Three-quarters of suicide deaths occur in low and middle-income countries (LMICs). Despite recent calls to advance the research agenda surrounding suicide, there is a dearth of evidence supporting effective strategies for early identification and prevention in low-resourced, culturally diverse contexts. To respond to the lack of mental health services in LMIC, there has been rapid dissemination of task-shifted interventions (the redistribution of health tasks from specialized providers to low-level or community-level workers) to treat common mental disorders, but these lack suicide-specific protocols. Given the high mortality of suicide, there is critical and urgent need to incorporate implementation strategies for suicide risk detection and referral within these programs. This young investigator grant will provide expert mentoring in adapting and implementing task-shifted suicide prevention evidence-based practices in a low-income setting. This project is situated in Nepal, a member of the South-East Asian region that holds the largest proportion of the world's suicides and some of the highest suicide rates. We propose to explore several multi-level strategies for suicide prevention that have growing evidence-base in LMIC (e.g., screening, safety planning, and brief intervention contact) and adapt and pilot the implementation of a suicide prevention package (SuPP) in a low-resource setting. Infrastructure for this research includes collaborators and staff at Kathmandu University's Dhulikhel Hospital (KUDH), the community's existing multilevel task-shifted intervention for depression, and mentor Dr. Lakshmi Vijayakumar's expertise testing suicide prevention EBPs in India. We use mixed-methods to complete three aims: (1) explore the multilevel targets of a Suicide Prevention Package (SuPP) including health system, institutional, provider, and patient preferences for cultural adaptation and optimization; (2) Create the initial implementation toolkit and training manual for SuPP for health system implementation; and (3) Conduct a small open, non-randomized, pilot trial to assess the feasibility and acceptability of SuPP within the existing health system.
To accomplish these aims we will use the Dynamic Adaptation Process (DAP)and EPIS framework (Exploration, Preparation, Implementation, Sustainment). Qualitative in-depth interviews (n=60) with health system stakeholders and staff, community counselors, and adults with lived experience of suicidal behavior (SB) will address Aim 1 (exploration phase). For Aim 2, the establishment of an Implementation Resource Team of health staff (IRT, n=12) at KUDH and a Community Advisory Board (n=15) of individuals and caretakers of mental health service users with lived experience of SB will guide a systematic adaptation of components included and implementation strategies for the Suicide Prevention Package (SuPP). Aim 3 will include an open pilot trial testing the implementation of SuPP in KUDH with 12 health workers (including 2 community counselors) and 25 enrolled eligible participants at risk for suicide. This project will inform how task-shifted models for mental health care can successfully integrate suicide prevention practices, ultimately saving lives and improving community-based mental health services. Our work will result in a suicide prevention package and adaptation process that can be utilized in diverse and disadvantaged settings around the world.
