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127]

ORIGINAL ARTICLE

A novel approach to suicide

prevention – Educating when it matters
A B S T R A C T
Nimisha D. Desai, Background: Looking at the burden of suicide, there is a dire need for medical
schools to incorporate suicide prevention training. Effective communication helps in
Paragkumar Chavda1,
early detection and management of suicidal behavior. Medical students can act as a
Sandeep H. Shah, GATEKEEPER if they receive adequate training. Methodology: This was an educational
Nilima Shah2, intervention study done at tertiary care teaching hospital to assess the knowledge and
attitude of medical students toward depression and suicide and to impart and assess
Saurabh N. Shah,
communication skills for suicide prevention in one of the four batches of students
Elavatsala Sharma in 4th semester. Pretest was conducted to assess knowledge and attitude toward
Departments of Psychiatry and depression and suicide, followed by training using interactive lectures, demonstration
1
Community Medicine, Gujarat of interview, and hands‑on training with patients and role‑plays. The posttest
Medical Education and Research and objective structured clinical examination (OSCE) were administered for skill
Society Medical College, Gotri, assessment. Feedback was taken regarding this intervention. Results: The mean marks
Vadodara, 2Department of of the pre‑ and post‑test were 8.96 (8.3–9.6) and 14.58 (13.8–15.3), respectively,
Psychiatry, Smt N H L Municipal out of 25. The difference was statistically significant (t = 13.24, P ≤ 0.0001) which
Medical College, Ahmedabad,
suggests improvement in knowledge. We found mixed responses in attitude statements
Gujarat, India
showing limited change. Mean obtained marks on OSCE examination out of 66 was
42.7. Among various components of OSCE, students scored high on rapport building.
The most useful components of trainings were role‑play, OSCE, and interaction with
Address for correspondence: patients as per their feedback. Conclusion: The intervention was found effective in
Dr. Paragkumar Chavda, increasing knowledge, changing attitude, and enhancing communication skills of
Department of Community
medical students toward suicide prevention. Training of communication skills for
Medicine, Gujarat Medical
Education and Research suicide prevention in depressed person should be given to every medical student as
Society Medical College, suggested by feedback.
Gotri - 390 021, Vadodara, India.
E‑mail: paragchavda@[Link] Keywords: Communication skills, depression, medical students, suicide prevention

S uicide and that too in the adolescents and young

adults is an emerging global issue. It is more so in
the lower‑ and middle‑income countries and the same is
Asian countries. Considering the increasing burden, the
World Health Organization has declared the theme for
World Health Day 2017 on Depression with the slogan
reflected in India. Globally, one‑year period prevalence of “Depression: Let’s Talk.”[3] In India, community‑based
major depression is in range of 5%–6% of the population studies on depression are few and suggest a point
with a lifetime prevalence estimate at 11%–15%.[1] The prevalence ranging from 1% to 7% with a rising trend over
young adults, postpartum women, and elderly form the the years.[4] Currently, the reported suicide rate in India is
vulnerable group for depression worldwide. Suicide 11.5/1 lakh population with a rising trend.[5]
accounts for overall 1.4% of all deaths worldwide, but
there is a great variation in the proportion of suicide as The studies in primary health‑care settings in India have
cause of death across different age groups. Among young reported a prevalence of depression as high as 20%–40%
adults (15–29 years of age), suicide is the second leading
cause of death.[2] This is especially so among the Southeast This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
Access this article online which allows others to remix, tweak, and build upon the work non‑commercially,
Quick Response Code: as long as appropriate credit is given and the new creations are licensed under
the identical terms.
Website: [Link]
For reprints contact: reprints@[Link]

How to cite this article: Desai ND, Chavda P, Shah SH, Shah N,
DOI: 10.4103/ipj.ipj_10_18
Shah SN, Sharma E. A novel approach to suicide prevention – Educating
when it matters. Ind Psychiatry J 2018;27:115-23.

