Round 1
A total of 55 participants completed the Round 1 questionnaire. The professional panel distribution (n = 29) had a minor difference between Chile (n = 12) and Argentina (n = 17) and included 14 psychologists, 11 psychiatrists, two general practitioners, one medical technologist, one social worker and one unspecified health professional. The average years of experience as a health professional was 28.0 years, with 58.6% females (n = 17) and 41.3% males (n = 12).
The lived experience panel (
n = 26) had more Argentinian participants (
n = 16) than Chilean (
n = 10). Fourteen were consumers and ten were caregivers and/or relatives. Of those who identified themselves as consumers in their primary role, two were also carers; and of those who identified themselves as carers in the primary role, two were also consumers. A total of 61.5% were females (
n = 16) and 38.5% were males (
n = 10). Two experts, one from Argentina and one from Chile, who had been invited as part of the health professional panel also self-identified as consumers. Conversely, two experts, one for each country, who had been invited as part of the lived experience group, also identified themselves as health professionals. See Table
1 for a summary of the sociodemographic characteristics of participants.
Table 1
Sociodemographic characteristics of participants
Age |
18–24 | 5 | 9.1 | 4 | 8.5 |
25–34 | 6 | 10.9 | 4 | 8.5 |
35–44 | 11 | 20.0 | 8 | 17.0 |
45–54 | 11 | 20.0 | 10 | 21.3 |
55–64 | 20 | 36.4 | 20 | 42.6 |
65 + | 2 | 3.6 | 1 | 2.1 |
Educational level |
Primary | 1 | 1.8 | 0 | 0.0 |
Secondary / high school | 6 | 10.9 | 2 | 4.3 |
Technical training | 7 | 12.7 | 6 | 12.8 |
Graduate (licenciate/bachelor) | 18 | 32.7 | 15 | 31.9 |
Postgraduate (master/doctorate) | 23 | 41.8 | 24 | 51.1 |
Sex |
Female | 33 | 60.0 | 28 | 59.6 |
Male | 22 | 40.0 | 19 | 40.4 |
Professionals | 29 | 52.7 | 24 | 51.1 |
Psychologists | 14 | 25.5 | 15 | 31.9 |
Psychiatrists | 11 | 20.0 | 8 | 17.0 |
General practitioners | 1 | 1.8 | 0 | 0.0 |
Medical technologists | 1 | 1.8 | 0 | 0.0 |
Social workers | 1 | 1.8 | 1 | 2.1 |
Unspecified health practitioner | 1 | 1.8 | 0 | 0.0 |
Source of experience (lay panel) | 26 | 47.3 | 23 | 48.9 |
Family experience or peer support experience | 10 | 18.2 | 7 | 14.9 |
Own experience | 16 | 29.1 | 16 | 34.0 |
Out of the 172 items included in the Round 1 survey, 116 items (67%) were endorsed as
essential or
important by 80% or more of the experts in both panels. Another 29 items (17%) required re-rating in Round 2, and 27 (16%) items were rejected (Fig.
1). Overall endorsement rates were 77.9% for the lived experience panel and 79.7% for the health professional panel, showing some preliminary consistency. Fifteen items (8.7%) were endorsed by one panel and rejected by the other panel, implying a good level of agreement between panels.
Differences between the Spanish-language guidelines for Chile and Argentina and the English-language guidelines
In total, across the two rounds, 172 items were endorsed, and 46 items were rejected. When comparing the English and Spanish guidelines, it was noted that 35 statements (20.3%) included in the English guidelines were not accepted by the Argentinian and Chilean experts. Among the 46 new items, the proportion of new suggested items rejected (23.9%) was slightly higher than the original items rejected (20.3%). Overall, 35 new items were added. See Supplementary file
3 for key differences between the English-language guidelines and those for Argentina and Chile.
The group of rejected statement included (a) many items recommending self-help (i.e., encouraging to use them or ask for past useful self-help strategies), (b) some attitudes for helping people who are at risk of self-harm or harm to others (i.e., to respect the person’s right to not seek help or ask the person to take steps to get help), (c) non-verbal skills in help-offering (i.e., sitting alongside the persons rather than directly opposite them or using minimal prompts to keep the conversation going), (d) encouragement for people to talk about their problems or seek help (i.e., recommending other available service like telephone counseling, encouraging the person to talk about feelings and thoughts or reinforcing an optimistic view if the person judge themselves too harshly), and (e) other items from different sections of the guidelines (i.e., do not adopt an over-protective attitude or discussing what is culturally appropriate for them).
