Barriers with regard to assessing suicide risk in the general practice.

Many PCPs brought up issues concerning the complexity and unpredictability of suicidality when exploring the issue with patients. They argued that suicidal ideation is difficult to recognize, that it exists in various forms, and that a lot of factors are involved in the suicidal process. PCPs also reported about patients who they felt use suicidality as a strategy to attract attention or as a means of manipulation, making it more challenging to differentiate between actual suicidal patients and patients who may need other forms of care. Additionally, some patients reportedly felt inhibited about discussing mental issues and, therefore, whether consciously or not, presented to their GP with physical complaints. PCPs found it hard to discuss suicidal feelings with these patients straight away and argued that it could take multiple consultations before crossing that bridge.

PCPs said that most patients did not give out distinctive signals indicating suicidality, nor did they proactively disclose their suicidal feelings. Therefore, they argued, it is necessary to actively explore suicide risk. However, many found it hard to determine when to explore this. Most PCPs reported they did not follow a systematic approach for assessing suicidal feelings, but relied on their gut feeling or on the course of the consultation when deciding to explore these thoughts. All PCPs agreed with the recommendation of the multidisciplinary guideline for diagnosis and treatment of suicidal behaviour, which states that suicidal feelings should be assessed during every depression-related consultation, although some argued that it is difficult to apply in everyday practice.

PCPs reported that patients’ suicidal behaviour strongly impacts their professional life. PCPs who experienced one or multiple fatal suicides in their career stated that they carried this experience with them for the rest of their life, especially if they felt that they did not handle the situation properly, which may lead to feelings of self-doubt and failure.

“I have lost someone who was in care in an MHC institution but who had also visited me just before. She jumped from a building […]. I felt like maybe I should have… even if she had come to me about her little toe, maybe I should have kept asking further. Asking her how she was really doing. I failed in that.” (R20)

Although PCPs often sympathized with their patients when they experienced suicidal thoughts, they could also be perceived as a burden, especially when patients were in suicidal crisis and could not be left alone.

“I once had an experience where a person thought this was the hospital. This man was so suicidal that I just stayed with him until the psychiatrist arrived in the evening. In that case, you get sort of stuck with the patient. I thought, if I let him walk out, he’ll jump straight out in front of a car.” (R4)

To address the suicidality of patients can impose a heavy burden on PCPs, who can feel pressured, stressed, and sometimes even personally responsible for their patient’s life.

Of the PCPs, especially GPs reported an enormous workload and very limited time. Not only for consultations with patients but also for extra activities in their GP practice, such as taking part in training- or research. It also played a role in the assessment of suicidal thoughts during consultations:

“When someone in the waiting room has chest pain and a suicidal or depressed patient who has an appointment with an MHC specialist tomorrow consults me, I decide not to ask any further. This might not be good for this patient, but overall it might be for the best.” (R20)

However, most PCPs did not agree with this statement and argued that patients who consult during surgery hours are generally stable and that medical assistants will alert them when this changes. Besides, there are more options than either discussing the matter right away or not discussing it at all. Most PCPs argued they prioritized their patient’s mental wellbeing over their schedule.

“A couple of times, it has happened that consultations take a bit longer, which is really annoying if it’s scheduled for 10 minutes. But in the end, these patients say, ‘Thank you, thank you for taking the time.’ And then, those 10 minutes extra are suddenly a great gift.” (R18)

Collaboration with MHC institutions.

Although it varied per region, many PCPs reported issues with regard to collaborating with MHC services. They argued that MHC services operate in isolation and fail to communicate information about patients. Another frequently mentioned issue was difficulties with access to MHC:

“Sometimes you have to pull some serious strings to get someone reviewed or referred. That is difficult. Access is difficult.” (R16)

This resistance was especially noticeable when patients were not in severe crisis, but when the PCPs were worried anyway and required support.

Further, many PCPs reported that processes are very time consuming. Speaking to a professional on the phone takes a long time, admitting a patient into care, starting treatment, or the provision of feedback are inordinately time consuming. While PCPs feel, especially when they refer a patient to the crisis service, that the situation is urgent and requires a fast response.

Additionally, PCPs expressed a need for transparency regarding the methods and procedures in MHC. Some stated that they did not know what happens with a patient during treatment in MHC.

“If you send patients to MHC, I sometimes say, ‘They disappear into a black box. That box is shaken a couple of times and at some point, they fall out.’ I never know what happens to my patients in the meantime, except maybe that they have been relocated six times. […] Sometimes I question whether–with all due respect–crisis services provide better care than I do.” (R2)

Another concern, which is also hinted at by the PCP from the quote above, is the quality of care. Patients are being transferred frequently and see many different health care professionals, who do not always follow the treatment plan that was agreed upon or sometimes not even showing up for an appointment. This kind of behaviour may evoke feelings of rejection and feeling rejected by the very organization that is supposed to provide help, hinders recovery even more.

“Crisis services arouse the feeling that patients experienced before: rejection. They already feel rejected and then they get it all over again.” (R9)

PCPs found the service provision of MHC institutions was substandard. They expressed the desire to collaborate more closely, including having the opportunity to call and discuss patients or to send them in for review, while patients remained treated in primary care. They want to work together, not to shuffle patients back and forth.

“It would be very helpful if they would welcome us in a friendly way, not just the patients, but us too as fellow caregivers. Because we can get at ease from these conversations, ‘Have you already thought of this or that?’. That can make a big difference. Often, we don’t need crisis services to take over but just to provide backup.” (R9)

Most PCPs were very understanding about the situation of the MHC services, which had suffered budget cuts, staff shortages, and onerous policy changes. Nevertheless, they were unsatisfied with the current collaboration and insisted on improvement. Most PCPs reflected on their own practice as well, arguing that they could also improve, but that this too required collaboration and communication.