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Desai, et al.: A novel approach to suicide prevention

among all outpatient attendees.[4] A large proportion of consent was obtained from the students. All of the 32 students
these patients also remain undiagnosed. Studies also posted in this batch volunteered to participate in this training.
indicate that most of those who attempt suicide have seen
a primary care physician in the past 1 month. Doctors General setting
are the potential gatekeepers who will have contact with The study was conducted in department of psychiatry
high‑risk patients. In this scenario, it is very important of a medical college from Western part of India with
for every doctor to have the basic training in how to annual intake of 150 undergraduate medical students. In
deal with patients who are in distress and express death this college, psychiatry training includes a 2‑week clinical
wishes; this unfortunately is not a part of standard posting during the 4th semester, 20 h of didactic lectures
curriculum. Preventing suicide can depend on the ability during the 6th semester, and 2‑week posting in psychiatry
of caregiver to make judgments about a person’s suicide during internship.
risk status, and for that effective communication skill that
incorporate empathy, compassion, and nonjudgmental Intervention
listening are important. The earlier studies have also A specially designed training intervention was designed
recommended a need for capacity building of primary and administered.
care workforce on detection of depression in primary care
settings.[6] Looking at the rising burden of these diseases Pretest was administered on the first day of the clinical
and limited number of trained psychiatrists available in posting that included the knowledge and attitude
India, the involvement of primary care physician appears assessment.
to be an important strategy for prevention of depression
and suicide at population level. [7] In this direction, The special training intervention was administered
recently, there have been suggestions for increasing the over 4 days in the middle of clinical posting. Day 1 focused
exposure to psychiatry within the undergraduate medical on depression, day 2 on suicide prevention, and day 3 and
curriculum.[8] 4 focused on relevant role‑plays. Prior written permission
from indoor patients was taken to demonstrate an interview
In the current scenario, psychiatry forms a very small and be examined by students during intervention.
part of the curriculum and the teaching‑learning is largely
didactic.[9] The undergraduate medical students are often Posttest same as pretest and objective structured clinical
at a loss and feel uncomfortable and underconfident examination (OSCE) were conducted 1‑day before the
in dealing with patients who are in distress and who last day of clinical posting for knowledge, attitude, and
express suicidal thoughts. Further, due to the academic skill assessment.
stress of studying in medicine, many of these medical
Specially designed intervention is highlighted below:
undergraduate students themselves are also at increased
risk of depression.[10,11] Thus, there is a need for skill‑based Day 1: Focus on depression (total time: 3 h)
training of undergraduate students in suicide prevention. 1. One hour interactive lecture on depression
The proposed training intervention aims to improve 2. Demonstration of an interview with a depressed
the attitude of the trainee doctors toward suicide and indoor patient by a faculty member
equip them with necessary skills for communicating 3. Selected volunteer student’s interaction with the
with depressed suicidal persons and offering the correct patient in the presence of a faculty member followed
guidance and help to their peers and patients. The by feedback and suggestions.
objective of this research was to assess the effectiveness
of a training intervention on communication skills Day 2: Focus on suicide prevention (total time: 3 h)
for suicide prevention among undergraduate medical 1. One hour interactive lecture on suicide including
students. suicide risk assessment
2. Demonstration of interview with depressed suicidal
METHODOLOGY indoor patient by a faculty member
3. Selected volunteer student’s interaction with the
Study design patient in the presence of a faculty member followed
This was an educational intervention study among by feedback and suggestions.
undergraduate medical students.
Day 3 and 4: Role‑plays (total time: 6 h)
Approval from the Institutional Human Ethics Committee Clinical case vignettes about patients presenting with
was taken before the start of the study. Written Informed varying degrees of severity of clinical depression were

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Desai, et al.: A novel approach to suicide prevention

