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Abstract Background In 2012, in The Netherlands a multidisciplinary practice guideline for the assessment and treatment of suicidal behavior was issued. The release of guidelines often fails to change professional behavior due to multiple barriers. Structured implementation may improve adherence to guidelines. This article describes the design of a study measuring the effect of an e-learning supported Train-the-Trainer program aiming at the training of the full staff of departments in the application of the guideline. We hypothesize that both professionals and departments will benefit from the program. Method In a multicenter cluster randomized controlled trial, 43 psychiatric departments spread over 10 regional mental health institutions throughout The Netherlands will be clustered in pairs with respect to the most prevalent diagnostic category of patients and average duration of treatment. Pair members are randomly allocated to either the experimental or the control condition. In the experimental condition, the full staff of departments, that is, all registered nurses, psychologists, physicians and psychiatrists (n = 532, 21 departments) will be trained in the application of the guideline, in a one-day small interactive group Train-the-Trainer program. The program is supported by a 60-minute e-learning module with video vignettes of suicidal patients and additional instruction. In the control condition (22 departments, 404 professionals), the guideline shall be disseminated in the traditional way: through manuals, books, conferences, internet, reviews and so on. The effectiveness of the program will be assessed at the level of both health care professionals and departments. Discussion We aim to demonstrate the effect of training of the full staff of departments with an e-learning supported Train-the-Trainer program in the application of a new clinical guideline. Strengths of the study are the natural setting, the training of full staff, the random allocation to the conditions, the large scale of the study and the willingness of both staff and management to participate in the study. Trial registration Dutch trial register: NTR3092

Background: Previous studies found that the implementation of service guideline recommendations can significantly reduce the number of suicides in mental healthcare. Important barriers to suicide prevention guideline implementation are a lack of professionals' knowledge and competence towards the suicide prevention guideline.
AIM: To assess professionals' knowledge of, competence in, and adherence to the suicide prevention guideline in twelve Dutch specialist mental healthcare institutions.
METHOD: In this study, professionals working at crisis teams and outpatient care teams from each of the 12 participating mental healthcare institutions in the network of supranet Care were invited to fill in a questionnaire examining professionals' knowledge of, competence in, and adherence to the suicide prevention guideline (N = 400). Results were analyzed with multilevel regression analysis and adjusted for confounding.
RESULTS: Although professionals scored high on knowledge, competence, and adherence towards the guideline, they did not know to what extent the guideline was implemented within their own team. Outpatient care teams scored significantly lower on professionals' knowledge and reported lower levels of competence. Furthermore, we found significantly higher scores on adherence to the guideline for professionals in crisis teams compared to outpatient care teams. Healthcare professionals also reported practice variation within and across Dutch mental healthcare institutions. CONCLUSIONS Practice variation within and across teams and mental healthcare institutions is undesirable. To reduce this variation, professionals and mental healthcare institutions should share best-practices and learn from each other how the quality of care for suicidal patients can be optimized.

Introduction: Improvement of the quality and safety of care is associated with lower suicide rates among mental healthcare patients. In The Netherlands, about 40% of all people that die by suicide is in specialist mental healthcare. Unfortunately, the degree of implementation of suicide prevention policies and best practices within Dutch mental healthcare services is variable. Sharing and comparing outcome and performance data in confidential networks of professionals working in different organisations can be effective in reducing practice variability within and across organisations and improving quality of care., Methods and Analysis: Using formats of professional networks to improve surgical care (Dutch Initiative for Clinical Auditing) and somatic intensive care (National Intensive Care Evaluation), 113 Suicide Prevention has taken the lead in the formation of a Suicide Prevention Action Network (SUPRANET Care), with at present 13 large Dutch specialist mental health institutions. Data on suicide, suicide attempts and their determinants as well as consumer care policies and practices are collected biannually, after consensus rounds in which key professionals define what data are relevant to collect, how it is operationalised, retrieved and will be analysed. To evaluate the impact of SUPRANET Care, standardised suicide rates will be calculated adjusted for confounding factors. Second, the extent to which suicide attempts are being registered will be analysed with the suicide attempt data. Finally, professionals' knowledge, attitude and adherence to suicide prevention guidelines will be measured with an extended version of the Professionals In Training to STOP suicide survey., Ethics and Dissemination: This study has been approved by the Central Committee on Research Involving Human Subjects, The Netherlands. This study does not fall under the scope of the Medical Research Involving Human Subjects Act (WMO) or the General Data Protection Regulation as stated by the Dutch Data Protection Authority because data are collected on an aggregated level., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Suicide prevention efforts often depend on the willingness or ability of people to disclose current suicidal behavior. The aim of this study is to identify characteristics that are associated with non-disclosure of suicidal ideation. Data from the Dutch cross-sectional survey Health Monitor 2016 were used, resulting in 14,322 respondents (age 19+). Multiple logistic regression analyses were conducted to assess the strength of the associations between demographics and health-related characteristics as independent variables, and non-disclosure of suicidal ideation as the dependent variable. The mean age of the respondents was 60 years (SD 16.7) and 45% were male. Of these adults, 5% ( n = 719) reported suicidal ideation in the past year, nearly half of which (48%) did not disclose suicidal ideation. Non-disclosure was significantly associated with social loneliness (OR = 1.29). Inverse significant associations were found for age (35⁻49 years, OR = 0.53), poor health status (OR = 0.63), frequent suicidal ideation (OR = 0.48), and severe psychological distress (OR = 0.63). The accuracy of this model was fair (AUC = 0.73). To conclude, non-disclosure is a substantial problem in adults experiencing suicidal ideation. Adults who do not disclose suicidal ideation are more likely to have few social contacts, while they are less likely to experience poor (mental) health and frequent suicidal thoughts.

