The re-development of the guidelines was conducted in three stages: literature search, questionnaire development and Delphi consensus survey rounds.
Literature search
A systematic literature search was conducted to find statements about how someone can help a person who is suicidal, including how to determine if someone is having thoughts of suicide, how to offer short-term assistance to the person, and how to seek appropriate professional support for them. The literature searched included online materials, research publications, books and existing suicide intervention courses.
Websites and online materials were searched using the Google search engines of English-speaking countries (Google.com, Google.com.au, Google.co.uk, Google.nz, Google.ca). The search terms `suicide’, `help’ (truncated to include terms such as `helping’ and `helped’) and `friend’ or `family’ were entered. The terms `survivor’, `after suicide’, `grief support’, `aftermath’ and `bereave’ (truncated to include terms such as `bereavement’ and `bereaved’) were excluded to ensure the return of the most relevant sites. The websites returned in the top 50 results from each search were reviewed. Overall, 205 unique websites were reviewed for potential first aid helping actions, with relevant statements found on 66 of these sites.
The research literature was searched through PsycInfo and PubMed, with the terms `suicidal’ or `suicide’ and `help’ (truncated as above), as well as `prevent’ or `assist’ searched for in the title and abstract, and the exclusion of results containing the terms `cell suicide’, `assisted suicide’, `suicide attack’ and `homicide suicide’ to improve relevance of results. Articles published before 2004 were also excluded from the searches, as the searches aimed to find new articles that have not been covered by the literature search for the initial version of the guidelines. Searches on both these databases returned 853 articles, which were then screened for relevance. Following the screening process, 4 articles were deemed relevant. The irrelevant articles were excluded through a hierarchical screening process, starting with titles (n = 791), abstracts (n = 45) and then full-text (n = 13).
To locate relevant books, a search of Amazon.com was also conducted using the search terms `suicidal’, `help’ and `friend’. Forty-five books were returned, with 5 of these considered relevant. These 5 books were purchased and read, with all containing relevant helping statements (references provided in Table
1).
Table 1
List of original sources for statements that were included in the Round 1 questionnaire
HelpGuide.org | |
Stop A Suicide | |
MayoClinic | |
ReachOut Australia | |
Suicide Prevention | |
Psych Central | |
Better Health Victoria | |
NASP Resources | |
American Academy of Child and Adolescent Psychiatry | |
Depression and Bipolar Support Alliance | |
Kids Help Line | |
Befrienders Worldwide | |
Child and Youth Health South Australia | |
University of Minnesota | |
Lifeline | |
SANE | |
Know the Signs | |
University of Notre Dame Counselling Centre | |
Survivors of Suicide | |
Re Think | |
San Francisco Suicide Prevention | |
U Matter | |
The University of North Carolina Campus Health Services | |
American Foundation for Suicide Prevention | |
Gustavus Alophus College Suicide Prevention Information | |
Real Warriors Military Support | |
National Suicide Prevention Lifeline | |
WikiHow | |
Suicide Call back Service | |
WebMD | |
University of Illinois Counselling Center | |
Choices: National Health Service UK | |
Quebec Health Portal | |
Mend a Friend | |
Queensland Government | |
Suicide: It’s no secret | |
World Suicide Prevention Day: Suicide Prevention Australia | |
Schizophrenia Fellowship of New South Wales | |
FNQ Suicide Prevention Taskforce | |
Grapevine Group | |
Super Friend | |
Queensland Government Health | |
Society for the Prevention of Teen Suicide | |
Erase Bullying | |
Crisis Centre | |
Here to Help | |
Health Link | |
New Brunswick Canada Health | |
Government of Alberta Information for teens | |
Half of Us | |
National Alliance on Mental Illness | |
Mental Health America | |
The Kelty Foundation | |
CHEO Health Center | |
Alberta Health Services | |
Western University Health and Wellness | |
C-Health | |
Faze Youth Magazine | |
Youth Services Jeunesse | |
Crisis Outreach and Support Team Hamilton | |
Suicide Prevention Information New Zealand | |
New Zealand Ministry of Health | |
Massey University New Zealand Health and Counselling Services | |
When Your Head Spins | |
Life | |
Kids Help Phone | |
Mental Health First Aid Australia | |
Books (N = 5) |
Hill K, Gorman J: How to help someone who is suicidal. Mind Publications 1995 |
Marcus, E: Why suicide? Questions and answers about suicide, suicide prevention, and coping with the suicide of someone you know. HarperCollins 2013 |