Overall, the item with the lowest endorsement was “The first aider should encourage the person to do a list of questions to discuss with the health professional at their first appointment”, which had an average rating of 41.0% (30.8% lived experience – 51.7% professional panel). With 51% average endorsement (46.2% lived experience panel – 55.2% professional panel), the statement “The first aider should use the following nonverbal skills to reinforce their nonjudgmental communication:—Sit next to the person and at an angle to them, rather than directly in front of them” was the second-lowest rated. Other rejected items included the following: The first aider should: “ask the person if what they are doing is helpful, and what else they could do to help”, “should know that recovery, for the most part, should be person-led” or “must respect the person’s interpretation of the signs and symptoms”.
On the other hand, the new statements added comprised considerations on the social determinants of mental health; considerations for minority or disadvantaged groups; the limitations of help mediated by virtual platforms; clues about non-verbal aspects of help and considerations about the first aider's expectations of help, especially in the face of circumstances such as the person's anger or embarrassment.
In the first section, experts added statements about social stressors (such as economic stress) which could lead to chronic depressive symptoms, identifying vulnerable groups (including members of the LGBTIQ + community) which may require particular consideration. In terms of first aid provision, experts included the recognition of the limits of self-help and the importance of personal meeting, the respect for the autonomy of the person in the decision to seek and receive help and considering that there are people who need to be accompanied in silence. Suggestions also comprised a range of actions including asking the person why they were upset, trying to politely redirect the conversation and reiterating their willingness to help, taking a break in the conversation and asking the person how they want to continue. Finally, the experts included some new suggestions, such as the necessity of the first aider considering in each case if they are suitable to provide first aid, learning to know their limits, asking for additional help, and being clear with the person if and when it is time to stop assisting them. They also included items about the need to be part of a support network for a more comprehensive response.
See Supplementary file
3 for a list of the statements excluded from the original guidelines and new items added in the final guidelines.
Differences between the lived experience and health professional panels
Over both rounds, the level of agreement between panels was high (with Spearman r = 0.63 in Round 1 and r = 0.59 for total items rated p < 0.01). Overall, for 75.5% (n = 130) of the statements there was less than a 10% difference in the percentage of panel members endorsing those items, including 8.7% (n = 15) of the items with complete agreement in both panels (i.e., 100% of the members of both panels endorsing the item). On the other hand, there were 6.9% of items (n = 12) where disagreement between panels was 20% or greater and only 1.7% of items with disagreement greater than 30%. The mean difference in inter-panel approval for the 172 items was 7.4%.
In round 2 the correlation between panels was lower (Spearman r = 0.47 P < 0.01). Two thirds of items had less than 10% difference in the percentage of members of panels endorsing those items, including 13.3% of items with an absolute agreement. Disagreements of 20% were found in 9.3% of items, including 4% of items with differences above 30%. The average difference between percentage approval for all 75 items was 9% between panels. The correlation between two panels, considering all statements rated (in case of re-rated statement, taking the last score), was r = 0.59 (p < 0.01).
The greatest differences in Round 1 included items related to the sources of help, the self-help strategy. For example the statement “If the person finds it difficult to discuss their thoughts and feelings openly, the first aider should let the person know about available services where they can talk to someone else, e.g. a telephone counselling service”, had a 34.6% difference (65.4% lived experience panel – 100% professional panel) and the statement “If the person is interested in self-help strategies, the first aider should: encourage them to consult reputable sources about what is most likely to be helpful, e.g. a health department-sponsored website” had a 29% difference (53.8% lived experience panel – 82.8% professional panel),
There were also differences in recommendations about reminding the person about their strengths. For example, the statement “If the person says that they feel they are a weak person or a failure, the first aider should let the person know that they do not believe that the person is weak or is at fault” had 41.6 percentage points difference in ratings (95.8% lived experience panel – 54.2% professional panel), the greatest difference in all rated statements. In addition, the item “If the person says that they feel they are a weak person or a failure, the first aider should let the person know that they don’t think less of them as a person” had 37.5 percentage points of endorsement difference (100% lived experience panel – 62.5% professional panel), the second greatest difference. Similarly, the statement “If the person judges themselves too harshly, remind them of their strengths and virtues” had 36.8 percentage points of endorsement difference (88.5% lived experience panel vs 51.7% professional panel).
There were also considerable differences in the endorsement of the item “The first aider should learn more about the depression by: seeking advice from people who have experienced and recovered from depression” had a 33.3% difference (88.5% lived experience panel vs 55.2% professional panel). Related to that, the statement “The first aider should consider inviting the person to jointly search for information and appropriate ways to deal with what they are experiencing” had 37.5% percentage difference (58.3% live experience panel vs 95.8% professional panel),
See supplementary file
1 for details of the ratings of statements by round and panel, and supplementary file
2 for the final guidelines text in Spanish.