prepared and reviewed by independent subject experts. simulated patients. The chosen staff underwent a 2‑h
The students were asked to volunteer to take the role of training on role‑playing as simulated patients for the
either a patient or a doctor. Those choosing the patient’s OSCE stations. This training was declared completed
role were randomly assigned a clinical case vignette. only when all the trainer faculty unanimously reached
A total of 9 role‑plays were conducted in the presence of a consensus that the performance by the simulated
a faculty member who provided necessary comments and patients was satisfactory.  The students were observed
clarifications to enhance the learning experience of the on these stations by the subject expert (faculty from the
students based on their comments after role‑play. department). The checklist developed for the observers
rated each activity on 3‑point scale – done accurately,
Intervention evaluation done partially, and not done.
The evaluation was done by administering a newly
developed knowledge and attitude questionnaire and Station 1, 3, and 5 were simulated patient stations carrying
the OSCE station material which were validated by two 20 marks each. Station 2, 4, and 6 were question stations
external subject experts who were not part of the study in on the diagnosis and management of patient scenarios of
the following manner: the preceding stations, carrying 2 marks each. Details are
1. Knowledge assessment: Done using a 25 mark paper shown in Table 1.
consisting of essay type questions (5 mark) and
objective questions in the form of true/false (10 mark) The students were informed that the score on the
and multiple‑choice question (MCQ) items (10 marks). knowledge assessment and OSCE examination would not
The same questionnaire was used before and after the be counted toward their internal assessment. The scores of
intervention OSCE were shared along with scoring sheets with students
2. Attitude assessment: Done using 20‑item questionnaire for their self‑assessment at the end of OSCE exercise.
where each item was to be rated on a 3‑point Likert
scale and filled anonymously. The statements were Feedback on this intervention was taken from participating
taken from three validated scales, that is, revised students and faculty. Feedback from students was taken at
depression attitude questionnaire; Suicide Opinion two levels – for role‑play and for the complete intervention.
Questionnaire and Attitude Toward Suicide Prevention Feedback related to their level of comfort in role‑play as
Scale relevant to the aim of the study[12‑14] patient or as interviewer on a Likert scale was taken for their
3. Skills assessment: Done using a six‑station OSCE. roles, respectively, from the 9 pairs of student volunteers
Three procedure stations and three question stations for role‑play at the end of the day. In the feedback form,
were developed for OSCE. The materials developed open‑ended questions were also included to capture
for the OSCE were “simulated patient’s scenarios” students’ reflection on their experience in role‑play. Overall
and “checklists for the observers.” Case scenarios’ feedback on the training intervention was obtained from
scripts were created based on real clinical cases and all the students on a semi-structured proforma after the
incorporated details including patient’s background, posttest. Feedback was also obtained from four faculty
chief complaints, guidance on facial expression members who participated in the training intervention.
and eye‑to‑eye contact, and sample responses to
possible questions. Paramedical staff members of the Data analysis
department of psychiatry with at least 5‑year experience The quantitative data were entered in Microsoft Excel
of working in the department were chosen to serve as Worksheet and analyzed in SPSS 17.0 (IBM Corp., Armonk,

Table 1: Objective structured clinical examination station details

Stations Evaluated tasks Time duration (min) Marks
Station 1: Simulated patient of moderate Assessing symptomatology of case and suicidal thoughts 7 20
depression with suicidal thoughts assessment using interview and communication skills
Station 2: Question station Diagnosis and management of case station 1 (2 MCQ items) 2 2
Station 3: Simulated patient of mild depression Assessing symptomatology of case using interview and 7 20
communication skills and proper psychoeducation of
depression
Station 4: Question station Diagnosis and management of case station 3 (2 MCQ items) 2 2
Station 5: Simulated patient of severe Assessing symptomatology of case using interview and 7 20
depression with active suicide ideation and past communication skills and suicide risk assessment
history of suicide attempt
Station 6: Question station Diagnosis and management of case station 5 (2 MCQ items) 2 2
MCQ – Multiple‑choice question

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Desai, et al.: A novel approach to suicide prevention

