Associations of training to assist a suicidal person with subsequent quality of support: results from a national survey of the Australian public

While mental health and primary care services can play an important role in detecting suicide risk and acting to reduce it, many people at risk of suicide are not in immediate contact with services. Psychological autopsy studies show that less than half of people who die by suicide are in contact with primary care services in the month before their death, and the rate of contact is even lower for specialist mental health care [1, 2]. For this reason, members of a suicidal person’s social network may be well placed to detect and act to reduce the person’s suicide risk. However, there are a number of barriers to members of a person’s social network taking on this role. While about one-third to a half of people who die by suicide explicitly communicate their intent to family members [3], in other cases the indicators of suicidal intent may be unclear and misread by the person’s family and friends [4, 5], and thereby not prompt preventive action. People in the social network may also not feel comfortable raising the issue of suicide with the person and alerting others in the social network [4]. They may also respond in a dismissive or disapproving way to the person’s expressions of suicidal feelings [6], thereby shutting down communication.

There is a need to determine what actions members of a suicidal person’s social network can take that are likely to be helpful and also what actions should be avoided. However, it is not feasible to test the preventive effects of specific actions by the public using experimental methods. For this reason, expert consensus has been used to develop suicide first aid guidelines for the public using the Delphi method. Kelly and colleagues [7] recruited 22 professionals, 10 people who had been suicidal in the past and 6 carers of people who had been suicidal in the past and presented them with 114 statements about how to assist someone who is thinking about suicide. These statements were sourced through a systematic search of both professional and lay literature. Thirty of these statements were endorsed at a high level and formed into guidelines. Subsequently, Ross and colleagues [8] re-developed the guidelines using two expert panels, comprising 41 suicide prevention professionals and 35 consumer advocates. The panelists rated 436 statements and endorsed 164 which were used to form updated guidelines. These guidelines provide a standard for improving the support that members of the public provide to suicidal persons in their social network.

When judged against these guidelines, community survey data reveal limitations in the public’s ability to act effectively to prevent suicide. In two Australian national surveys, respondents were shown a vignette of a person with depression and suicidal thoughts and asked what they would do if the person was someone they knew and cared about [9, 10]. Coding of open-ended responses showed that while many would listen to the person, provide support and encourage professional help-seeking, very few would assess the person’s risk of suicide or act to reduce this.

A range of gatekeeper training programs have been developed to improve the response of the public and professionals to suicidal persons. A review of these programs concluded that gatekeeper training can improve knowledge, beliefs/attitudes, self-efficacy, and reluctance to intervene, but transfer to actual intervention behaviour is largely unstudied [11]. In Australia, a number of training programs have been rolled out to improve the public’s ability to assist suicidal persons. Probably the most widespread is Mental Health First Aid (MHFA), which is a 12–14 h course training members of the public in how to provide initial assistance to someone developing a mental health problem or in a mental health crisis, including helping a person with suicidal thoughts or behaviours [12]. MHFA training has been received by over 2% of the Australian population. A meta-analysis of trials evaluating MHFA showed improvements in knowledge, stigmatizing attitudes and helping behaviours towards people with mental health problems [13]. However, there has not been any specific evaluation of the impact of MHFA training on support given to suicidal persons. Other common programs in Australia are QPR (Question, Persuade, and Refer) and Applied Suicide Intervention Skills Training (ASIST). QPR is a 1.5–2 h course specifically on suicide prevention. Evaluations of QPR have shown improvements in knowledge, self-efficacy and helping behaviour [14]. ASIST is a 2-day program aimed at both professionals and the public. Evaluations of ASIST have found improvements in knowledge, confidence and intervention skills, but mixed results on intervention behaviour [15].

The present study aimed to use Australian national survey data to investigate associations between training in how to assist a suicidal person and actions taken on suicide. The survey investigated Australian community members’ attitudes, intentions and behaviours toward helping someone in severe distress or at risk of suicide. As part of this survey, participants were asked about their intentions to assist a hypothetical person in a vignette and about any actions they took to assist a family member or friend in distress over the previous 12 months. Participants were asked about intentions and actions that were either recommended or not recommended in the expert-consensus guidelines developed by Ross and colleagues [8]. Participants were also asked about any training or course they had taken in how to help someone who is suicidal, allowing a comparison between those who had received various types of training and those untrained. It was hypothesized that people who had received training would have higher quality intentions and actions.