Background: It remains difficult to predict and prevent suicidal behaviour, despite growing understanding of the aetiology of suicidality. Clinical guidelines recommend that health care professionals develop a safety plan in collaboration with their high-risk patients, to lower the imminent risk of suicidal behaviour. Mobile health applications provide new opportunities for safety planning, and enable daily self-monitoring of suicide-related symptoms that may enhance safety planning. This paper presents the rationale and protocol of the Continuous Assessment for Suicide Prevention And Research (CASPAR) study. The aim of the study is two-fold: to evaluate the feasibility of mobile safety planning and daily mobile self-monitoring in routine care treatment for suicidal patients, and to conduct fundamental research on suicidal processes., Methods: The study is an adaptive single cohort design among 80 adult outpatients or day-care patients, with the main diagnosis of major depressive disorder or dysthymia, who have an increased risk for suicidal behaviours. There are three measurement points, at baseline, at 1 and 3 months after baseline. Patients are instructed to use their mobile safety plan when necessary and monitor their suicidal symptoms daily. Both these apps will be used in treatment with their clinician., Conclusion: The results from this study will provide insight into the feasibility of mobile safety planning and self-monitoring in treatment of suicidal patients. Furthermore, knowledge of the suicidal process will be enhanced, especially regarding the transition from suicidal ideation to behaviour.The study protocol is currently under revision for medical ethics approval by the medical ethics board of the Vrije Universiteit Medical centre Amsterdam (METc number 2017.512/NL62795.029.17).

In The Netherlands, on average 40% of all suicides concern patients treated by mental healthcare institutions (MHIs). Recent evidence indicates that implemented guideline recommendations significantly reduce the odds for patients to die by suicide. Implementation of the multidisciplinary guideline for diagnosis and treatment of suicidal behaviors is a main objective of the Dutch National Suicide Prevention Strategy. To this end, 24 MHIs that collectively reported 73% of patient suicides in 2015 received an educational outreach intervention offered by the national center of expertise., Aim: To investigate changes in levels of implementation of guideline recommendations; and to assess the degree of variation on suicide prevention policies and practices between MHIs., Methods: Implementation study with a prospective cohort design studying change over time on all domains of a Suicide Prevention Monitor, a guideline-based instrument assessing suicide prevention policies and practices within MHIs. Data were collected in six-month intervals between 2015 and 2017., Results: MHIs improved significantly on four out of ten domains: the development of an organizational suicide prevention policy; monitoring and trend-analysis of suicides numbers; evaluations after suicide; and clinician training. No improvement was measured on the domains pertaining to multi-annual training policies; collaborative care with external partners; recording and evaluation of suicide attempts; routine assessment of suicidality in all patients; safety planning and involving next of kin and carers. Furthermore, marked practice variation between MHIs was found which did not decrease over time., Conclusion: This study shows significant improvement in the implementation of four out of ten guideline-based suicide prevention policies in 24 specialist mental healthcare institutions in The Netherlands. The implementation level of suicide prevention policies and practices still appears to vary significantly between MHIs in The Netherlands.

The European Alliance against Depression (EAAD) program is to be introduced in The Netherlands from 2017 onwards. This program to combat suicide consists of interventions on four levels: (1) increasing the awareness of suicide by local media campaigns; (2) training local gatekeepers, such as teachers or police officers; (3) targeting high-risk persons in the community; and (4) training and support of professionals in primary care settings. The implementation starts in seven Dutch pilot regions. Each region is designated as a Suicide Prevention Action NETwork (SUPRANET). This paper describes the SUPRANET program components and the evaluation of its feasibility and impact. The findings will be used to facilitate the national implementation of EAAD in The Netherlands and to add new findings to the existing literature on EAAD.