New York, USA). Student’s t‑test was used for statistical Table 2: Demographic details of the participating
significance. The qualitative data obtained in the form of students (n=32)
students’ reflective feedback were processed manually by Frequency (%)
thematic analysis. Gender
Male 14 (43.8)
Female 18 (56.3)
RESULTS
Religion
Hindu 30 (93.8)
This section presents the details of the learning of the
Muslim 2 (6.3)
students in the domains of knowledge, attitude, and skills Domicile
and feedback from students and faculty on the training Rural 4 (12.5)
intervention. The demographic details of the participating Urban 28 (87.5)
students are presented in Table 2. Present stay
Hostel 16 (50.0)
Knowledge assessment Local 16 (50.0)
Table 3 shows the pre‑ and post‑test scores on the Family type
knowledge assessment of students. The posttest marks Extended 9 (28.1)
were significantly higher compared to pretest marks. The Nuclear 23 (71.9)
mean obtained marks for essay type questions were 0.2 and
2.7 out of a total of 5 in pre‑ and post‑test, respectively. For Table 3: Comparison of pre‑ and post‑test scores
MCQs, the difference was more with the mean obtained on assessment of knowledge of students
pretest marks at 2.7 and posttest marks at 4.3 out of 10.
Mean obtained Statistical significance
For true/false questions, there was little difference with marks (out of 25)
pretest mean marks at 6.1 and posttest marks at 7.6 out of Pretest (n=32) 8.96 (8.3‑9.6) t=13.24, P≤0.0001
10. On other variables of interest, namely, gender, religion, Posttest (n=31) 14.58 (13.8‑15.3) (statistically significant)
domicile, present stay, or type of family, there was no The range is defined by 2 standard errors on either side of mean
statistically significant difference.
suicide are caused by a weakened willpower and most
Attitude assessment suicide attempts are impulsive in nature, many felt that
Table 4 shows comparison of the responses of students there may be situations where suicide may be a reasonable
on pre‑ and post‑intervention attitude assessment. solution, many agreed that they would feel ashamed of a
suicide attempt by a family member, and many students
For some of the concepts, there was already a favorable
attitude from beginning which was reflected in pretest. Most could still not differentiate between a transient emotional
students opined that suicide prevention is their responsibility, distress and depression.
they can prevent suicide even when a person has made up a
Thus, unlike knowledge scores, the expected change in
strong mind for the act, there are warning signals preceding
suicide, some religious beliefs have a helpful role in suicide attitudes toward depression and suicide did not occur
prevention, even the young people may have stressors completely. This finding indicates that changing attitudes
strong enough leading them to suicidal ideation, and it is are not as easy as giving knowledge.
their business to prevent suicide and hence if approached
Skills assessment
they should intervene in a person’s life to prevent a possible
The skills assessment was done using OSCE as a posttest after
suicide attempt. Most students differed from the idea of
suicide clinics for painless suicide from the beginning. completing the training intervention. Each OSCE skill station
carried 20 marks with the subsequent question station of
The change seen due to the intervention can be described 2 marks. Thus, we clubbed together the marks from procedure
as – more number of students posttest were comfortable in and related question station for ease of understanding. The
talking with depressed person, were aware that suicide happens observation checklist on procedure station was divided into
with warning, and were found to be aware that the possibility four main components, namely, rapport building and empathy,
of a person repeating a suicide attempt is high. Negligible depression assessment, suicide risk assessment, and overall
number of students in posttest felt that people have a right approach. Figure 1 presents the mean marks obtained by
to take their own lives as against one‑third students in pretest. students on the three stations that ranged from 13.3 to 14.7
out of 22. Overall mean obtained marks were 42.7 out of 66.
There was not much change in some components – many Among various components of OSCE, students scored high
students even in the posttest felt that depression and on rapport building. We also analyzed if having taken part in

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Table 4: Comparison of pre‑ and post‑intervention responses on attitude assessment

Statements for attitude assessment Type of Agree Neutral Disagree
test
Unfavorable statements
Depression and suicide are caused only by weakened willpower Pretest 24 3 5
Posttest 16 11 4
Depression is a transient condition, resulted from emotional distress Pretest 30 2 0
Posttest 23 5 3
People with depression are hard to talk with Pretest 15 10 7
Posttest 7 7 13
Suicide prevention is not my responsibility Pretest 0 2 30
Posttest 0 0 31
People have the right to take their own lives Pretest 9 6 17
Posttest 2 9 18
Once a person has made up their mind about taking their own life no one can stop them Pretest 3 3 26
Posttest 2 4 25
There is no way of knowing who is going to commit suicide Pretest 3 6 23
Posttest 1 2 28
Most suicide attempts are impulsive in nature Pretest 16 12 4
Posttest 19 6 6
Suicide happens without warning Pretest 12 8 12
Posttest 1 5 25
People who attempt suicide are, as a group, less religious Pretest 1 11 20
Posttest 2 7 22
There may be situations where the only reasonable resolution is suicide Pretest 17 7 8
Posttest 16 6 9
I would feel ashamed if a member of my family committed/attempted suicide Pretest 20 9 2
Posttest 15 10 6
Suicides among young people, (e.g., students) are particularly puzzling as they have Pretest 2 1 29
everything to live for Posttest 0 1 30
If someone wants to commit suicide, it is their business and we should not interfere Pretest 8 7 17
Posttest 4 7 20
We should have suicide clinics where people who want to die could do so in a painless and Pretest 9 8 15
private manner Posttest 6 5 20
Once a person survives a suicide attempt, the probability of his trying again is minimal Pretest 8 9 15
Posttest 4 5 21
Favorable statements
Depression is a disease like any other (e.g., asthma, diabetes) Pretest 12 11 9
Posttest 22 4 5
People who usually commit suicide are usually depressed Pretest 20 7 5
Posttest 23 6 2
A large proportion of suicide is preventable Pretest 3 14 14
Posttest 2 12 17
I don’t feel comfortable assessing someone for suicide risk Pretest 25 6 1
Posttest 29 0 2

