Implementing Suicide Prevention Into Primary Care in Nepal

Official title

Integrating a Suicide Prevention Package of Strategies Into Decentralized Primary Health Care Systems: an Implementation Pilot Study in Rural Nepal

Overview

Suicide remains a major contributor to global mortality, with particularly high and persistent rates in low-resourced settings such as South Asia. In Nepal, ongoing integration of mental health services into primary care provides a critical opportunity to strengthen suicide risk assessment and management. Despite the scale-up of mhGAP training for primary care providers (PCPs), gaps remain in the systematic detection, referral, and follow-up of individuals at risk for suicide. There is an urgent need to enhance mhGAP implementation with strategies that address provider workload, stigma, and inequities within the health workforce. Using experience-based co-design principles and RE-AIM this study will assess the feasibility and acceptability of integrating an implementation strategy package to optimize mhGAP suicide prevention delivery in Nepal's decentralized primary healthcare system. This clinical trial leverages deep collaboration with a community advisory board of individuals with lived experience of suicide throughout the trials' design, delivery and analysis. This R34 will generate critical preliminary evidence on the feasibility, acceptability, and implementation of an integrated suicide prevention package within government primary care facilities in Nepal. The findings will inform the design and parameters of a future fully powered effectiveness trial, while aligning with Nepal's national suicide prevention strategy and advancing WHO and NIMH global mental health priorities.

Interventions

• Behavioral Suicide Prevention Package (PSuPP)
  Implementation package to optimize mhGAP siucide prevention delivery which includes: \[assessment optimization\] systematic assessment training using systematized screening questions, an embedded decision-support tool, \[risk management optimization\] culturally adapted safety planning, and \[follow up care optimization\] a collaborative care protocol with CHWs to support patient follow-up uptake and continued care.

Primary outcome measures

• Percent intervention arm uptake to assess feasibility [Time frame: 6 months]
• Percentage of interviews that hold themes [Time frame: 6 months]
• Percent retention to assess feasibility [Time frame: 6 months]
• Structured checklist to assess fidelity [Time frame: 6 months]
• Percent successful allocation procedures [Time frame: 6 months]
• Percent adherence to the randomization protocol [Time frame: 6 months]
• Percent deviations to the randomization protocol [Time frame: 6 months]
• Percent participants who completed all follow up measures [Time frame: 6 months]
• Percent missing measure items per participant [Time frame: 6 months]
• Mean Beck Scale for Suicide Ideation (BSSI) score [Time frame: Baseline; 3 months; 6 months]

Secondary outcome measures (11)

• Suicide Prevention Knowledge survey [Time frame: Baseline, 3 months; 6 months]
• Mean Self-Efficacy in Mental Health Care survey score [Time frame: Baseline; 3 month; 6 month]
• Mean Clinical Competency and Communication Skills (ENACT) score [Time frame: Baseline; 6 months]
• Columbia Suicide Severity Rating Scale [Time frame: Baseline; 3 months; 6 months]
• Mean Patient Health Questionnaire (PHQ-9) score [Time frame: Baseline; 3 months; 6 months]
• Mean Suicide Cognitions Scale (SCS) score [Time frame: Baseline; 3 months; 6 months]
• Suicide-Related Coping Scale (SRCS) - Internal Coping Skills [Time frame: Baseline; 3 months; 6 months]
• Suicide-Related Coping Scale (SRCS) - External Coping Skills [Time frame: Baseline; 3 months; 6 months]
• Mean Generalized Anxiety Disorder (GAD-7) score [Time frame: Baseline; 3 months; 6 months]
• Mean Social Connectedness Scale score [Time frame: Baseline; 3 months; 6 months]
• Client Service Receipt Inventory to assess health service uptake [Time frame: Baseline; 3 months; 6 months]

Eligibility criteria

Inclusion criteria

Primary Care Providers

• Health workers with a prescribing license employed in government health facilities in Bagmati Province.
• Are between 21-65 years, per government health system criteria.
• Participants will be required to have competency in Nepali, be actively engaged in care provision within their health facility

Patients:

• Patient lives in the study site
• Is under the care of a PCP at a facility site.
• Patient meets any level of suicide risk based on mhGAP 2.0 criteria.
• Patients who have been treated for mental illness before or presently (expected in both groups).
• Speaks Nepali.
• Levels of Suicide Risk (as defined by mhGAP 2.0)

Exclusion criteria

Primary Care Providers

• Healthcare workers without proper government credentials will be excluded.
• Health workers who plan to migrate or who do not intend to stay in the study area for at least a year.

Patients:

• Patient requiring immediate hospitalization
• Unable to consent as determined by the diminished capacity tool.

Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.

Healthy volunteers: No

Study design

Allocation

Randomized

Model

Parallel assignment

Masking

Double blind

Primary purpose

Health services research

Study locations

Nepal · 1 center

• Primary care facilities — Dolakhā

Identifiers

NCT: NCT07362056 · 2000036105 · 5R34MH135122 · 1R34MH135122-01

Primary sources (government registries)

• ClinicalTrials.gov (US NIH)

View this study on ClinicalTrials.gov ↗