Crisis-management, Anti-stigma, and Mental Health Literacy Program for University Students (CAMPUS): A preliminary evaluation of suicide prevention

Participants

One-hundred thirty-six medical students (88 males and 48 females) at the University of Tsukuba, a national university in the Kanto region of Japan, participated in this program as part of a required course. The participants had little knowledge about psychiatry and suicide because they were second-year undergraduates of average age 19.96 years (SD = 1.39; range, 19–29 years).

Contents of CAMPUS

The main lecture is composed of three components, mental health literacy, anti-stigma, and crisis management, each lasting about 20 min, and was created using a Power Point presentation (Microsoft Office PowerPoint 2016). A handout with “fill in the blanks” format is distributed to the students. In addition, CAMPUS includes two exercise sessions. In the first gatekeeper training session, students watch a 13-min gatekeeper training film showing student consultation scenes produced by the Ministry of Health, Labour and Welfare of Japan (2016). Next, they are divided into groups of three and perform a close listening exercise and discuss the importance of listening on outcome. This session requires about 30 min and is performed in combination with the second lecture on crisis management. In the second role-playing session, new groups of three perform two role-playing exercises in which they are assigned roles of a student with self-stigma (i.e., problems with mental illness, gender identity, and bullying) or suicide thoughts, a friend who listens to the student, and an observer. After the “student” reads a detailed scenario, he consults about his issues to the friend for a few min. Thereafter, the group discusses how the “student” can resolve these issues, how to proceed with consultation, and the mental issues faced by the “student.” One role-playing session with discussion requires about 30 min. Facilitators trained in the use of CAMPUS monitor and facilitate these sessions. Students also complete various assessment scales before and after the program as detailed below.

Procedures

Prior to the intervention, we explained the importance of suicide prevention education for undergraduate medical students to the educational coordinator staff. It could be implemented within regular or irregular classes only when the university in Japan agreed with it. We obtained permission from the dean of the medical school to implement the suicide prevention education as a required class.

The CAMPUS was conducted using three class hours (one frame, 75 min) in July 2019, with mental health literacy and anti-stigma covered in the first hour, crisis management and gatekeeper training in the second hour, and role-play sessions in the third hour. There was the lunch break between the first and second sessions. The main lecture was conducted by one author who is a psychiatrist at the university. The first author (a clinical psychologist) and three other psychiatrists acted as facilitators.

Self-reported questionnaires were administered before the program (pre-program), immediately after the program (post-program), and six months later (follow-up) in January 2020 to assess CAMPUS efficacy. The follow-up questionnaires were distributed after another class and collected during break time. The participants had no opportunity to participate in classes related to mental health and suicide for the intervening six months.

Measures

We used the following measures to evaluate the general efficacy of the CAMPUS.

Suicide behaviors

The Suicidal Behaviors Questionnaire-Revised (SBQ-R) is a 4-item self-report measure of suicidal ideation (Osman et al., 2001). The total score ranges from 3 to 18. The cut-off point for non-clinical samples is 7.

Depression

The Patient Health Questionnaire-9 (PHQ-9) is a 9-item self-report measure in which each item is scored from 0 (Not at all) to 3 (Nearly every day) as a measure of depression severity (Kroenke et al., 2001; Pfizer, 2014). The total score ranges from 0 to 27, and the cut-off point for non-clinical samples is 5.

Help-seeking intentions

The General Help-Seeking Questionnaire (GHSQ) is a measure of help-seeking intentions for various resources when facing personal and emotional problems (Wilson et al., 2005). Each item is scored on a 7-point Likert scale ranging from 1 (Extremely unlikely) to 7 (Extremely likely). The help-seeking intentions for informal resources (intimate partner, friends, parents, and other relative/family members) and for formal resources (mental health experts, help lines, doctors, and ministers or religious leaders) were analyzed separately in the present research.

Self-efficacy as a gatekeeper

The Gatekeeper Self-Efficacy Scale (GKSES) is a 9-item measure of confidence in gatekeeper skills (Takahashi et al., 2020). The good internal consistency (Cronbach’s α coefficient was.95) and validity were confirmed using data of 875 students. The students answered questions pertaining to gatekeeping skills including their knowledge of suicide prevention using a 7-point Likert scale from 1 (Not at all) to 7 (Extremely).

Self-stigmatize attitude

There is no single scale appropriate to measure self-stigma because the target differs markedly among individuals. Therefore, we used two psychological indices that are closely related to self-stigma. The first was a scale measuring self-acceptance of undesirable attributes by Tsukawaki et al. (2009). The scale consists of eight items such as “I accept naturally my weakness.” Each item is scored on a 5-point Likert scale from 1 (Agree) to 5 (Disagree). The second was the Japanese Self-concealment Scale (JSCS) (Larson & Chastain, 1990; Kawano, 2000), a 12-item scale assessing the tendency to actively conceal negative and distressing personal information from others. Each item is scored on a 5-point Likert scale from 1 (Strongly disagree) to 5 (Strongly agree). Self-concealment is related to suicidality (Hogge & Blankenship, 2020), suicidal behavior (Friedlander et al., 2012), and help-seeking attitudes for psychological professional services (Masuda et al., 2012). Positive changes on these two scales are considered indicative of self-stigma mitigation.

The SBQ-R and PHQ-9 were measured prior to intervention and at the six-month follow-up, while the GKSES, GHSQ, self-acceptance, and JSCS self-concealment scales were measured at all three time points.