the role‑play affected their performance in the OSCE. There more comfortable playing their roles, performing in the group
was no statistically significant difference in mean OSCE score and being evaluated. However, two of them mentioned that it
among those who took part in role‑play and those who did not. was uncomfortable since the interview forced them to reveal
personal information. Two students also mentioned that the
Feedback from students interviewer failed to show empathy while many appreciated
Feedback from students who participated in the nonjudgmental attitude and patient listening by the
role‑play interviewer as depicted in the following narratives:
We conducted a total of 9 role‑plays with 9 doctor–patient
dyads. Figure 2 displays the quantitative part of the feedback. “At last, when as a patient I had a doctor to listen to me I
The students who played the role of patient found themselves felt comfortable, as patient has someone to talk to.”

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“As a patient, I was not that comfortable talking to the Overall, they felt that before this series of the role‑plays,
person in front of me everything about my problem and they were uncomfortable talking to patients with
my life…… on the other hand felt relieved and felt assured depression. They also feared that they may say something
that someone is there to listen to me quietly without which may increase the patient’s stress. With this series of
judging me” role‑plays, they found themselves more comfortable. They
also appreciated the role of nonverbal communication.
A larger proportion of students from the interviewer group One student mentioned,
found themselves uncomfortable during the role‑play as
can be seen from Figure 2. They expressed varied feelings “We were as good as a layman for interviewing such patients
about the role‑play which included the need for studying when we started this term, now at least we know something.
more about depression and suicide, importance of listening This is unlike medicine term where at the end of the term
and communication skills, and ensuring to take the history we are confident that we can take history from the patient.”
of suicidal ideation with depressed patient. Some of their
At the end of the role‑play, the number of students fully
responses in their own words:
satisfied with their performance in role‑play was more in
“The purpose of this activity  (is) fulfilled for me as it the patients’ group as compared to the interviewers’ group.
Majority also felt that they required some more clarity for
helped me get an idea of how to actually prepare myself,
participating in role‑plays.
although I think it would have been a lot better if I had
studied more on subject. Actually playing a role gives you Overall feedback from students at the end of training
an idea of the suffering, so it inspired me to study more This overall feedback was obtained from all students
and be well informed.” participating in this training. Table 5 displays the quantitative
part of the feedback. The most useful components of
“It was quite difficult to do role of doctor. I was very training as per their perspective were role‑play (n = 20),
nervous…………. but in between the role‑play I went OSCE (n = 9), interacting with patients (n = 4), and lecture
blank as I didn’t know what to ask. I was so nervous that on suicide (n = 1). Here are verbatim responses from a
I didn’t ask patient’s name and if she is having ideas about couple of students.
suicide. Overall there was a lot to learn from role‑play. It
was very good experience.” “The act of role‑playing was enjoyable as it not only
made us more aware of risk of suicide among depressed
“It was kind of awkward performing in front of class plus patients and how to deal effectively but also made us more
knowing that the patient is a dummy patient. So it was hard empathetic toward them.”
to show empathy knowing that sufferings were fake. If it
would have been real patient the concern and empathy “It helps us learn how to communicate with patient. We
would have come with flow.” learned from role‑play about how to react to patients and
how to question the patient.”

We also asked the students’ suggestions for further

improvement in this training intervention. Four students
mentioned to include more interaction with real patients.

