Training General Practitioners in Bulgaria to Reduce Suicide Rate
Condition: Suicide
MeSH terms: Suicide
Study type: Interventional

Summary: 
      The purpose of this project is to improve the management of suicide and common mental
      disorder by general practitioners (GPs) in Bulgaria in order to reduce the suicide rate in
      intervention regions. The study uses a natural experiment design which utilizes a training
      program aimed at improving the GPs management of suicide risk and detection of common mental
      disorders. The training program will be offered to four regions (North East, South West,
      South Central, South East), leaving two regions for control (North Central, North West), in
      order to evaluate the effect of the intervention.
    

Detailed description: 
      The purpose of this project is to improve the management of suicide and common mental
      disorders by general practitioners (GPs) in Bulgaria. The study uses a natural experiment
      design which utilizes a training program aimed at improving GPs management of suicide risk
      and detection. The training program will be offered to four regions (North East, South West,
      South Central, South East), leaving two regions for control (North Central, North West), in
      order to evaluate the effect of the intervention. Thus, the study's outcome variable will be
      suicide rate, while region will be study unit.

      The project is a collaboration between The National Centre of Public Health and Analysis
      (NCPHA) and The Norwegian Institute of Public Health. In short, NCPHA is responsible for
      coordination, management and implementation, while The Norwegian Institute of Public Health
      (NIPH) will provide advice for highest possible quality and effect of the intervention. The
      NIPH will also evaluate the training program, which will be used to train the GPs to improve
      their skills in the management of suicide risk, and the recognition and treatment of anxiety
      and depression.

      The suicide rate is higher in Bulgaria compared to several other European countries (WHO,
      2015). It is well known that patients often contact their GP days or weeks prior to suicide
      (Luoma, Martin, & Pearson, 2002). There is also some evidence suggesting that improved
      management of suicide risk by GPs may successfully reduce suicide rates in the general
      population (Mann et al., 2005; Pfaff, Acres, & McKelvey, 2001; Rutz, Vonknorring, & Walinder,
      1992).

      This project will test if an improvement of skills and knowledge in general practitioners
      (GPs) may reduce the suicide rate in Bulgaria. There are several studies indicating that this
      might have positive effect on suicide rates (Hegerl, Althaus, Schmidtke, & Niklewski, 2006;
      Mann et al., 2005; Nock et al., 2008; Pfaff et al., 2001; Rutz et al., 1992; Szanto, Kalmar,
      Hendin, Rihmer, & Mann, 2007; Székely et al., 2013; WHO, 2014), however there are also
      studies showing limited evidence for effective suicide prevention interventions and a need
      for further investigation (du Roscoat & Beck, 2013; Robinson, Hetrick, & Martin, 2011).

      The best method for testing effects is a randomized controlled trial. However, we are unable
      for practical reasons to randomize, hence the project is set up as a controlled trail, where
      the north east and northern part of Bulgaria serves as the control group for the intervention
      group being the remaining other four districts of Bulgaria. The regions are selected by the
      NCPHA on the basis of practical considerations, not within our control.

      The aim is to deliver the intervention to 1650 GPs and 350 social workers and psychologists
      in these four regions. GPs in the control regions are not supposed to receive the
      intervention. The purpose of the trial is to explore if this intervention may reduce the
      suicide rate and the rate of attempted suicides in areas where GPs participate in the
      training program, compared to the control areas. GPs and health professionals is emphasized
      because with increased knowledge and skills, these professionals may be able to improve
      treatment and recognition of anxiety and depression in their patients, and they may also be
      able to improve their management of suicide risk.

      The intervention will be implemented during January 2016 until June 2016, and effects will be
      evaluated by trajectories of suicide rates for the period 2012-2018. The suicide rate is 10.8
      per 100 000 inhabitants per year according to the WHO (WHO, 2015). From this, we would expect
      529 suicides in the intervention area and 227 in the control area per year, presuming no
      effect of the intervention, equal suicide rates in the regions, and a 70/30 distribution of
      the population between these regions.

      Intervention: The intervention consists of two components, Phase I. Distance learning and
      Phase II. Seminars.

