BackgroundMental illness-related stigma is common, and is associated with poorer outcomes in people with mental illness. This study evaluated the attitudes of primary care nurses towards people with mental illness and its associated factors; and the effectiveness of a short video-based contact intervention (VBCI) in improving these attitudes using a Malay version of the 15-item Opening Minds Stigma Scale for Healthcare Providers (OMS-HC-15-M).MethodsA 5-minute VBCI was developed comprising elements of psychoeducation and interviews of people with mental illness and the people they interact with, relating to experience of mental illness and recovery. A pre-post cross-sectional study was conducted on 206 randomly selected primary care nurses in Penang, Malaysia. The OMS-HC-15-M questionnaire was administered before and immediately after participants viewed the VBCI. The difference in mean pre-post VBCI scores using paired t-tests, effect size and standardised response mean (SRM) were obtained. Factors correlating to attitudes were obtained using univariate and multivariate regression analyses.ResultsDifferences in pre-post VBCI score were statistically significant (p<0.001) with a 14% score reduction, a moderate effect size and SRM at 0.97 (0.85–0.11) and 1.1 (0.97–1.2) respectively. By factoring in the Minimal Detectable Change statistic of 7.76, the VBCI produced a significant improvement of attitudes in 30% of the participants. Factors associated with less stigmatising attitudes at baseline were previous psychiatry-related training, desiring psychiatric training, and positive contact with people with mental illness.ConclusionsThis is the first study in Malaysia to show that a brief VBCI is effective in improving attitudes of primary care nurses towards people with mental illness in the immediate term. Further studies are needed to determine if these results can be sustained in the longer term and generalizable to other health care professionals. Qualitative studies are warranted to provide insight to the factors correlating to these attitudes. (300 words)

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Major depression is a risk factor for suicide, accounting for up to 60% of suicides.(1-4) The literature has shown that a large proportion of patients who died by suicide had made contact with a primary care health provider within the three months preceding their deaths.(5-7) Patients who died by suicide were also more likely to visit their primary care practitioner than a psychiatrist.(6) This suggests that primary care practitioners are in a unique position to identify at-risk individuals and possibly intervene. (6,8,9) Primary care practitioners have been identified as one of the key potential gatekeepers in suicide prevention efforts.(10) Despite this, not all primary care practitioners routinely ask about suicide in depressed patients. WHAT CAN I DO IN MY PRACTICE?There are concerns that enquiring about suicide in patients who are depressed may trigger suicide, but evidence has shown this to be untrue. (12) Acknowledging and discussing suicide may reduce, instead of aggravate, suicidal ideation. Asking about suicide may help primary care physicians to identify high-risk patients who require urgent intervention (such as hospitalisation) and to uncover risk factors, some of which are amenable to intervention. (9) There are numerous tools to screen for suicide risk. One of the more widely used suicide assessment tools is the SAD PERSONS scale. This is a ten-item mnemonic, which was first developed as a tool for medical students and non-psychiatrist physicians to guide suicide risk assessment.(13) The use of the tool has been found to improve identification of persons with suicidal ideation. (14) The letters in the mnemonic represent demographic, behavioural and psychosocial risk factors for suicide (Box 1). Each risk factor that is present is accorded a score of 1 point, for a maximum of 10 points. Patterson et al recommended that: (a) patients with scores of 3-4 should be closely monitored; (b) hospitalisation should be strongly considered for those with scores of 5 and 6; and (c) patients with scores of 7-10 should be hospitalised for further assessment.(13) A systematic review of the performance of the SAD PERSONS scale in the clinical setting concluded that it did not acutely predict suicide behaviour. (15) Nonetheless, it is an easy scale to remember and use in the primary care setting.Information acquired via such assessment tools can add to the overall information obtained during a thorough suicide assessment. However, a systematic review concluded that there was insufficient evidence for the usefulness of suicide risk screening tools and that suicide assessment tools should not replace a thorough suicide assessment. (16) Each risk factor that is present is accorded a score of 1 point, for a maximum of 10 points.Patterson et al (13) recommended:• Close monitoring for patients with scores of 3 to 4• To strongly consider hospitalisation for those with scores of 5 and 6• Hospitalisation for further assessment for patients with scores of 7-10Note: Regardless of the score obtained, overall clinic...

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Ketamine has shown effectiveness as a rapid-acting antidepressant with antisuicidal effects in terms of reduction of suicidal ideation in the short term. However, the evidence for long-term maintenance ketamine therapy for treatment-resistant depression (TRD) and suicidal behavior is limited. This case series (N=13) highlights the role of adjunctive

Media guidelines on safe suicide-related reporting are within the suicide prevention armamentarium. However, implementation issues beleaguer real-world practice. This study evaluated the perspectives of the Malaysian media community, persons with lived experience of suicidal behavior (PLE), and mental health professionals (MHP) on suicide-related reporting in terms of the impact, strategies, challenges, and the implementation of guidelines on safe reporting. Three focus group discussions of purposively sampled Malaysian media practitioners (n = 8), PLE (n = 6), and MHP (n = 7) were audio-recorded, transcribed, coded and thematically analyzed. Inclusion criteria were: English fluency, no clinical depression or suicidal ideation (current), no recent previous suicide attempts or suicide bereavement. Three major themes emerged: (1) Unsafe Reporting; (2) Impact; and (3) Safe Reporting. Most described current reporting as unsafe by being potentially triggering to media users and may contribute to contagion effect. Positive impacts identified included raised awareness toward suicide and its prevention. Unsafe reporting was attributed to inadequate awareness, knowledge, and guidance, lack of empathy and accountability, job-related factors, popularity-seeking, lack of monitoring and governance, and information source(s) with unsafe content. Majority agreed on how suicide stories should be framed to produce a safe report. The media community diverged on how detailed a suicide story should be. Safe reporting challenges included difficulties in balancing beneficial versus harmful details, social media ubiquity and its citizen reporters. Participants suggested these safe reporting strategies: stakeholder engagement, educational approaches, improving governance and surveillance, and guidelines revision. Most acknowledged the relevance of guidelines but were unaware of the existence of local guidelines. Implementation challenges included the dilemma in balancing media industry needs vis-à-vis safe reporting requirements, stakeholder engagement difficulties and social media regulation. There is poor awareness regarding safe suicide-related reporting across all groups. PLE and MHP were negatively impacted by current unsafe messaging which aggravated trauma and grief reactions. Postvention support gaps for mental health professionals were highlighted. Safe reporting promotion strategies should include stakeholder engagement to increase awareness on minimizing Werther and maximizing Papageno effects. Strategic re-examination and dissemination of local media guidelines to address new media issues, and effective surveillance mechanisms, are crucial in sustainable improvement of safe reporting practices.

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