Lack of specialist knowledge and clinical skills

There was consensus among GPs about the lack of learning modules on youth suicide prevention. Although GPs felt relatively confident in dealing with general mental health problems, they felt ill-equipped to assess and manage effectively suicide risk in young people. Uncertainty about specific youth suicide predictors as well as a weighting approach to accurately identify risk emerged from GPs’ narratives.[…] family history, writing about death, expressing hopelessness, planning (…) poverty, I mean, I think I probably (I would tick) to most of those, actually. So, I suppose, what I don't have a sense of what weighting to give, you know, are there five there that, you know, if you tick yes to all five then actually you're in the red zone, I don't really… (GPF2 FG1)

Equally challenging for GPs was the accurate recognition of warning signs and how to distinguish between signs indicating imminent suicide risk from behavioural and affective changes that form part of ‘normal adolescence’. Linked to this was a general uncertainty among GPs about distinguishing between what they called ‘truly suicidal behaviour’ and a ‘cry for help’ in young people. This meant they often felt uncertain about management options, that is, when to make a referral to secondary mental health services and how to appropriately respond to a ‘cry for help’ particularly when it comes to young people engaging in self-harming behaviour.It's very difficult to find who's really suicidal because, as I said, we do, most of the time, they will not come here and say I'm suicidal. Yes, there are a few of them, again, I don't know how much (…) they're young people but they're (…) the one if they are depressed, they do use it as, you know, this cry for help, whether they're actually, most of the time it happens, they're actually not going to do anything about it, and, but they just trying to get some attention, or some help at the time. (GP FG4)…Which ones should we arrange further review for or the crisis team etc? Who is safe for us to keep and monitor in whatever time period that is and who needs actually to be seen now by somebody else? (GPM1 FG1)

GPs highlighted the importance of open communication and direct questioning about suicide as a way of facilitating disclosure and combating suicide-related stigma. However, the majority of GPs expressed concerns about the optimal way of communicating openly with young people during consultations. Building rapport and finding the most appropriate way of asking sensitive questions, particularly when dealing with young people who were not forthcoming, had very complex presentations, or were accompanied by a parent, made the risk assessment process very challenging for GPs.(…) but with the younger people, as I said, probably, I think it is difficult, they wouldn't be that much forthcoming which is sometimes (…), sometimes they are good as well, don't say that everybody is the same. But sometimes it can be a bit difficult as well, or they will say, Oh, we don't want to discuss (…) (detail) if it brings the things back, because mostly (…) people, there's something, you know, more deep-rooted or they don't want to talk against, if there's something in the family, if they've come in with the family, that sometimes can be a bit difficult. (GPF FG4)

An additional challenge that some GPs faced was balancing confidentiality and disclosure of risk when working with at-risk young people, particularly those under 16. GPs were concerned that the need for breaching confidentiality could potentially alienate young people and impede a trusting doctor–patient relationship. Reflecting on their ability to strike a balance, GPs acknowledged certain skill deficits in how to appropriately phrase questions and communicate the need for parental involvement where they felt it was necessary:…the times that I've often said, would you like me to speak to your mum or dad, I am quite concerned about you, they always, I don't know what I say, but they always say No thanks, I don't want you to talk to them…I'd quite like to be able to know what I'm saying wrong. (GPf6 FG1)

Patient-related barriers

GPs talked extensively about patient-related barriers to suicide prevention with lack of help seeking and an unwillingness to reveal the true extent of distress and suicidal intentions identified as the most significant issues. GPs also believed that young people who are ‘truly’ suicidal and have a dedicated plan would most likely not seek help or share their plans with their GP.(…) the majority of them that had gone out and killed themselves hadn't come in to tell us about it first. We hadn't seen one of them for two years, and one I'd seen with her daughter but she'd never presented on her own…So they don't, they don't come in. If they're going to do it, they're going to do it. (GPR F2)

