Standardized patients (SPs) are recognized as an important educational resource in the health care professions. As the use of SPs expands, both age groups and types of simulations represented also expand. Adolescent SPs are now utilized with greater frequency. A literature regarding the many benefits and limited risks associated with adolescent SP work supports this increased activity.1,2,3,4 While the use of adolescents enhances the range of possible scenarios, certain case simulations may present greater risk for adolescents than others,1 necessitating research into the specific risks and benefits associated with these simulations. Suicidality case simulations represent one such category of simulation.1 Although adolescent SPs have been employed in simulations of suicidality, assessment of risks and benefits has not been undertaken.5 Our psychiatric OSCE group has recommended caution regarding the use of adolescent SPs in psychiatric case simulations until research evaluates such risks.6 One hypothetical risk associated with adolescent SPs performing suicidality simulations is suicide contagion.
Suicide contagion refers to the link between adolescents' exposure to a “suicide” stimulus and subsequent rise in suicide attempts or suicide rate.7 Contagion is considered most likely to occur in already suicidal adolescents and to be a time-limited risk, lasting two weeks.8 Suicide stimuli include media coverage of a real suicide or fictional depictions of suicide in movies or television programming.8 Although the risk of suicide contagion has not been raised in the SP literature, it has been raised in the child psychiatric literature pertaining to school-based adolescent suicide prevention programs. School professionals have been cautioned regarding the delivery of these programs to unscreened adolescents because of the phenomenon of suicide contagion and the negative reaction of adolescents with suicidal histories to such programs.9,10 School-based adolescent suicide prevention programs commonly employ videos, interviews with suicide attempters, plus information regarding adolescent suicide, psychopathology, and development.11 These programs' curricular resemblance to SP training methods further emphasizes the need for investigation of the possibility that suicide contagion may be a risk associated with suicidality simulations.
The implications of suicide contagion for SP programs that use adolescent suicidality simulations warrants investigation. This study investigated suicidality backgrounds among SP applicants who were considered at hypothetical risk of suicide contagion.
This research received scientific and ethical approval from the University of Toronto Research Ethics Board. Adolescent SP applicants were screened for suicidality backgrounds. Screening methods were the Achenbach Youth Self Report (YSR), Child Behavior Checklist (CBCL), and SP trainer employment interview. The Achenbach YSR, completed by the adolescents, and the CBCL, completed by one parent or guardian, assessed adolescents' psychological status.12 The SP trainer employment interview assessed employment suitability. This screening data was collected in the context of a larger study that evaluated adolescent SP selection methods and the risks and benefits of SP work. A description of the full study is reported elsewhere.1 Briefly, prospective adolescent SPs were recruited from local high schools. Interested adolescents attended information meetings at the Faculty of Medicine, University of Toronto. At these meetings, study goals and SP selection and exclusion criteria were explained. Adolescent and parent consent was obtained for study participation. Adolescents selected to be SPs were randomly divided into three SP groups: waitlist control, low-stress medical role, and high-stress psychosocial role. A suicidality simulation was not used. The University of Toronto SP Program was employed for SP training activities. Our study SP trainer (NM), Associated Director of this SP program, coordinated these activities and the employment interviews. The study OSCE was the final examination for the second-year clinical methods course for the Faculty of Medicine, University of Toronto, in 1998. The SPs completed multiple simulations interspersed with rest breaks during a full-day OSCE. The SPs were debriefed after the OSCE by means of individual and group interviews. The Achenbach YSR and CBCL were re-administered after the OSCE.
The three screening components are described more fully below.
Achenbach Youth Self Report and Child Behavior Checklist
Adolescent SP applicants completed the Achenbach YSR, and their parents or guardians completed the CBCL.12 These questionnaires were well-standardized, widely-used measures of generalized child and adolescent psychopathology with established reliability and validity. Each questionnaire listed 112 items rated on a three-point scale (not true, sometimes true, and often true). Items were to be answered in reference to adolescents' functioning over the previous six-month period. These instruments generated a “Total Problems Score” plus broadband T-scores for Internalizing (emotional) Problems, and Externalizing (behavioral) Problems. Based on the T-scores the adolescents were placed outside or within the “clinical range” indicative of clinically significant internalizing or externalizing problems. Adolescents who scored outside the clinical range were selected to be SPs. Adolescents who scored within the clinical range were not selected to be SPs because they were designated at potential general risk for adverse simulation effects.1 These designated adolescents completed a brief follow-up interview with the study's child psychiatrist (MH).
