A Comparative Study of Attitude of Mental Health Versus Nonmental Professionals toward Suicide.

BACKGROUND: Suicide is a major public health problem. Suicide can be prevented by understanding the disorder. Attitude plays a significant role in doing so. AIM: To assess the attitudes of mental health professionals and non-mental health professionals towards an act of suicide and to compare the two groups regarding their attitudes.
MATERIALS AND METHODS: A semistructured questionnaire having yes/no type questions was administered to 30 mental health and 30 nonmental health professionals. A blind analysis of the data was done. STATISTICAL ANALYSIS: Comparative analysis using mean and standard deviation and analysis of variance was performed to rate significance in differences of responses to questions that rate attitudes.
RESULTS: The results show a significant positive attitude of mental health professionals toward dealing with the patients who attempted suicide. DISCUSSION: Considering the magnitude of the problem, simple training and education of nonmental health professionals can change their attitude toward patients who attempt suicide, which in turn leads to an optimal management.
CONCLUSION: The study shows that the mental health professionals are much more positive in their approach towards a patient of parasuicide.

INTRODUCTION

Suicide is emerging as an important cause of mortality.[1] The alarming figures given by World Health Organization and various other surveys[2] make it imperative to examine its various aspects. Suicide is the 11th leading cause of death in adults, 4th leading cause in children, 3rd important cause in young people aged 15–24 years, and it accounts for 30 000 deaths per year.[34] Individuals who survive an act of suicide run a risk of reattempt, and that too of high lethality.[5]

Clinical decision making is influenced by a complex interplay of patient–clinician interact ional, sociocultural, and contextual variables.[6] The management of a patient trying to commit suicide should be based on theoretical and empirical judgments; unfortunately, research shows that ‘irrelevant’ factors can also affect the clinician's judgment, e.g., patients attractiveness, socioeconomic status, and values of treating professionals.[6] These factors can interfere in the proper management and follow-up of patients who are at risk of attempting suicide, and this can serve as an impediment in prevention strategies.[5]

Clinicians belonging to specialities, other than mental health professionals, are frequently contacted by individuals who are contemplating an act of suicide;[7] hence, they serve as an important link in the management and prevention of suicide. In a recent study, it has been shown that nonmental health professionals form an important link in the management and prevention of suicide.[3] An active liaison between mental and nonmental health professionals can serve to decrease the rate of suicide.[8] A study of attitudes of mental health and nonmental health workers can show the loopholes in the proper assessment and management of this problem; subsequently, it can also highlight the need for training and education of this important group (namely, nonmental health professionals). A limited number of studies on this subject are available, and practically scant literature from India has prompted the present study.

MATERIALS AND METHODS

Study design

The study was a prospective one. The study included a group of 30 clinicians from various departments dealing with emergency medicine, e.g., general medicine, surgery, neurology, anesthesia, neurosurgery, and orthopedics (group I). Thirty mental health professionals, e.g., psychiatrists, psychologists, psychiatric social workers, and psychiatric nurses, were included in the mental health group (group II). The study was conducted at a nodal multispeciality tertiary care hospital. The hospital is a central government-run hospital that caters to a large population of patients and serves as an important treatment center for a large catchment area. The study was approved by the ethical committee of the institute.

We employed a questionnaire used in another Indian study for measuring the attitude of clinicians of the emergency departments.[9] Since the emergency department is the first point of contact for a patient who attempts suicide, we chose the clinicians who attend to emergency cases. The clinicians were the trainee residents who are posted in the emergency department on a rotational basis or are called to attend to the emergency referrals. This questionnaire is a simple yes/ no self-reporting questionnaire and has 34 items. The questions are grouped under six factors that are related to ‘rejection’, ‘manipulativeness’, ‘understanding’, ‘helpful’, ‘acceptance’, and ‘anxiety’. The questionnaire sheets were given to the respondents after taking a written informed consent. The questionnaire sheets were collected from the respondents after 1 day. The responses were analyzed by clubbing the responses under the six factors. The identity of the respondents was kept confidential, and the first author (M.S.) was blinded to the group of the respondents, i.e., both mental and nonmental health groups. An exercise to examine the reliability of the instrument has been carried out by the previous authors and also by us, and the instrument has been found to be having a good reliability. Each participant was asked to give responses on the reporting sheet, and the data were analyzed by rating the ‘yes’ and ‘no’ responses. For the mental health group, we chose all the professionals who deal with the behavioral and psychological aspects of the patients.

Statistical Analysis

The data were analyzed by using SPSS version 13 for windows. The data were subjected to a comparative analysis by measuring mean and standard deviation between the factors; groups were again subjected to analysis of variance to find out the level of significance regarding the various factors. The factors were clubbed as ‘positive’ if they conveyed attributes such as empathy, concern, understanding, open mindedness, acceptance, and helpful behavior. ‘Negative’ attitudes were the ones that conveyed hatred, anger, indifference, manipulativeness. The factors were grouped under six broad factors as follows: Factor 1–acceptance; factor 2–understanding; factor 3–helpful behavior; factor 4–manipulativeness; factor 5–indifference; factor 6–rejection. The grouping was done on the basis of the predominant attitude being conveyed by the responses to the questions.

