This interesting paper explores young people’s views and experiences of primary care for suicidal behaviour and/or self-harm. Here suicidal behaviour refers to suicide ideation, plans and attempts; self-harm refers to self-injury or self-poisoning regardless of suicidal intent.

Self-harm and suicide prevention in young people are global public health priorities. Suicide is among the leading causes of death in young people worldwide (WHO, 2014) and rates of self-harm and suicidal behaviours in the young are prevalent and increasing (NHS Digital, 2017). As many as a quarter of 17-year-olds were recently reported to have self-harmed in the previous year (Patalay et al., 2021). We know that self-harm in young people increases the risk for future suicide and early mortality substantially (Hawton et al., 2020). Intervention approaches that support early recognition and response to suicidal behaviour and self-harm in the young are therefore vital in suicide prevention efforts.

Primary care is one community-based setting well-positioned to make a difference. Around half of those reporting self-harm have been in contact with a General Practitioner (GP) in the six months prior to self-harm (Sayal et al., 2014). Data from healthcare records show that help-seeking in those at risk of suicide increases in the weeks before death by suicide (John et al., 2020) and just under a quarter of young adults will have seen a GP in the month prior to taking their own lives (Luomo et al., 2002). A GP visit is a vital opportunity to identify, assess and manage suicide risk.

GP and healthcare professionals have outlined service-level and individual factors that challenge and facilitate the provision of care around suicidal behaviour and self-harm for young people (e.g. Michail & Tait, 2016). But missing from our understanding is an adequate focus on youth needs and a failure to sufficiently incorporate young people’s perspectives on the care and risk assessment process for suicide and self-harm in general practice. This study aims to redress this omission, and inform future provision, by finding out what young people have to say about their experiences of care practice for suicidal behaviour and/or self-harm and importantly what they think good practice should look like.

Methods

The study uses qualitative methods to gain insight into young people’s experience and views and findings are presented in line with a consolidated reporting checklist. Ten participants (seven identifying as female and three as male) aged between 16-24 years (mean age 20.67 years) took part. All had experience of discussing suicidal behaviour and/or self-harm with their GP (and in seven cases had undergone a risk assessment). They joined one of two face to face focus-groups in youth service settings in Perth, Australia each lasting around 75 minutes. They were recruited via convenience sampling and were remunerated for their time.

Sessions followed a semi-structured, open-ended interview schedule which was developed in collaboration with a youth advisor and young person’s consultation group, and pilot tested with young people. The schedule explored perceptions and experiences of ‘risk’ and assessment processes for suicidal behaviour and/or self-harm; barriers and enablers to help-seeking in primary care; considerations for GPs when responding to disclosure and communicating with young people about suicidal behaviour and/or self-harm; and suggested ways to improve practice.

Data were analysed using Thematic Analysis (Braun & Clarke, 2006) with disconfirming case analysis conducted to accommodate dissonant cases and a reflexive process including memo-writing. Transcripts were second coded by an author independent of the study and consensus for the codes and thematic structure was reached among the authorship team.

Results

Five themes were identified:

1. Collaborative and ongoing dialogue

Young people wanted their GP to be the one to initiate a conversation about mental health and suicidal behaviour/self-harm. They felt young people might not know what to expect from a GP and wanted that information as well as greater transparency and agency around treatment decisions.

2. Loss of privacy when disclosing risk

Young people were concerned about the consequences of disclosure. They worried about confidentiality and the privacy of their medical records and wanted greater clarity about the information held about them and what would happen to it.

3. Labels, assessment and risk

Young people described negative connotations of ‘risk’ or being ‘assessed’, preferring a less intimidating and less stigmatising focus e.g. on ascertaining ‘wellbeing’. Risk assessment tools were seen as blunt instruments liable to miss important nuance, and concerns were voiced that inflexible/binary categorisations of risk invalidate the needs of some. Young people wanted acknowledgement of individual experiences and needs in the round (both difficulties and protective factors).

4. GP attitudes

Young people recognised that perceptions of GP attitudes towards suicidal behaviour/self-harm (communicated verbally and non-verbally) influenced comfort disclosing and discussing mental health. Trusting and opening up to a GP was more likely where non-judgmental, friendly concern and active listening was shown rather than perceived tick-box questioning. Young people recognised the tension between the time needed to build a genuine connection and the time constraints of a consultation.

5. Provision of practical support

Having a GP explore practical resources or even rehearse how to access them rather than simply signpost was felt to be instrumental in enhancing the likelihood that they would be adopted. An active follow-up to check-in and provide further guidance if needed was also advocated.

Conclusions

The authors conclude that findings identify concerns and priorities for young people, as well as critical components of good clinical practice, that will help inform what constitutes youth friendly best-practice for suicidal behaviour and self-harm in primary care.