Role of the MHSS.

GPs reported that the MHSS was an enormous relief in terms of providing care for suicidal patients. MHSS are trained to support patients with mental health problems and they have more time than GPs to spend with patients, whereas GPs cannot always provide the close monitoring that these patients may require. Some GPs even argued that MHSS should be given more responsibilities with regard to suicide prevention.

“I think you should make people aware that MHSS play an important role in this; they may even be more important than GPs. They often have more time, expertise, and experience than GPs in dealing with these issues. [This helps] especially when you are kind of insecure as a GP.” (R17)

However, all participants argued that GPs have a distinct part to play in suicide prevention, because, if GPs do not recognise patients’ psychological complaints, patients may not get a referral at all to neither MHSS nor MHC services.

Engaging GP practices in SUPRANET.

Regions were responsible for contacting and inviting GP practices to participate, which was a challenging task because of PCPs’ limited available time. One PCP questioned whether the project attracted the right kind of participants using this strategy.

“Only PCPs who are interested in the topic, will sign up for such a program. They often have a background in or affinity with the topic, and, therefore, perform better when faced with these problems during a consultation. The ones who need it the most, who don’t have good communication skills or an affinity with the problem, will not sign up voluntarily”. (R19)

Therefore, this PCP suggested offering the training during the contracted training hours of GP practice staff, so that it is harder for PCPs to avoid the training and it might facilitate implementation.

One of the non-clinical SUPRANET professionals argued they could have used more support during the recruitment phase. When this region involved MHC services to engage GP practices things started to move. Various reasons were offered for this effect: PCPs may favour being approached by other medical doctors, MHC services offered the training for free, and the training was reduced to one or two hours instead of four. An advantage of this approach was instant contact between primary care and MHC, which also facilitated communication and collaboration in daily practice. However, this approach also had some important disadvantages, since there was less control and continuity with regard to the content of the training.

Leadership of SUPRANET.

In most regions, a PCP, often a GP, functioned as implementer and spokesperson for SUPRANET. This PCP was responsible for bringing together colleagues from various practices and logistically organising the suicide prevention training. In addition, some of these PCPs were also involved in the continuity of care aspect of SUPRANET. This latter demanded a lot of time and energy and these PCPs argued they expected more support and cooperation from both MHC services and 113 Suicide Prevention. In the absence of this, one PCP felt isolated and became demotivated.

“I’ve sort of lost my motivation. […] I don’t see it happening anymore. I have really put a lot of time into it. […] It feels like it was my request to start this project, but that is not the case. We have been asked by 113 Suicide Prevention, […] and we said yes, but on the assumption that MHC services were also taking part”. (R2)

SUPRANET as strategy for applying suicide prevention practices.

Almost all PCPs evaluated the suicide prevention training positively. Although they stated it did not offer any ground-breaking insights, the majority thought it had increased their knowledge about and awareness of suicide prevention. In addition, some argued that SUPRANET had made them feel better equipped to assess patients’ suicide risk:

“Since the training, I ask more often and more targeted questions about people’s emotions and their suicide risk, sometimes very directly, like, ‘Would you take your life?’ […] I did that before as well, but because of the training you become aware of certain aspects of your practice you can improve.” (R1)

Further, the PCPs thought it was valuable to discuss clinical cases with colleagues, since there is usually no time for this during practice hours. They also appreciated being able to practice communication skills during the training and learned, for example, the importance of making actual contact with patients:

“Asking about the patient’s feelings of despair and just carefully listen, without thinking of a solution straight away, were two eye-openers, which I applied the next day. […] and it worked. The lady said: ‘I am so happy that I could tell my story, that you just listened to me’. So, I thought, ‘This works well’.” (R18)

However, there was also some critique on the training, with regard to both content and form. Some PCPs wished the training included more new scientific knowledge and insights. One PCP reported that he would have liked to learn more about risk groups and when to discuss suicidal feelings with patients, instead of how. Other suggestions included incorporating more information about discussing suicidal feelings with specific subgroups, such as children and adolescents, patients with different cultural backgrounds or bereaved family members.

Initially, PCPs thought that conducting four hours of training outside office hours would be too demanding. Afterwards, most were content with it and considered it as something you should prioritize.

“I get it, people want it to be as quick and efficient as possible, but, in terms of effectiveness I think this [the duration] was good. I understand that people want it shorter; everybody is busy, they always are. But I think you should make time for it. There are certain things you just have to make time for.” (R19)

However, since PCPs initially felt resistance towards the duration, they suggested to shorten the training or to split it up into two parts: an individual online training complemented with a face-to-face group training to practice communication skills. The PCPs also strongly recommended follow-up training, since they believed it is not only important to raise awareness but also to maintain it.

The additional materials (checklist, information material, flyers and posters and information module on suicide in relation to medication) were rated by some participants as helpful. Some argued, for instance, the checklist served as a reminder for asking all the relevant questions. Others thought the information material was useful for disseminating knowledge to colleagues. The poster and flyers were, to the PCPs’ knowledge, never used by patients as an encouragement to discuss suicidal feelings. Although not many PCPs completed the module on medication and suicide because of the strict scheduling of training time within their GP practice, they thought this module would be very relevant because not all PCPs have the same knowledge with regard to medication. The continuity of care was assessed as an important component of SUPRANET, which required a lot of improvement, though hardly any PCPs experienced this due to lagging implementation.