stigma and barriers to care - Uniformed Services University of the ...

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism
ing signs more effectively. It also trains them to directly ask kids whether they are
suicidal, and then gives them a way to provide those kids direct links to existing
mental health services. That is the model. Does anybody think it is workable This
is the model we are trying to use.
DR. ZATZICK: There is a provider level denominator and it might take a very
sophisticated provider. I would be interested in what the aptitudes were of the
population of providers in training, the providers being the gatekeepers.
DR. BROWN: There are some differences at the gatekeeper level. There is an
idea that we have been calling a “surveillance model” and it does have the potential
of having an effect. In this school district about 8% of kids who reported that they
had a suicide attempt this last year were known to the school. If you were able to
improve the ability to recognize suicide warning signs and to marshal each person’s
ability by a very small amount, you might have a better effect, particularly with a
large number of staff in the school. Instead of 8% you could potentially identify 40
% prior to attempt.
We conducted a randomized trial called QPR in a large school district that had
already decided they were going to implement the training and we simply stepped
in with the support of NIMH and then later with SAMSHA funding to do this
randomized trial in all 32 middle and high schools that were available. The school
district was extremely well organized. The Mental Health Coalition was also very
organized. This is not a disaster model at all. The only two schools that had a suicide
occur during the previous year were already trained prior to the trial because the
school felt that something needed to be done. If there was a suicide that actually
occurred in this school, instead of stopping the study, we were allowed to continue.
That was because this school district had an average of four suicides per year. It had
50,000 individuals, not very much above the national average.
When we initially were funded we did not have this technical paper regarding
what kind of evaluation opportunities that the dynamic waitlist or rollout design
offered, so we came in with a standard waitlist randomized design. Sixteen schools
were trained early on; sixteen schools were trained later on. Everybody in the school
district was required to get training. What we found was that asking 32 schools to
get trained is like herding cats. It took a long time to do. We realized that what we
really need to do from a logistics point of view is to focus on smaller numbers of
groups at the same time.
We locked on four schools at one time and said, “We want to get you trained
this month and then we will evaluate you,” and then we would go to the next set
of schools, and then the next set of schools, and so on. We switched to this rollout
design so that eventually everybody got trained on the schedule we had intended but
in a much more systematic way. That is what the idea of rollout design is. Logistically,
the design actually increased the proportion trained in schools. It took much
less time to do and it increased the statistical power as well.
We did two-year evaluations from the perspective of those who were trained.
We had strong increases over a two-year period of knowledge of warning signs. We
also had some very strong effects in shifting attitudes. People were definitely willing
to take on gatekeeper roles. Self reported intervention behaviors were examined.
When asked, “Did you ask a student about suicide” they replied, “Yes, a little bit,
but not very much.” The training effects and benefits of getting to those students
who were suicidal only occurred in about 14% of the staff who were already
engaged with students. Wendi Cross has done a great deal of work on identifying