Strengths and limitations

There is a good rationale for this work. The importance of a GP consultation as an opportunity for early intervention is recognised, so too the need for holistic, psychosocial risk assessments and open communication around suicidal behaviour and self-harm. What this study provides is a platform for young voices to contribute to debates around how best to deliver this care for youth. Noteworthy is the sound qualitative methodology to strengthen interpretation and conclusions and the robust participatory framework involving young people in study development and design. Participant validation of the findings would have further enhanced credibility. It would be nice to see young people’s involvement in dissemination strategies.

Although it is stated that young people’s views were well aligned within and across groups, it is not clear how representative across participants the illustrative quotes are, as they are only assigned by gender and group allocation. Given the age range of participants and sensitive nature of the research focus, it would be useful to hear a little more too about the focus group process and steps taken to mitigate any power imbalance among the groups and with facilitators.

The authors underscore the importance of supporting autonomy and scaffolding understanding where necessary. This is good practice for any patient-centred consultation, but particularly so for young people and it is good to see reference of the need to be sensitive to an emerging sense of identity, agency and capacity for decision-making in young people. Additional emphasis on the need to tailor to distinct and changing developmental needs across the broad span of childhood and adolescence would be helpful, particularly where behaviours may emerge at an early developmental stage.

Additional exploration of the ways in which GP-patient conversations may need to change in response to need or risk – and the impact on therapeutic connection – as well as steps to mitigate disruption would be of interest (e.g. where patients are not able to see the same GP). Discussion of practice in the context of remote or digital consultation, a growing method of conducting patient consultation pre-Covid and increasingly relevant now, would be a timely and necessary extension.

Implications for practice

A primary strength of the study is the practical and often simple recommendations from young people which they propose to assist the therapeutic relationship (e.g. friendliness, compassion, open body language, more explanation). These small changes would likely support and optimise confidence in communication for all parties and are useful training targets. The findings complement and extend existing knowledge around assessment and care but also reinforce the importance of delivering on accepted good practice (such as providing a follow-up consultation). We gain much needed context of the impact of practice at an individual level.

It would be nice to see further work look to involve young people with clinicians in exploring issues around the implementation of some of these recommendations (e.g. rehearsal of accessing resources in primary care). The authors point to potential standardised clinical decision support systems and electronic resources to support disclosure. It is unclear if young people discussed such approaches in the study. Exploring the delivery of these tools with young people would be an important addition to understanding their feasibility, particularly given the apprehension reported here around privacy and the recording of personal data.

Statement of interests

Jo Lockwood who wrote this blog has worked with one of the study’s authors (MM) on a non-related project.

Thanks to Matt Horrocks for comments on this blog.

Links

Primary paper

Bellairs-Walsh I, Perry Y, Krysinska K, Byrne SJ, Boland A, Michail M, Lamblin M, Gibson KL, Lin A, Li TY, Hetrick S, Robinson J (2020) Best practice when working with suicidal behaviour and self-harm in primary care: a qualitative exploration of young people’s perspectives. BMJ Open 

Other references

Braun V, Clarke V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2):77-101.

Hawton K, Bale L, Brand F, Townsend E, Ness J, Waters K, Clements C, Kapur N, Geulayov G. (2020) Mortality in children and adolescents following presentation to hospital after non-fatal self-harm in the Multicentre Study of Self-harm: a prospective observational cohort study. Lancet Child Adolesc Health.

John, A., DelPozo-Banos, M., Gunnell, D., Dennis, M., Scourfield, J., Ford, D., . . . Lloyd, K. (2020). Contacts with primary and secondary healthcare prior to suicide: Case–control whole-population-based study using person-level linked routine data in Wales, UK, 2000–2017. The British Journal of Psychiatry, 217(6), 717-724

Luoma  JB, Martin  CE, Pearson  JL (2002) Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry 159:909–16.

Michail M, Tait L. (2016) Exploring general practitioners’ views and experiences on suicide risk assessment and management of young people in primary care: a qualitative study in the UK. BMJ Open 12;6(1)

NHS Digital (2018) Mental health of Children and Young People in England, 2017  accessed 6 Jan 2021

Patalay, P., & Fitzsimons, E. (2021). Psychological distress, self-harm and attempted suicide in UK 17-year olds: Prevalence and sociodemographic inequalities. The British Journal of Psychiatry, 1-3

Sayal  K, Yates  N, Spears  M, et al (2014) Service use in adolescents at risk of depression and self-harm: prospective longitudinal study. Soc Psychiatry Psychiatr Epidemiol ;49:1231–40

World Health Organisation (2014). Preventing suicide: a global imperative. accessed 6 Jan 2021

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