Gordon, S: When living hurts: What-to-do book for yourself or someone you care about who feels discouraged, sad, lonely, hopeless, angry or frustrated, unhappy, bored, depressed, suicidal. URJ Press 2004 |
Nelson, RE: The power to prevent suicide: A guide for teens helping teens. ReadHowYouWant.com 2009 |
Cook J: How to help someone who is depressed or suicidal: Practical suggestions from a survivor. Rubicon Press Inc. 1993 |
Suicide prevention course materials (N = 6) |
ASIST (Livingworks) |
SafeTalk (Livingworks)
|
Suicide Prevention Skills Training (Griffith University)
|
ACE (The US Military) |
ASK about Suicide (The University of Texas) |
QPR (The Salvation Army, Australia) |
Journal articles (N = 4) |
Barrero SA: Preventing suicide: A resource for the family. Annals of General Psychiatry 2008, 7:1 |
Deisenhammer EA, Ing CM, Strauss R, Kemmler G, Hartmann H, Weiss EM: The duration of the suicidal process: How much time is left for intervention between consideration and accomplishment of a suicide attempt? Journal of Clinical Psychiatry 2009, 70:1 |
Kelly CM, Jorm AF, Kitchener BA, Langlands RL: Development of mental health first aid guidelines for deliberate non-suicidal self-injury: A Delphi study. BMC Psychiatry 2008, 8:62 |
Norris D, Clark MS: Evaluation and treatment of the suicidal patient. American Family Physician 2012, 85:6 |
Existing suicide intervention course materials were also obtained where possible. This involved searching for courses online, contacting the organisations and requesting course materials where these were not available online. We were able to locate course materials from 6 suicide prevention courses, as listed in Table
1. Materials obtained included participant workbooks and trainer notes, all of which were thoroughly read, with relevant helping statements extracted.
Questionnaire development
Relevant helping statements that were found in the literature search, as well as the statements included in the previous Delphi questionnaires, formed the content of the first questionnaire. Statements were considered acceptable for inclusion in the questionnaire if all three authors agreed that they described how someone can help a person who is suicidal with clear and non-ambiguous actions. For example, the statement `Talk to the suicidal person in a private place’ was considered acceptable, as it clearly specifies what actions are required by the first aider. The statement `Try to connect with the suicidal person’ was considered unacceptable, as it does not specify the actions the first aider should take or what is meant by the term `connect’.
These statements were grouped into categories based on common thematic content. Statements were edited so that those with similar content were combined to reduce repetition throughout the questionnaire. Statements were also edited to improve clarity, through systematic re-wording or elaboration through examples. This editing occurred in meetings of the working group, which were held to edit and develop a draft of the questionnaire, including its categories and structure of statements. The working group comprised the authors of this paper who are all researchers with previous experience in conducting research using the Delphi methodology and in MHFA training programmes.
The questionnaire was completed online through an online survey website, Survey Monkey. Participants were given a two to three week time period to finish the questionnaire for each of the three rounds. The questionnaires could be completed at times that were convenient to participants, and in multiple sittings if desired.
Delphi consensus survey rounds
The consensus survey was conducted using the Delphi method. (Jones et al., [
22]). The Delphi method involved identifying and recruiting panels of experts in the field of suicide prevention to rate the importance of helping statements. Statements that achieved substantial consensus regarding their importance for inclusion in the guidelines were considered as the recommended actions to help someone who is experiencing suicidal thoughts.
Participants were recruited from developed English-speaking countries (Australia, United Kingdom, Ireland, Canada, United States and New Zealand) to join one of two expert panels representing two areas of expertise: professionals or consumers. To be considered as having expertise in suicide prevention, panellists were required to have professional experience working in the field of suicide prevention (i.e. as a researcher, clinician, mental health worker, social worker), or personal experience with suicidal thoughts and/or attempts. Potential professional panellists were identified as experts through their involvement with suicide prevention organisations, while potential consumer panellists through their advocacy roles in suicide prevention.