Figure 1: Box and whisker chart on score obtained by students on

objective structured clinical examination assessment (n = 32) mean
is represented by middle value, boxes are 1 standard deviation on
either side of mean, and whiskers are minimum and maximum values Figure 2: Feedback from the students who acted in role‑play (n = 18)

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Table 5: Overall feedback from students regarding the intervention

Domain Statements Strongly agree Agree Neutral Disagree Strongly disagree
Training related Training useful for professional role 22 9 0 0 0
Objective clearly communicated 18 13 0 0 0
Significantly contributed to knowledge 19 11 1 0 0
Significantly contributed to skills 18 13 0 0 0
Role‑play is a suitable teaching method 18 13 0 0 0
Balance of theory and practical 19 11 1 0 0
Teacher related Stimulates interest in subject 17 14 0 0 0
Appropriate teaching techniques used 15 15 0 1 0
OSCE related Appropriate as per learning objective 12 19 0 0 0
More stressful and physically taxing 0 2 6 21 2
Fair means of evaluation and decreases 7 12 10 1 0
element of luck
OSCE – Objective structured clinical examination

One student suggested including videos. The other students part of India. Worldwide, there is an increasing focus
who made suggestions for improvement in their own on psychiatry curricula for undergraduate students. The
words; mental health issues have risen rapidly and formed a
large part of the disease burden in the West. In UK, the
“We gave appropriate focus on the Counselling part, but academia has also responded to this new challenge by
if we had more time, I would have loved to learn more incorporating changes in their curricula.[15] Studies from
aspects also.” Australia and Asia‑Pacific also suggest that there is need
to address inadequacies in teaching of depression and
“Yes, during role‑play I acted as patient. I would also like suicide in undergraduate curriculum.[16,17] With rapid
to be doctor but it’s not possible due to lack of time” change in lifestyle, we see similar movement of the
epidemic curve in South Asian counties now. However,
All students expressed that this should be made as routine our medical school curricula are yet to adequately address
in teaching. They expressed that the role‑play helped them this new challenge.[7] A survey in Australia among medical
to learn the communication skills and improved their schools, students, and general practitioners has suggested
confidence. the need for more structured and hands‑on component
on suicide prevention in medical curriculum.[18] Similarly,
Feedback from the faculty in India also the suggestions for improving the psychiatry
About the training education has been made at multiple levels; increasing
All the faculty members involved in the project suggested duration of exposure to psychiatry, making the teaching
that this should be implemented in future batches. They more skill based and focusing more on the primary care
felt that the skill‑oriented training (role‑plays and OSCE) psychiatry. The Vision 2015 document of Medical Council
was the strength of this intervention. The limitations of India (MCI) stresses on the revised curriculum to be
mentioned were that it is a time‑consuming task to address more skill and competency based. It has identified 5 roles
a moderately large batch size of approximately 30 students of an Indian Medical Graduate, one of which is the role of
in clinical posting using this intervention. a good communicator.[19] The revised version of graduate
medical education regulations from MCI has clarified the
Objective structured clinical examination
new vision of MCI in detail. It includes “the ability of
The feedback from the faculty suggested that the OSCE
medical graduate to assess the risk of suicide and manage
examination was well organized, it was in alignment with
appropriately” as one of the six core competencies under
the learning objectives, the scores provide a true measure
the department of psychiatry.[20]
of the clinical skill of student, and that it eliminates the
chance of bias in examination. As discussed earlier, the need to focus on the undergraduate
psychiatry curriculum is vital as it prepares the future
DISCUSSION basic doctor in dealing with the issues such as depression
and suicidal risk. Not only that depression is a substantial
We implemented a skill‑based training on recognition of proportion of the outpatient clientele in primary care
depression and suicide risk assessment among a small settings but the primary care physicians in such settings also
group of undergraduate medical students in Western have an unmet need for training to deal with such cases.  A

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Desai, et al.: A novel approach to suicide prevention

study from the USA shows that although the primary care development of culture‑specific clinical case vignettes.[28]
physicians perceive the severity of the depression correctly, Hence, in this study, we ensured to develop our own clinical
they are hesitant to perform suicide risk assessment.[21] case vignettes for role‑plays and OSCE stations rather than
using prepared vignettes available from other sources.
Lake traces the roots of failure of the primary care physician
in identification of suicide risk in the undergraduate Finally, there has also been innovations in teaching suicidal
psychiatry curriculum. He argues that since primary care risk assessment by innovative methods. Foster et al. have
physician has limited time available with them for the demonstrated feasibility and effectiveness of an interactive
mental health assessment of their patients, the medical virtual patient for teaching suicide risk assessment to
school should also train the students in ultra‑short medical students.[29] Such an exercise was beyond the scope
interviews for depression and suicide risk.[22] for a limited resource setting like ours.