GPs also identified that the involvement of caregivers in consultations could sometimes prove to be counterproductive. GPs acknowledged the importance of involving caregivers in consultations and encouraged young people to reach out to friends and family for help. However, they expressed concerns that in some cases such involvement could hinder an open communication with young people by preventing them from revealing the true extent of their distress, symptoms or suicidal ideation:(…) if they've come in with the family, that sometimes can be a bit difficult. I do always offer if I think that, you know, the mum is here, dad is here, and that, and they're not coming up with anything, I do offer them, would you like me to ask mum or dad to go out? Sometimes, they do, you know, and we do it, but sometimes probably they know that (…) if they go out, they will know that probably they are going to tell me anything so it can be, I think it all depends on individual really… (GP FG4)

Organisational barriers

Difficulties in accessing secondary mental health services, dysfunctional referral pathways and lack of communication with mental health providers were identified by GPs as significant obstacles to the effective management of suicidal young people.I think that's something that a lot of GPs empathise with. [laughter] The sort of the long waiting times and those phone calls to the crisis, (…) and obviously, although we do whatever we can but they are (referring to crisis team) the specialism, isn't it, psychiatry? So then we want some specialist help sometimes, there can be a bit of a resistant (there), you know, taking the patient over. (GP FG4)

What the above account reveals is GPs’ frustration with having to ‘force’ crisis teams to consider patients they felt were high priority. This alludes to poor communication with crisis teams primarily due to the lack of clarity about the severity levels of risk required for referral. The following account is indicative of poor liaison between primary care and mental health professionals.But some day, we do find it a bit difficult for the crisis team to take, Oh, have you done that? you've seen the patient yourself? and it looks like, come on, I'm telling you what I know, and it can be sometimes a bit of, you know, battle of, please take it, (…) we don't want to take it. (GP FG4)

Practice constraints such as time limited consultations and a heavy workload were perceived by GPs to be significant barriers to conducting a thorough suicide risk assessment. This often left GPs feeling frustrated and concerned that they only get to see ‘a snapshot’ of young people's lives in a 10 min consultation which makes it is very difficult to form an accurate picture of the social context and circumstances to reliably assess risk. GPs reported that very often assessment of risk and associated management is based on clinical judgement or ‘gut feeling’ with all GPs emphasising the need for regular review of at-risk young people along with a ‘watch and wait’ approach for depression. One GP said:I think the other thing which is difficult is most of the time, especially in the younger people, it is very more circumstantial, I don't know, broke up with a boyfriend, you know, new relation, bit of a stress in the family situation, maybe some abuse, and the problem is only come and see us for the ten minutes, so it can sometimes be quite difficult and most of the management is usually done, the community counselling, so this kind of an engagement to see them that regularly, can be sometimes quite a bit challenging really. (FG4)

Provision of specialist education

GPs acknowledged the need for specialist education to improve their knowledge and clinical skills in the assessment and management of suicide risk in young people. There was general consensus that further education on youth-specific suicide predictors, including those related to the social context (eg, bullying) of young people would be valuable for GPs. Having a list of questions to use during consultations followed by training on how to ask these questions would alleviate GPs’ anxiety related to professional performance and would provide a benchmark for good practice in the assessment and management of suicide risk in primary care. Training on how to effectively involve family members in consultations without jeopardising doctor–patient confidentiality was also highlighted.

In terms of clinical skills, GPs emphasised the need for specialist training on communication and managing challenging consultations with young people. They proposed the involvement of young people in the delivery of such training to obtain their views and expectations from a GP consultation.(…) comm- communication skills for the younger, younger, adolescents…really. Because they switch off, when you ask them questions (…). Yes, [agreeing with receiving training on how to ask sensitive questions], but also, what to do when you reach a blank wall. (GPRM6 FG3)

