Training General Practitioners in Bulgaria to Reduce Suicide Rate: A Controlled Study

The purpose of this project is to improve the management of suicide and common mental disorders by general practitioners (GPs) in Bulgaria. The study uses a natural experiment design which utilizes a training program aimed at improving GPs management of suicide risk and detection. The training program will be offered to four regions (North East, South West, South Central, South East), leaving two regions for control (North Central, North West), in order to evaluate the effect of the intervention. Thus, the study's outcome variable will be suicide rate, while region will be study unit.

The project is a collaboration between The National Centre of Public Health and Analysis (NCPHA) and The Norwegian Institute of Public Health. In short, NCPHA is responsible for coordination, management and implementation, while The Norwegian Institute of Public Health (NIPH) will provide advice for highest possible quality and effect of the intervention. The NIPH will also evaluate the training program, which will be used to train the GPs to improve their skills in the management of suicide risk, and the recognition and treatment of anxiety and depression.

The suicide rate is higher in Bulgaria compared to several other European countries (WHO, 2015). It is well known that patients often contact their GP days or weeks prior to suicide (Luoma, Martin, & Pearson, 2002). There is also some evidence suggesting that improved management of suicide risk by GPs may successfully reduce suicide rates in the general population (Mann et al., 2005; Pfaff, Acres, & McKelvey, 2001; Rutz, Vonknorring, & Walinder, 1992).

This project will test if an improvement of skills and knowledge in general practitioners (GPs) may reduce the suicide rate in Bulgaria. There are several studies indicating that this might have positive effect on suicide rates (Hegerl, Althaus, Schmidtke, & Niklewski, 2006; Mann et al., 2005; Nock et al., 2008; Pfaff et al., 2001; Rutz et al., 1992; Szanto, Kalmar, Hendin, Rihmer, & Mann, 2007; Székely et al., 2013; WHO, 2014), however there are also studies showing limited evidence for effective suicide prevention interventions and a need for further investigation (du Roscoat & Beck, 2013; Robinson, Hetrick, & Martin, 2011).

The best method for testing effects is a randomized controlled trial. However, we are unable for practical reasons to randomize, hence the project is set up as a controlled trail, where the north east and northern part of Bulgaria serves as the control group for the intervention group being the remaining other four districts of Bulgaria. The regions are selected by the NCPHA on the basis of practical considerations, not within our control.