The professional panel comprised 41 experts, some of whom had multiple roles, including 11 professors and 7 associate professors in psychiatry or psychology, 9 psychologists, 8 psychiatrists, 3 mental health nurses, 3 suicide prevention researchers, 2 suicide support program coordinators, 2 physicians, 1 social worker, and 3 who worked in other mental health support roles. This panel represented global professional opinions in suicide prevention, coming from many different English-speaking backgrounds (see Table
2). Professional panellists were recruited through editorial boards of relevant academic journals and suicide prevention organisations. The heads of these boards and organisations were emailed an invitation to participate and a copy of the project’s plain language statement, asking these to be forwarded on to the relevant members. The academic journal editorial boards contacted included
Crisis and
Suicide and Suicidal Behaviour. Professional panellists were also recruited through suicide prevention organisations, such as the International Association of Suicide Prevention, Suicide Prevention Australia, the Australian Suicide Prevention Advisory Council, the American Foundation for Suicide Prevention, the American Association of Suicidology, the Canadian Association for Suicide Prevention, the Suicide Prevention Resource Center, the University of Oxford Centre for Suicide Research and Suicide Prevention Information New Zealand. Professionals were also asked to nominate any colleagues who they felt would also be appropriate panel members.
Table 2
Participant characteristics (data collected in Round 1)
Mental health professionals (n = 41 ) | 28-71 | 50 | 32 | 13 | 12 | 9 | 5 |
Consumers (n = 35 ) | 24-66 | 47 | 77 | 9 | 22 | 0 | 4 |
The consumer panel comprised of 35 suicide consumer advocates (people who have experienced suicidal ideation or made a suicide attempt in the past). Consumers were recruited through depression and mental disorder advocacy organisations, including beyondblue (Australia), Depression and Bipolar Support Association (United States), National Alliance of Mental Illness (NAMI) (United States), Depression Alliance (United Kingdom), and Depression Support Network (New Zealand). In a similar fashion to recruitment of the professional panel, email invitations and plain language statements were emailed to the advocacy group coordinators for the information to be forwarded on to the group members. Consumers who had written websites that offered support and information to other consumers, as well as promoted recovery from suicidal ideation, were also identified as potential panellists. Considered as online advocates, they were also invited to participate through email invitation. Consumers were also asked to nominate anyone they knew who they felt would also be appropriate panel members.
The outcome for each item was determined using predetermined criteria. Statements that were rated as essential or important by 80% or more of the members in both panels were endorsed as helping actions to be included into the guidelines. Statements were re-rated in a subsequent round of the questionnaire if they were rated as essential or important by 70-79.9% both of the panels, or they were rated as essential or important by 80% of more of one panel, but less than 80% by the other panel. Statements that were rated as essential or important by less than 70% of both panel members were excluded.
Participants were instructed to rate the statements presented in each questionnaire according to how important they believed they are to the aims of mental health first aid and the role of the first aider (detailed participant instructions are included in the Additional files
1,
2 and
3). In Round 1, panel members were also asked to provide feedback through a textbox at the end of each section of the questionnaire. This feedback textbox was intended for use by panellists to suggest helping actions that were not covered in the questionnaire, but generally panellists used the textboxes to provide rationales for their ratings. The comments made were reviewed by the working group. Suggestions that contained novel ideas were used to create new helping statements to be included in the subsequent Round 2 questionnaire. Also, statements that received feedback suggesting ambiguity in the interpretation of its meaning were re-phrased to make them clearer and included in Round 2. Statements from Round 1 that met the criteria to be re-rated were also included in the Round 2 questionnaire.
The third and final questionnaire was comprised of new statements that were developed from Round 1 feedback and presented for the first time in Round 2, but required re-rating in a further round. Items that still did not achieve consensus after being re-rated were rejected from inclusion in the guidelines.
Following each of the three rounds, each panellist was sent a report containing a summary of the results from the previous round. The report included a list of the statements that had been endorsed for inclusion in the guidelines, as well as a list of the statements that had been rejected from inclusion. The statements to be re-rated in the subsequent round were also included, with the report personalised to include the individual panellist’s rating for each statement, as well as a table summary of each panel’s ratings for the statement.
The statements that were endorsed across the three survey rounds were compiled. These statements were then used to form the guidelines, with working group meetings held to finalise structure and wording. The final draft copy of the guidelines was then disseminated to panellists for their final comment on the document. While panellists could not suggest new content at this stage, they were able to provide feedback on the wording of the document to improve clarity and reduce ambiguity.