Enhancing GPs’ therapeutic skills was a recurrent theme emerging from the data. GPs acknowledged that consultations are primarily focused on assessment and pharmacological management with very little therapeutic input. Providing GPs with the necessary clinical skills to deliver brief psychological interventions and counselling to manage distress was suggested to significantly facilitate consultations with young people by enhancing engagement and management options.Something that I did a few years ago was a workshop and some brief interventions in psychology and it was quite helpful…it was quite good. I'd like a refresher in that really because we, do a lot of questions, me asking questions, we go over a lot of things which, I suppose, to them, it is, for us, it's educational for them, it may be going over more of the negativity that's brought them to us (…) in the first place, and like you say, I'd like to be a then, to be able to take that, and be able to offer something back which is, which has to be (necessarily) fairly brief, but still (…) be effective as possible. (FG1 GPm5)

Educational content and implementation

GPs expressed their views on optimal, feasible and acceptable ways of developing and delivering an educational intervention to support them in the identification and management of suicide risk in young people. Small, face-to-face group training in practice during clinical meetings or with multiple practices and a cross-section of GPs’ length of experience was proposed. Online resources were proposed as a practical and cost-effective way of supplementing the main training session. GPs highlighted the importance of adapting the training for different learning styles and years of experience.I think online are a good back-up for people who are time-pressed but I don't think there's anything to beat actually meeting in small groups, and particularly with, not just your own practice, I think it's really useful to, at cross (practice) event for, like, you know, for like, this focus group, but, you know, groups of say, up to fifteen or so, where, you know, there's enough conversation going without people feeling too intimidated but also, supported. And a cross section of experienced and younger GPs as well, because we do learn from each other. (FG3 RF1)

For the successful delivery and implementation of the intervention, GPs emphasised the role of a professional with a good understanding of the role of GPs and experience in conducting risk assessments. There was consensus that a GP with youth mental health expertise would be the most suitable trainer supported by a representative from the mental health provider (eg, CAMHS or crisis teams). A short film or video clip on young people's experiences and views on how to improve GP service provision was supported by most GPs.I think that [referring to the involvement of young people in the delivery of training] would be really good…or even (…) what we do is what we think is right from our point of view, but we may be doing something completely, ignoring something which is important for these young people. I think that would be very good. To know what they're [thinking]. (FG4)

Provision of suicide risk assessment tool

As a way of addressing communication challenges between GPs and the mental health provider, some GPs supported the use of a mutually agreed validated suicide risk assessment tool across primary and secondary care that would facilitate the accurate identification of those at-risk and inform decision-making about their management.Yeah, the other thing is, if you had a threshold or a score, it would help us convey very simply to someone like the crisis team the level of risk that's involved. So if the score was out of twenty, and we can say, I'd like you to review this young man who I think may be suicidal and he's got a score of eighteen out of twenty on the (PRIMIS) score, then, again, I think that's a way of communicating between professionals so that everyone realises, because otherwise, that can be very frustrating about having to almost repeat your entire consultation that you've just spent sometimes twenty, thirty minutes or even more doing, you're pretty confident by that point that they are at risk, but it's then being able to convey that to other people…so I think that's why, in an increasingly, you know, combative world, that's why we quite like things that are very solid that we can rely on. (FG1 GPm1)

However, the majority of GPs reported serious concerns about the usefulness and acceptability of such a tool and its potential impact on the dynamics of a consultation. Concerns about its predictive validity and the possibility of its use leading to inappropriate referrals (false positives) or to high-risk cases not being correctly identified (false negatives) were also voiced. One GP who opposed to the use of screening tools raised concerns about assessing psychological problems in the same way as physical problems:It's more difficult, though, isn't it, the psychological problems rather than physical where you say temperature is, blood pressure is…pulse is… (FG1 GPm4)

Instead, GPs supported the use of a guided decision-making tool that would facilitate a standardised way of recording risk history, ongoing social circumstances and informing clinical decision about management options.Unless it [referring to risk assessment tool] was reliable, unless it actually actively…related to risk, you could then (underrate) people who were actually at risk, or overate loads of people. And it might be unhelpful…I mean, it's quite difficult, like, five questions more helpful than thirty years of GP experience, and likely to aid anything… (FG3 RF2)