RESULTS

Thirty respondents filled the questionnaire in both the groups. The mental health group consisted of psychiatrists (n=8), psychologists (n=14), psychiatric social workers (n=6), and psychiatric nurses (n=2). In the nonmental health group, the respondents belonged to the nonpsychiatric clinicians, a majority of them from the department of general medicine (n=18) and the rest from the departments of surgery (n=4), neurology (n=6), and gynecology and obstetrics (n=2). Table 1 shows the t-test comparison of the two groups on the six significant factors (P=0.006–0.007). The nonmental health group showed significance regarding attitude toward management, but the positive attitudes toward the patient was lacking. Table 2 shows the presence of positive attitude in mental health professionals, namely, acceptance, understanding, and helpful attitude; the attitudes were significantly higher in this group. Table 3 shows the comparison between the various factors of the two groups; this reveals that the sixth factor of rejection is the most sensitive factor in order to understand the attitude of the two groups (significant=0.365), and this can have a negative effect on the clinician–patient interaction. Table 4 shows the correlation of factors of mental health professionals. The factor of acceptance is highly significant (significant=0.767). The attitude of acceptance leads to better patient response.

Table 1

Mean and standard deviation and t-test comparison between the two groups

Table 2

Comparison by analysis of variance

Table 3

Correlation matrix of six factors within the nonmental health professional group

Table 4

Correlation matrix of six factors within the mental health professional group

DISCUSSION

Our study gave results that were to some extent predictable. The mental health group was more positive toward handling the suicidal patients. On the other hand, the nonmental health group was more indifferent toward the suicidal patient. The factor depicting rejection was significantly higher in the nonmental health group. The mental health group deals with people undergoing stress and difficulties; hence, they are adept at addressing and discussing such issues and their training helps them in this aspect. The patients are dealt without any anxiety regarding issues of helplessness, despair, and nonadjustment. On the other hand, nonmental health professionals have not been trained to deviate from a ‘biological model’ of illness and try to understand the issues without letting the patient's emotional state interfere with the development of illness. The work pressure and their own anxieties can also act as deterrents for their ‘soft’ handling. Another major issue is the medicolegal aspect, which makes the procedure tedious and complicated. The exercise of handling the suicidal patient becomes an exercise of handling unnecessary paperwork rather than optimal assessment and management.[910]

An appropriate handling of suicide attempters is important as this group is vulnerable and at risk of reattempt and finally of completion of suicide.[1011] In India, culturally organophosphates serve as a common suicidal tool because of their easy availability. Suicide attempters automatically reach a general medical setup first.[12] The clinicians who form a part of the emergency team and are responsible for the management have to be trained adequately so as to bring about a positive change in their perception regarding mental illness and psychiatric patients, because the emergency department is the first point of contact and forms a link to reach the mental health professionals.[101314] It is noted that about 70% of all nonfatal self-inflicted injuries that come to an emergency setup are a result of unreported suicide attempt.[15] Asia contributes to 61% of all suicide cases worldwide.[2] This alarming figure is partly due to poor access to mental health facility and partly due to various other factors that are sociofamilial and cultural in nature.[16] One significant factor that is cited is the failure of nonmental health professionals to detect the possibility of suicide, because of negligence and insecurity as regards to the process of handling such patients.[17] Nonmental health professionals are frequently approached by the suicide attempters in a period between contemplation and completion that can even be within a year.[18] The above study also reported that men and older people frequently approached the services during the contemplation phase.[18]

The mental health professionals, namely, doctors, psychologists, psychiatric nurses, social workers, behaviorists, and especial educators, are equipped to assess and manage the suicidal patients. On the other hand, the nonmental health professionals can have a change in attitude toward suicidal patients as a result of education and training. This initiative can be helpful in prevention and in decreasing the risk of suicide attempt.[1619-22] A study done by Beautrais[23] showed that a positive change in attitude was observed when attitudes were compared before and after the educational training program.

If suicide is examined as a continuum, then it begins as an ideation, continues with planning and preparing and ends with threatening, attempting, and completion of suicide. This continuum can be interrupted at multiple places and thus prevention can be achieved.[1824]

Our study focused on an important negative factor of medicolegal complications, which is indeed a practical problem. This unnecessary paperwork and legal procedures serve as an impediment for the nonmental health professionals,[9] and a system needs to be evolved to address such issues. As far as the mental health group is concerned, by the time the patient reaches them the medicolegal issue has already been addressed; hence, they do not have to face the problems of legal formalities; therefore, this particular aspect is not a deterrent for mental health professionals.

Our study gives an indication that attitudes can be changed by a short training that can be incorporated during the internship period. Another aspect that needs to be highlighted is the active role of crisis intervention teams; this kind of addition to an emergency setup can decrease the burden on the clinicians of the emergency department, which can further translate into positive attitude toward the suicide attempter.[11] For patients at risk of self-harm, the crisis intervention team can serve as a link from the community outreach.[19]

In summary, suicidal patients form a special subset of all emergency referrals and this particular group can be helped to a large extent by minor changes such as positive handling, proper referral, and immediate crisis intervention by an expert team.[1] Our study had some important limitations. The tool used by us has yes and no responses; this could be improved by an instrument that has a scoring pattern as our respondents were sometimes not in agreement with the responses. The sample was small; hence, the generalizability of the data is limited. We would suggest that the study be carried out on a larger population and a pre- and post-training assessment of attitudes can be undertaken.