Adolescents' suicidality background was identified by two YSR items: “I think about killing myself” and “I deliberately try to hurt or kill myself” or two CBCL items: “Talks about killing self” and “Deliberately harms self or attempts suicide.” Endorsement of one or more of these items on the YSR or the CBCL resulted in an SP's being designated at hypothetical risk of suicide contagion with suicidality simulations. Adolescents were selected to be SPs with this designation in the absence of scores within the clinical range on the YSR and/or the CBCL.
SP Trainer Employment Interview
SP applicants completed an SP trainer employment interview regardless of scores on the YSR and CBCL. This 30-minute interview addressed three areas: (a) work history, (b) attitudes toward the medical profession, and (c) health and background variables. Three health background questions were asked: (1) Do you have any health conditions (e.g., epilepsy, asthma) that might affect and/or inform your work as a SP? (2) Do you have any physical characteristics that could be incorporated into a role (e.g., scars, problem joints, heart murmurs, etc.)? (3) Have there been any serious health or family concerns that you and your family have had to cope with (e.g., illness, death, and divorce)? There was no specific question regarding suicidality or psychiatric history. SP applicants were judged suitable, borderline, or unsuitable for SP employment based on this interview.
In total, eighty-three adolescents (ages 14–16) completed the SP screening. A single adolescent endorsed the YSR item “I deliberately try to hurt or kill myself” and reported a past history of suicide attempt. A small group of adolescents (9%, n = 8, including this single adolescent) reported past suicidal ideation. Of these eight adolescents, seven (again including this single adolescent) were identified through endorsement of YSR suicidality items. One adolescent did not endorse the YSR suicidality items but did score in the clinical range on the YSR and, in the follow-up interview, reported past suicidal ideation. These eight adolescents comprised four girls and four boys. No parent, regardless of their adolescent's response, endorsed the CBCL suicidality items regarding their adolescent.
Of these eight adolescents that reported past suicidal ideation, three scored within the clinical range on the YSR and completed follow-up interviews. These interviews confirmed that all three adolescents had past histories of suicidal ideation and one had a past history of attempt. These three adolescents included the single adolescent who endorsed the YSR item “I deliberately try to hurt or kill myself” and the adolescent who did not endorse the YSR suicide ideation item but reported past suicidal ideation in this interview. Two had received previous psychiatric and mental health treatment, including psychiatric hospitalization. Two wished additional psychiatric consultation. None of these three adolescents was acutely suicidal at the time of the study in the clinical judgment of the study child psychiatrist who completed these interviews.
These three adolescents with clinical Achenbach scores were excluded from SP participation because they were designated at potential general risk for adverse effects. However, all three participated in the SP Trainer employment interview and were considered suitable for SP employment. The SP trainer did not identify these adolescents' suicidality backgrounds.
The remaining five adolescents who endorsed the YSR suicide ideation item were not within the clinical range for their Achenbach scores. These adolescents were designated at hypothetical risk for suicide contagion with suicidality simulations but were eligible for SP participation in other simulations. The SP trainer did not identify these adolescents' suicidality backgrounds. According to the SP trainer employment interview, two of these five adolescents were unsuitable for SP employment. The interview identified one of these adolescents unsuitable for SP employment because she or he lacked sufficient motivation for SP work and the other unsuitable because she or he had a chaotic family background and hostile affect.
Of the remaining three eligible adolescents, two were randomly assigned to be SPs. This represented 5% of the study SPs.1 These SPs were assigned to the high-stress role and completed nine to ten simulations during the OSCE. Neither SP expressed worrisome simulation effects when debriefed. On post-test evaluation with the Achenbach YSR and CBCL neither adolescent scored within the clinical range after the OSCE. One adolescent again endorsed the item “I think about killing myself,” but the other did not.
In summary, eight adolescents reported suicidal ideation and/or attempt. Five of these eight were excluded from SP participation by means of screening instruments: three on the basis that they were designated at potential general risk for adverse simulation effects and two on the basis of employability issues. Of the three SP eligible adolescents, two participated in the study OSCE and neither demonstrated substantial change in the Achenbach YSR and CBCL scores.
The Achenbach questionnaire and child psychiatric interview identified suicidality backgrounds in 9% (n = 8) of our adolescent SP applicants. Based on the literature,7,8,9,10,11 these adolescents can be considered at hypothetical risk of suicide contagion with suicidality simulations. We stress that this is a hypothetical risk. Actual manifestation of this risk and accompanying adverse effects, suicidality, were not documented because a suicidality simulation was not used. Documentation of the presence of a real risk and accompanying adverse effects awaits future research, although such research must proceed with great caution.
