Challenges in detecting and treating depression and a glimmer of hope in suicide prevention

Australian & New Zealand Journal of Psychiatry, 54(4) After a summer of bushfires, followed by floods and the continuing COVID19 pandemic, it is heartening to be able to read some positive findings about a possible suicide prevention programme. School students who participated in a teen mental health first aid course (tMHFA) were better able to recognise suicidality and use appropriate first aid interventions towards peers at risk of suicide. Hart et al. (this issue) conducted a cluster randomised crossover trial in high schools in which high school students either received tMHFA (three 75-minute sessions) or a physical first aid course of similar duration. An assessment of mental health literacy was made prior to the programme, immediately after the programme, and 12 months after training. The participants were assessed on the basis of their responses to a vignette about a fellow student with marked depressive symptoms and ‘ . believes his family would be better off without him’. The students who received tMHFA were more likely to recognise suicidality and apply appropriate first aid interventions (e.g. they asked about suicide, told him they noticed something was wrong with him and wanted to make sure he was okay, and suggested that he tell an adult) than the students who had received the physical first aid course. Remarkably, this suggests that providing even a brief four-session course in mental health first aid may go somewhere towards helping students recognising and providing appropriate first aid to their colleagues who may be expressing suicidal ideation. Such first aid programmes could easily be adopted in high schools equipping students with valuable skills that could lower the risk of suicide in this vulnerable group. However, it is important to note that while this shows some promise as a universal intervention, particularly encouraging help-seeking, it is of concern that the level of healthcare utilisation among suicide attempters is not optimal, as shown in a study from Austria (Niederkrotenthaler et al., this issue). Niederkrotenthaler and colleagues, using administrative data from lower Austria, examined the patterns of healthcare utilisation of patients diagnosed with the common mental disorders who had attempted suicide and compared them to those who did not attempt suicide. The former, those who had attempted suicide, had lower rates of healthcare utilisation (contacts with general practitioners [GPs]) prior to a suicide attempt. Furthermore, women attempters had high higher levels of contact with psychiatrists following an attempt, whereas male attempters had no increase in contacts with psychiatrists and their level of contact with GPs, in fact, dropped following the attempt. Those who attempted suicide had been prescribed higher levels of psychotropic medications (antidepressants and antipsychotics) and benzodiazepines, especially the male attempters. The authors discuss the reasons for this poor follow-up of such patients, including the point that such patients may be disinclined to seek a consultation or keep follow-up appointments. This is a critical issue for all of us and we need to be rigorous in ensuring such patients attend follow-up visits. The high levels of medication use, accompanied by lack of contact, suggest a lack of therapeutic engagement – perhaps because it is easier to write a prescription than invest time in developing a good therapeutic relationship that requires frequent contact. They also noted that there was a very low use of psychotherapy services following a suicide attempt suggesting once again that this too is an area of marked unmet need. Antidepressant use across Australia, and worldwide, has been increasing, but, as has been noted previously in this Journal, there has been no discernible decrease in the population prevalence of depression, begging the question: Are antidepressants being prescribed appropriately? Davidson et al. (this issue) examine this in a longitudinal cohort study of antidepressant use in primary care. The Diamond Study is a longitudinal cohort study of patients attending primary care in which 789 adult primary care patients with depressive symptoms were followed up for 2 years every 3 months Challenges in detecting and treating depression and a glimmer of hope in suicide prevention