      Phase I: Distance learning will be based on a web-based system with login features. The login
      feature will include reading material and active learning strategies, e.g. videos and tasks.
      There is evidence to support that active learning strategies is more effective in improving
      GPs' attitudes, behaviors and skills than passive learning strategies, such as provision of
      reading material. Some highly cited reviews (Michael, 2006; Prince, 2004; Shellman & Turan,
      2006) of active learning strategies (e.g. actors role-playing patients) conclude that there
      is evidence that active learning strategies have an improved effect on learning compared to
      passive learning (e.g. lectures). In addition, active learning also receives more positive
      feedback and higher attendance rates than passive learning approaches. Employing active
      learning is not necessarily excessively time-consuming (Fenwick, Vassilas, Carter, & Haque,
      2004). In fact, evidence suggest active learning is a more time-efficient approach in terms
      of educational outcomes for participants (Haidet, Morgan, O'Malley, Moran, & Richards, 2004).
      Video is an effective medium in communicating clinical skills and techniques, compared to
      written material only. Videos are also included with the purpose of motivating the GPs for
      staying in the learning program and demonstrating good clinical practice with "fake"
      patients. There will be features in the website checking that the GPs have actually started
      the video clips. The main purpose of the written material is to provide practical tools for
      the GPs in their clinical management. Thus, they are to include practical questions for the
      GP to ask the patient in the management of suicidal behavior or common mental disorders. In
      addition, some of the texts will be more oriented towards extending GPs' knowledge about
      suicide, suicidal behavior and common mental disorders. To increase the likelihood that the
      intervention will be effective the login feature will include the possibility for GPs to
      communicate with lecturers and each other by an internal e-mail system. To keep track of
      website activity the technical subcontractor which is responsible for the website will
      prepare reports on a weekly basis with information on how frequently the various parts of the
      website is used. The GPs are incentivized to participate in the intervention by "certificate"
      and "credits". To receive certificate or credits it is required that the GP has (a) viewed
      and opened relevant sections on the website, (b) passed a test (e.g. multiple choice), and
      (c) participated in the seminar.

      Phase II. Seminar: The seminar will last for two and a half days. Participation will be
      rewarded with a course certificate. Successful recruitment to these seminars is also related
      to the payment of the sub-contractors. There is, as cited above, evidence that practical and
      active participation in real live sessions are more effective ways of learning than simply
      reading of a screen. So the seminar of about 18-22 hours is the major part of the
      intervention. The seminars will disseminate the key learning goals for the seminar.

      Learning goals: The purpose of this project is to improve the management of suicide risk,
      anxiety and depression by GPs. Consequently, the GPs are expected to learn some practical
      skills, useful techniques, and also change attitudes and reduce stigma, and ultimately change
      and improve clinical practice.

      The main learning goal is to improve management of suicide risk, and also improve recognition
      and treatment of common mental disorders. The learning goals will be restricted to suicide
      risk and depression, general anxiety disorder and panic disorder diagnosis. GPs will also
      learn what not to do in order to decrease potentially harmful practice. The achievement of
      these goals is based on a combination of activities, including reading material, watching
      video and attending lectures.

      Documentation of effects of the intervention: The effect of the intervention is to be
      measured by a controlled trail with intervention and control groups. The main outcome of this
      trail is the development of the suicide rate in the intervention regions compared to the
      control regions, and this information will be based on registry information of suicide rates.
      Data will be analyzed on aggregated level by region and time only, and not with any attempt
      to link suicide or patients to GPs.

      Power analysis: The incidence of suicide is about 10 in 100000 in the general population per
      year. The outcome will be monitored during 24 months follow-up starting just after the
      intervention has been implemented long enough to expect an effect. The study has 75 percent
      power to detect a reduction in suicide rate from 20 in 100000 per two years follow-up to 17.5
      in 100000, with a 1-sided test (alpha = 0.1). In other words, among the 2000 GPs attending
      the training, there will be about 800 suicides during the 24 months follow-up period. The
      trail has 75% power to detect a significant (p<.05, 1-sided) effect if the number of suicides
      among GPs being trained is reduced from 800 to 700 during the observation period. We will
      also analyse suicide attempts, which is about four times more common than suicide.
    

Intervention name(s): Training program
Intervention type(s): Other
Intervention description(s): An internet based training program will be offered to GPs. We will also offer face-to-face seminars with academic psychiatrists.
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: General Practitioner; Training Program