There is a need to focus on the training methodology used

CONCLUSION
for psychiatric teaching. In our training intervention, we used
lectures, demonstration of interviews with real patients, and Overall, this training intervention on depression and
role‑plays. We could achieve substantial improvement in the suicide risk assessment for undergraduate medical students
knowledge scores and good improvement in attitude and was successful in increasing the knowledge of students
skills. A study from Hong Kong that used movie, discussions, on the topic. There was improvement in attitude of the
and skill‑based training to students showed good effect in students, yet there is the scope of improving it further. The
attitudes and a confidence in dealing with issues related to role‑plays and OSCE gave students hands‑on opportunity
suicide.[23] A study from Zimbabwe used simulation‑based at interviewing a patient with depression. The students
teaching on depression. Unlike our intervention, they trained found the training to be useful. They appreciated the
psychiatric nursing staff to play as simulated patients. They role‑play and OSCE the most among all interventions. They
reported increased confidence of students in assessing and wanted that this training be given more time and continued
managing depression.[24] Serial role‑playing to teach complex for subsequent batches. The faculty also accepted the merits
tasks such as suicide risk assessment has been described in of this new way of teaching and wanted to incorporate it
literature.[25] We invited students themselves to play the role in routine teaching.
of patient as well as a doctor in our study. In our study, not
only in pretest but also in posttest only a small proportion of Limitations
students reported to be comfortable assessing someone for The major limitation of the study was that it was conducted
suicide risk. The reason for this may be that in pretest they in a small sample and in a limited period. This was due to
were unaware about how to assess a patient for suicide risk, feasibility issues as the authors wanted to first understand
while in the posttest they realized that suicide risk assessment the changes that can be brought about by such an exercise.
is challenging task which calls for considerable amount of The intervention is also time‑consuming and will be a major
communication skill. limitation when done on a larger scale.
The reason for limited change in the attitude may In our intervention, we wanted to locally develop videos
be because of the limited time the students spend in for helping students learn the psychiatric interview but that
psychiatry. We need to explore the ways to address could not be completed because of the limited availability
this issue of attitude change. A study of impact of of time. While there are successful attempts at use of
psychiatry posting on attitudes toward mental illnesses already available movies for helping students learn about
and psychiatry among students shows positive change in suicide and its prevention,[30] we intend to use them in
attitude toward psychiatry but not much change in attitude future batches of this training. Another limitation of our
toward mental illnesses.[26] A randomized trial from China intervention was that we could not provide opportunity
compared lecture and lecture + self‑directed learning on to each student in role‑play during the teaching sessions.
knowledge and attitude toward depression among medical However, each student underwent OSCE assessment with
undergraduates. They found lasting change in knowledge feedback.
and attitude in self‑directed learning group.[27] The reason
for this could be that they used the medical humanities Acknowledgment
exercises extensively. A study from Oman medical school This research was part of the Advance Course in Medical
suggested that the clinical vignettes used should be Education from MCI Nodal Center at Smt N H L
adapted for local use. They observed that Omani students’ Municipal Medical College, Ahmedabad for the first author.
perceptions were different for the same vignettes compared The author wishes to acknowledge the contributions made
to students from the USA. Thus, there is a need for the by all the nodal center faculty and participants that helped

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Desai, et al.: A novel approach to suicide prevention

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Junior Residents from Department of Psychiatry for their on depression in medical schools in the Asia pacific region.
support during the project. Australas Psychiatry 2004;12 Suppl:S28‑32.
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from: [Link]
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Industrial Psychiatry Journal  123 Volume 27 | Issue 1 | January-June 2018