Background: Randomized studies examining the effect of training of mental health professionals in suicide prevention guidelines are scarce. We assessed whether professionals benefited from an e-learning supported Train-the-Trainer programme aimed at the application of the Dutch multidisciplinary suicide prevention guideline., Methods: 45 psychiatric departments from all over the Netherlands were clustered in pairs and randomized. In the experimental condition, all of the staff of psychiatric departments was trained by peers with an e-learning supported Train-the-Trainer programme. Guideline adherence of individual professionals was measured by means of the response to on-line video fragments. Multilevel analyses were used to establish whether variation between conditions was due to differences between individual professionals or departments., Results: Multilevel analysis showed that the intervention resulted in an improvement of individual professionals. At the 3 month follow-up, professionals who received the intervention showed greater guideline adherence, improved self-perceived knowledge and improved confidence as providers of care than professionals who were only exposed to traditional guideline dissemination. Subgroup analyses showed that improved guideline adherence was found among nurses but not among psychiatrists and psychologists. No significant effect of the intervention on team performance was found., Limitations: The ICT environment in departments was often technically inadequate when displaying the video clips clip of the survey. This may have caused considerable drop-out and possibly introduced selection bias, as professionals who were strongly affiliated to the theme of the study might have been more likely to finish the study., Conclusions: Our results support the idea that an e-learning supported Train-the-Trainer programme is an effective strategy for implementing clinical guidelines and improving care for suicidal patients., Trial Registration: Netherlands Trial Register (NTR3092 www.trialregister.nl)., (Copyright © 2015 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Every year, more than six million people lose a loved one through suicide. These bereaved by suicide are at relatively high risk for mental illnesses including suicide. The social stigma attached to suicide often makes it difficult to talk about grief. Participating in online forums may be beneficial for the bereaved by suicide, but it is unknown what they communicate in these forums., Aims: What do the bereaved by suicide communicate in online forums? We examined which self-help mechanisms, grief reactions, and experiences with health-care services they shared online., Method: We conducted a content analysis of 1,250 messages from 165 members of two Dutch language forums for the bereaved by suicide., Results: We found that sharing personal experiences featured most prominently in the messages, often with emotional expressions of grief. Other frequently used self-help mechanisms were expressions of support or empathy, providing advice, and universality (recognition), while experiences with health-care services featured only occasionally. Compared with previous studies about online forums for somatic illnesses, the bereaved by suicide communicated more personal experiences and engaged much less in chitchat., Conclusion: Online forums appear to have relevant additional value as a platform for talking about grief and finding support.

Background: To strengthen suicide prevention skills in mental health care in The Netherlands, multidisciplinary teams throughout the country are trained in the application of the new Dutch guideline on the assessment and treatment of suicidal behavior. Previous studies have shown beneficial effects of additional efforts for guideline implementation on professionals' attitude, knowledge, and skills. However, the effects on patients are equally important, but are rarely measured. The main objective of this study is to examine whether patients of multidisciplinary teams who are trained in guideline application show greater recovery from suicide ideation than patients of untrained teams., Methods/design: This is a multicentre cluster randomized controlled trial (RCT), in which multidisciplinary teams from mental health care institutions are matched in pairs, and randomly allocated to either the experimental or control condition. In the experimental condition, next to the usual dissemination of the guideline (internet, newsletter, books, publications, and congresses), teams will be trained in the application of the guideline via a 1-day small interactive group training program supported by e-learning modules. In the control condition, no additional actions next to usual dissemination of the guideline will be undertaken.Assessments at patient level will start when the experimental teams are trained. Assessments will take place upon admission and after 3 months, or earlier if the patient is discharged. The primary outcome is suicide ideation. Secondary outcomes are non-fatal suicide attempts, level of treatment satisfaction, and societal costs. Both a cost-effectiveness and cost-utility analysis will be performed. The effects of the intervention will be examined in multilevel models., Discussion: The strengths of this study are the size of the study, RCT design, training of complete multidisciplinary teams, and the willingness of both management and staff to participate., Trial Registration: Netherlands trial register: NTR3092.

Background: 113Online is a combination of a website and a telephone help-line for suicidal persons, their relatives and bereaved next of kin. The services it provides include crisis intervention, self-tests and brief psychotherapy. aim: To discover whether 113Online can in fact prevent suicidal behaviour – since it has now been in operation for more than a year., Method: We were able to obtain information about the visitors of the website, check on the usage of services provided by 113Online and study the results of the self-tests., Results: The results for the first year indicated that there was a great need for anonymous online help for persons contemplating suicide. Scores for the self-tests showed that the website was visited by severely suicidal persons. It is surprising that so few of the users thereafter sought assistance from the conventional mental health care services., Conclusion: The 113Online seems to be a promising approach to suicide prevention. The online assistance reaches its target population and seems to fulfil needs that are not being met by the regular health care services.