Statistical analyses

We hypothesized that participants with strong suicidal ideation at baseline would demonstrate reduced ideation as measured by the SBQ-R if the program is effective, while no such change would be observed in those with low baseline ideation. Conversely, most subjects should demonstrate improved attitudes and competence related to suicide prevention.

Changes in the scale scores were evaluated using repeated measures one-way analysis of variance (RT-ANOVA) with main factors time (pre-program, immediately post-program, and six-months post-program) with post hoc Bonferroni correction for multiple comparisons. The significance level of ANOVA was adjusted by Bonferroni’s correction to p < 0.0083 (p < 0.05 divided by six). When the main effect for time was significant, the Bonferroni test was used for post hoc analyses. The effect size is expressed by partial η² (η_p²). SPSS ver. 25.0 was used for all analyses.

Ethical considerations

Written informed consent was obtained from all participants before the program. All students were informed of program aims and required attendance but that the questionnaires were optional. Follow-up e-mails were sent to students if the program SBQ-R or PHQ-9 score indicated cause for concern. The e-mails stated that they could always consult the University Health Center. The study was approved by the Medical Ethics Committee of the University of Tsukuba (No. 1402-1).

Participant flow

Among the 136 medical students attending the CAMPUS program as required, 121 (79 males and 42 females, 89.0%) completed all questionnaires before and immediately after the program. In addition, 107 students (67 males and 40 females, 78.7%) answered the follow-up questionnaires at six months post-program.

Correlations between pre- and post-program psychometric scores

The correlations between pre- and post-program test scores are shown in Table 1. Pre-program suicidal ideation as measured by the SBQ-R was positively but weakly correlated with depression severity as measured by the PHQ-9 (r = 0.25). Despite greater depression severity among participants at higher scores (showing greater suicidal ideation), SBQ-R was negatively correlated with help-seeking intention for informal resources as assessed by the GHSQ (r = −0.25). Also, SBQ-R was positively correlated with greater self-concealment score (r = 0.37). Poor self-acceptance was more strongly correlated with depression (r = −0.34) than with suicidal ideation (r = −0.19). Self-efficacy as a gatekeeper was correlated with help-seeking intentions for formal resources both pre-program (r = 0.33) and post-program (r = 0.39). Self-efficacy as a gatekeeper and self-acceptance were unrelated pre-program (r =0.04), but significantly correlated post-program (r =0.40).

Longitudinal effects of the CAMPUS

The numbers of participants according to SBQ-R scores pre- and post-program are shown in Table 2. Among 107 participants who completed all follow-up tests, 59 scored 3 (lowest limit) on the SBQ-R pre-program while 48 scored 4 or more (44.9%). Of those, eight people had more than the cut-off points (7). At six-months follow-up, a greater number of participants scored 3 (n = 70) and fewer scored 4 or more (n = 37, (34.6%; p = 0.04 by McNemar’s test). Of those, six people had more than 7 cut-off points. The highest score was 9 points pre-program, but it was 11 points after six months.

Next, average scores for all pre-program, post-program, and follow-up tests as well as the results of one-way RT-ANOVA are shown in Table 3.

Depression scores were below the clinical cut-off point pre-program and at follow-up. The PHQ-9 depression severity scores were reduced at follow-up compared to pre-program baseline, but main effects of time were not significant (F(1, 105) = 0.26, p = 0.61, η_p² = 0.00).

Help-seeking intentions for informal resources were greater in the post-program than in the pre-program, but the main effect of time was not significant (F(1.68, 163.08) = 3.76, p = 0.03, η_p² = 0.04). There was a significant main effect of time on help-seeking intention for formal resources (F(1.57, 157.33) = 14.88, p < 0.001, η_p² = 0.13). Scores were higher post-program, but decreased significantly at follow-up.

There was a significant main effect of time on gatekeeper self-efficacy (F(2, 208) = 142.45, p < 0.001, η_p² = 0.58). Participants demonstrated higher scores post-program, but scores decreased significantly from post-program to follow-up. Nonetheless, the score at follow-up was still higher than pre-program, indicating a long-term enhancement of gatekeeper self-efficacy.

There was also a main effect of time on self-acceptance score (F(2, 210) = 7.55, p < 0.001, η_p² = 0.07), and the participants demonstrated significantly improved scores post-program as well as at follow-up. Alternatively, self-concealment was not changed significantly (F(1.74, 182.80) = 1.25, p = 0.29, η_p² = 0.01).

Limitations

This study has several limitations. First, this study was a one-group pre-post design; hence, it was not possible to randomize or establish a control group due to conflicts with university’s regular courses and educational ethical consideration. The psychological scale scores confirmed after six months should be influenced by a variety of factors that affect the individual during the six months of student life. However, applying for suicide prevention education in Japanese universities is a hurdle due to the framework in which the classes are conducted. Realistically, it would be desirable to be able to compare the results with those of the control group, preferably by means of a crossover study in which the timing of the education is shifted. Second, this study looked at the effects of self-reported selective questionnaires alone. It is necessary to examine the changes in students’ attitudes and actions, which do not appear in the questionnaire, through qualitative methods, such as interviews. Third, although the questionnaire responses were voluntary, attending the CAMPUS was compulsory. Required participation may have raised gatekeeper self-efficacy and knowledge of suicide, but coercion in education can induce psychological reactance (Brehm, 1966). However, suicide prevention programs for elementary and junior high schools are similarly required, and required classes do not always have a negative impact on students. Nonetheless, it is necessary to consider how the form of education affects the program.