Acknowledgment of this risk is important. Since SPs are not real patients, any risk, even a hypothetical one that might alter that status, should be clarified. The policy of “first do no harm” is as pertinent to medical education as it is to medical practice. Cognizant of this hypothetical risk, SP programs and psychiatric educators appear to have two options open to them while risk clarification through future research is undertaken.
One option is to abandon the use of suicidality simulations. This option would eliminate the need for screening SPs for the hypothetical risk of contagion. However, to stop using this state-of-the-art technique for teaching and testing clinical skills in suicidality assessment would have potential harm. Its elimination would constitute a potential risk to real adolescent suicidal patients who require well-trained, skilled medical graduates.
The second option is to proceed with suicidality simulations, but adopt a screening method for suicidality-background identification while research clarifies whether suicide contagion is a real risk. Our screening method for suicidality background comprised clinical components: administration of Achenbach questionnaires plus child psychiatric interviews for applicants with clinical Achenbach scores. This screen identified adolescents with both suicidality backgrounds and Achenbach scores in the clinical range, and provided them the opportunity of referral to psychiatric services. In essence, this screening method provided an ad-hoc suicide prevention program, representing a unique benefit for SP applicants with suicidality backgrounds. Unfortunately, the administration of psychometric measures for such screening requires additional funding and trained personnel. Our study had the luxury of participation by a child psychiatrist and child psychologist, resources unavailable to most SP programs. SP programs may need to consider alternative screening approaches when faced with limited, perhaps absent, clinical resources.
An alternative approach for screening is the SP employment interview. Our study's interview did not identify adolescents with suicidality backgrounds, but it was not designed to do so. This should not be a problem as long as suicidality simulations are not used. Our SPs with suicidality backgrounds were provided the opportunity to obtain the benefits of SP work1 without an untoward change in their suicidality status as measured by the Achenbach questionnaires. However, if the SP employment interview is to be used as a screening method, it requires adaptation by the addition of questions regarding suicidality and psychiatric background.
Adaptation of the SP employment interview in this manner, however, may not be optimum, for various reasons. First, an employment interview might not be an appropriate time to expect adolescents to reveal a history of suicidality. An employment interview is a time when people try to present their best images, and therefore it is not a time to expect disclosure of sensitive information that might lead to rejection of employment. Second, most SP employment interviews are conducted by SP trainers,13 professionals who may not have training in the recognition of psychiatric risk or in the management of such risk if it were revealed. Finally, evidence from our larger study1 suggests that discomfort with portraying suicidality simulations is more pervasive than is implied by suicidality background alone. In that study, 23% of SPs indicated some level of discomfort with simulation of an adolescent who had attempted suicide. The additional task of screening for SP comfort level with suicidality simulations appears necessary. Given our assumption that suicide contagion is a risk only when suicidality simulations are encountered, these points suggest that the SP employment interview may not be the optimum point at which to screen SPs for suicidality simulations. Perhaps this interview should continue to focus upon general SP employability, and simulation-specific screening activity for suicidality simulations be reserved for that time when a SP is being considered for such a simulation.
In this study, one adolescent endorsed the Achenbach YSR questionnaire item: “I deliberately try to hurt or kill myself.” The other seven endorsed or described suicide ideation, but not attempt. Yet, all eight adolescents were designated at hypothetical risk of suicide contagion with suicidality simulations. By contrast, a narrow definition of suicide-contagion risk, used in research regarding adolescent suicide prevention programs9 designated only adolescent with previous suicide attempts at potential risk of suicide contagion. Research should evaluate whether a broad or narrow definition is used when designating SPs at risk of suicide contagion.
Our study has limitations that may restrict generalization of its findings. A suicidality simulation was not used. One might speculate about the impact upon adolescent SP recruitment when recruiting for suicidality simulations. Perhaps the suicidality group would decrease if such adolescents chose to avoid psychiatric consultation, or increase if such adolescents chose to obtain psychiatric consultation. For our study, the applicant screen had individual impact for adolescents if psychopathology was identified. Some applicants may have considered the Achenbach suicidality items indicative of psychopathology and did not endorse them. The suicidality group (9%, n = 8) may, therefore, represent an underestimate of suicidality among applicants. Finally, the small number of SPs (n = 2) from the suicidality-background group limits the strength of our finding that such designated adolescents can participate in non-suicidality simulations with greater benefit than risk.
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