Table 1 shows the sociodemographic characteristics of the sample. Figure 1 shows the breakdown of the sample according to training received. Because the number of participants who had done ASIST and QPR was small), these were combined with the Other group. The categories of training overlapped, because some people had more than one type of training.

Characteristic	N (%)
Female gender	1785 (59.5%)
Aged 18–30	356 (11.9%)
Aged 31–59	1408 (46.9%)
Aged 60+	1238 (41.2%)
Bachelor’s degree or above	1215 (40.5%)
Non-urban location	1254 (41.8%)
Exposed to suicide	1839 (61.3%)

Of the 3002 participants, 1056 knew someone who was distressed in the past 12 months and 935 did something to support the person. Multiple binary regression analyses were carried out to see whether training was a predictor of knowing someone and, among the subgroup that did, whether support was provided. After adjusting for covariates, only MHFA training was associated with knowing someone (OR = 1.51, 95% CI 1.05–2.17, P = 0.026). There was no association of training with provision of support.

The findings show that training in how to help a suicidal person is associated with increased intentions to act in ways recommended by guidelines for the public, and decreased intentions to act in ways recommended against by the guidelines. All three types of training—professional, MHFA and other—had similar small-to-medium associations with positive intentions. However, the association with reduced negative intentions was small-to-medium for professional training, but only small for MHFA and other training. For actions to help a distressed person in the past 12 months, all types of training were associated with taking more actions recommended by the guidelines, with small-to-medium effect sizes. Associations with actions not recommended were not significant. When specific intentions and actions were examined, training was associated specifically with a greater willingness to talk openly about suicide with a distressed person. It should be noted when considering these findings that the associations with professional training were in relation to helping a family member or friend, rather than in the context of helping a client in a professional role.

We are not aware of any previous studies that have examined associations with suicide-relevant training in the context of a community survey. However, a US study used a similar approach in a large cross-sectional survey of behavioural health care staff [18]. This study found that staff who had received training in ASIST, QPR or other suicide-relevant training had greater suicide knowledge and confidence in working with suicidal persons. However, unlike the present study, the US study did not assess whether this greater knowledge and confidence was associated with behaviour.

The present study found associations between intentions to support a hypothetical person in a vignette and supportive actions to a family member or friend in the previous 12 months. The associations showed some specificity, with positive intentions correlating with positive actions and negative intentions with negative actions. While the associations were measured cross-sectionally in the current study, they support the findings from longitudinal studies that mental health first aid intentions predict subsequent mental health first aid actions [19, 20]. These findings indicate that suicide helping intentions can be used as a proxy short-term outcome where it is not feasible to measure behaviour, e.g. at a post-test assessment after a training course.

The major limitation of the study is that the data are cross-sectional, limiting causal inference. Although a variety of potential confounders were adjusted for, it is possible that there are other unmeasured differences between the groups that were not. We also lacked data on how long ago the training was received and, in many cases, information about what the content of the training was. If the training was within the past year, then it is possible that it followed rather than preceded any reported behaviour. The only specific type of training we can draw conclusions on is MHFA, which is a broader type of training in how to assist people developing mental health problems or in mental health crisis situations, with assisting a suicidal person being only one component. In fact, the present study is the first to examine suicide-specific outcomes of MHFA training and adds to the evidence from trials that such training increases knowledge, reduces stigmatizing attitudes and improves supportive behaviours towards people with mental health problems [13].

Other limitations are the low response rate and possible biases in the sample. We found that 4.7% of the sample reported having received MHFA training, whereas the population estimate of adults having done MHFA training is 2.6%, indicating an over-representation of people with an interest in mental health.

On the other hand, the methods used in the present study have some strengths. The study examined the effects of training in a real-life community context. In trials to evaluate suicide-relevant training, the measures used generally only cover short-term changes and are often transparent in their purpose and thus potentially subject to biased reporting to please the researcher. In the current study, there was no obvious connection between the purposes of the study and any training received. Participants were told that the study was on “what Australian adults understand about recognising and assisting an individual in severe distress”, with the question on training being asked towards the end of the interview.

The findings show that training in how to help someone who is suicidal is associated with better quality intentions and actions towards a distressed person in the social network, in particular a greater willingness to talk openly about suicide. The magnitude of the association was similar for short courses and professional training. If these benefits can be confirmed in controlled trials, it would indicate that such courses merit wider dissemination in the community to increase the support provided to suicidal persons and to reduce the risk of suicide.