide prevention.9 10 Similarly, 50% of nursing students in north India and Jodhpur harbored a positive attitude toward the prevention of suicide.11 12 The majority of these respondents in all the above studies had no exposure to any programs focusing on management or prevention of suicide.

There is limited literature about the efficacy of suicide prevention program from the Indian setting. There is only a single study done on 32 second-year medical students, which had assessed the effect of a training program (as part of clinical posting) on knowledge and attitude toward curbing suicide.13 With this background, the current study was aimed to assess the effect on the attitude of medical students toward suicide prevention through a brief training on the management of suicide attempters.

Materials and Methods

Results

At baseline, 243 students were enrolled with the help of convenient sampling. Majority of students belonged to the final-year MBBS course (n = 85) followed by second-year (n = 62), third-year (n = 57) and first-year (n = 39). At the end of the study, postintervention data on their attitude toward suicide prevention was available from 195 students, who had completed the intervention.

The sociodemographic data of the sample is documented in Table 1. The typical profile of the subjects was that of a male belonging to nuclear family residing in urban area. Nearly one-third of students had experience in managing patients with suicidal ideation.

The attitude of the students before the intervention is represented in Table 2. At the baseline, the majority of the respondents had a positive attitude toward the prevention of suicide with regard to most of the questions.

The attitude of the students after the intervention is represented in Table 3. The attitude strengthened further after the intervention, from (dis)agree to strongly (dis)agree. The students reported even lesser resentment, more responsible efforts, ease, competence, and expectancy on working for suicidal patients after the intervention.

The comparison of attitude of the students before and after the intervention is represented in Table 4. After the intervention, they considered the possibility of suicidal ideas emerging due to the need for help, not for the purpose of attention-seeking, and instead of considering suicidal communication as individual's choice, they agreed on substantial preventability of suicide with comprehensive management. Their misconceptions were resolved to a greater extent.

Discussion

The index study found that the brief intervention could improve the medical students’ attitude toward suicide prevention. The study also demonstrated the feasibility of carrying out a brief intervention for undergraduate medical students. A randomized controlled trial on brief intervention (as a part of project WHO Multisite Intervention Study on Suicidal Behaviors (SUPRE-MISS), similar to our study, delivered to suicide attempters and conducted in five countries demonstrated a significant reduction in deaths due to suicide.17

At the baseline, the majority of the students reported a positive attitude toward suicide prevention. This could be because nearly one-third of the respondents had clinical experience in managing patients with suicidal ideation. The greatest improvement in attitude was found in the statement that, “People are serious about committing suicide. They do not tell anyone.” About 24% and 73.8% of the students disagreed (either strongly disagree or disagree) to this statement before and after the intervention, respectively.

Significant improvement was noted in areas such as competence in assessment of suicidal ideation, attitude toward efforts for prevention of suicide, and attributes of patients with suicidal ideation. The study finding is in concordance with several studies. A study assessing the effectiveness of brief intervention of suicide prevention for clinical and nonclinical general hospital frontline professionals noted that the intervention resulted in improvement in attitude with the greatest improvement for the domain of competency.16 In Hong Kong, an intensive training about prevention of suicides consisting of decreasing stigmatization, negative appraisal, and enhancing sensitivity regarding suicide was performed for 2 weeks for third and final-year medical undergraduates.18 Positive attitude toward suicide was noted following the intervention.18 In the USA, significant improvement in suicidal risk assessment skills was noted in students who received case scenario-based training.19

However, an Indian study found that there was limited improvement in attitude about suicide prevention after the intervention, which consisted of interactive sessions, clinical interview, and role play supervised by a psychiatrist, and the majority of the respondents were not comfortable in assessing patients with suicidal ideation. This difference in findings could be due to difference in the baseline attitude of the students, which was largely positive, experience in managing patients with suicidal ideation, shorter duration of intervention as well as variation in mode of delivery of intervention.8

Our study was bound by certain limitations. The study findings cannot be generalized to other settings, as it was conducted in a single college in northwestern India. The attitude was assessed immediately at the end of the intervention. Studies with a longer follow-up period are warranted. Furthermore, the sample was predominantly male, and one previous study noted that girls had a greater negative attitude than boys about suicide.9 Hence, our study findings could be influenced by the sociodemographic profile.

Newer teaching and learning methods such as simulation, role plays instead of traditional lecture methods, need to be adopted.5 Culture-sensitive teaching methods for prevention of suicide can help in improving skills toward suicide. There is a need for studies assessing the effectiveness of such intervention in the hospital setting by assessing the suicide rates before and after the intervention.

Brief intervention on suicide prevention can be incorporated as a part of the medical curriculum to prevent untoward suicides. This can reap rich dividends in the form of improving the competency of medical students in the management of patients with suicidal ideation; moreover, they can act as gatekeepers whenever they encounter such individual or patient.20 Positive attitudes toward prevention of suicide amongst the medical students can lead to long-term outcomes in terms of early detection and timely referral to psychiatrists.

To conclude, brief training on the management of suicide attempters is feasible and was found to be effective in improving attitude on suicide prevention among undergraduate medical students. There is a vital need for multipronged efforts for effective suicide prevention, with a comprehensive approach incorporating regular training on suicide prevention and comprehensive management of suicide attempters in the medical curriculum.