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Research Article | DOI: https://doi.org/10.31579/NPCP.2019/008
*Corresponding Author: John McIntosh, Mackay Superclinic Group, Mackay, Australia, James Cook University, Mackay, Australia, Department of Psychiatry and Psychotherapy Email: jmcintsh@tpg.com.au
Citation: McIntosh J., McIntosh E., (2019) Community Based Mental Wellbeing and Suicide Intervention. Long Term Improvements in Mood, Workplace and Suicide Intervention with the TUFMINDS Program. Neural Plasticity and Clinical Practice, 2(1); DOI: 10.31579/NPCP.2019/008
Copyright: ©2019. John McIntosh. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Received: 05 November 2019 | Accepted: 08 November 2019 | Published: 25 November 2019
Keywords: Resilience, Depression, Anxiety and Stress Scores
Background: Suicide rates and mental illness remain high globally despite increasing expenditure and efforts in this field. Historically individuals in mental health crises have delays in accessing treatment so universally accessible, community based, online or smartphone programs that provide active mental health and suicide intervention have the potential to provide major benefits.
Aims
To evaluate the long-term benefits of the TUFMINDS program to deliver mental wellbeing and suicide intervention education in communities and workplaces. This program teaches individuals to recognise and eliminate their negative thoughts and replace them with positive alternatives. This results in improved mental wellbeing, resilience and mood and coping skills. It also provides suicide knowledge and practical steps for active intervention and support of users and others around them.
Method
34 participants from a single business attended 6 hours of training on site watching the TUFMINDS video program with a pre and post questionnaire. Eight months later a follow up questionnaire was filled out with 30 of the participants. The evaluations measured the short and long term impact of the TUFMINDS program on mood, resilience, workplace, mental illness and suicide knowledge, self-efficacy and measured the suicide assistance actions provided as a direct result of the TUFMINDS training within this group.Participants’ outcomes were also compared between those that did and did not use the TUFMINDS program subsequent to the initial training. This is available on a free smartphone app and use of this TUFMINDS app was voluntary so the two groups could be compared.
Results
Participants showed significant improvement in optimism, resilience, depression, anxiety and stress scores as well as noticeable improvements workplace measures. Suicide knowledge, skills, confidence and willingness to assist others increased immediately after the training and after 8 months the improvements were sustained and further magnified. The research also found a dramatic increase in the number of times participants recognised suicidal risk in others and even greater increase in numbers of times action was taken to assist that person. There was no evidence of any iatrogenic effects from the training.
It was also found that use of the TUFMINDS app to reinforce the training after the initial 6 hours of training provided extra benefits. So non-users improved their scores post training, the users of the app showed 10 -30% higher scores in the same time period.
This research provides further evidence of the effectiveness of the TUFMINDS training as a stand-alone program to provide mental wellbeing and suicide understanding and assistance with ongoing improvement occurring after the training, unlike other training programs where fall off in skills occurs over time. The research allso shows that use of the TUFMINDS processes (smartphone app / online) for reinforcement after the training provides significant further benefit for those users.
Limitations
The lack of a control group, use of some non-validated questionnaires and the small sample size are limitations of this study.
Conclusions: Direct mental health training in the workplace and in the community is effective to increase mental resilience, wellbeing and mood. The research confirms several earlier studies showing that online or smartphone programs are effective to increase knowledge and mental wellbeing. This study also shows that the benefits are sustained long term and enhanced dramatically with ongoing use of the TUFMINDS program.
The other important aspect is that this study demonstrates improved suicide knowledge and willingness to actively assist others in the suicidal crises which is confirmed by the dramatically increased numbers of recognitions and active interventions by participants to assist these individuals.
This study supports the proposal that mental health interventions can be provided in video, online or digital formats across workplaces and communities safely, practically and at low cost with TUFMINDS providing progressive benefits to the individuals and workplaces over time.
Suicide is the leading cause of death in 15 – 44 year old Australians and 25% of deaths in the 15-24 year olds (1 Australian Bureau of Statistics, 2016). The presence of suicidal thoughts and suicide attempts are also very high in young people with 7.5% reporting the thinking in the past 12 months and 2.4% have made an attempt [2]. Despite the significant efforts and national expenditure to reduce these rates, no significant improvement has been seen and there is limited evidence of effectiveness of suicide prevention interventions [3, 4]
There are programs that focus on awareness about suicide, like safeTALK Program [5]. while others focussed on warning signs and help seeking strategies and gatekeeper training.
Universal education was found to be more effective than gatekeeper training in reducing suicide attempts and severe suicidal ideation [6]. So the logic is that the national focus needs to be in this direction.
Concerns have been raised that suicide prevention programs may create iatrogenic effects of increasing suicide risk in participant’s especially vulnerable younger people [7, 8].However, several studies have shown this not to be the case [5, 9, 10]. And these studies reflect the importance of monitoring any suicide intervention program to track and measure this risk.
The apparent deficiency across all of these suicide programs appears to be the absence of active mental illness interventions for the individuals at risk. The programs tend to focus on awareness, support and referral and this follows the historical approach of programs avoiding direct mental health treatment and intervention for the affected person. These treatments have been left to professionals and only provided in face to face consultations but the delay in accessing this professional help and not being available after hours is well reported [11]. This lack of active mental health intervention in the community may be one of the reasons that these national programs and high-level national spending has not improved the suicide rates over the decades.
Another important aspect of addressing suicide risk is to have strategies in place to address impulsivity. Research also shows very clearly that the timeframe between suicidal ideation and suicidal action is very short [12].The findings were that 75% of suicide attempts occurred within one hour of the initial suicidal thought. This very short timeframe from initial thoughts to action proves the importance for immediate access to suicide support and mental health intervention. The person at risk therefore needs to have access to the information, education and support at any time of day or night and not be dependent on obtaining a professional consultation or their geographical situation.
The question being addressed in this research is whether digital or online solutions could be a potential delivery method to provide effective mental health intervention and suicide support with TUFMINDS and evaluate the outcomes.
The TUFMINDS program is available as a smartphone program (as a free app) and can be accessed online or provided as video to view in businesses, classes or social groups.
The Tufminds Program is a Series of Videos, Audios and Workbooks That Aims to:
This program was created based on evidence-based processes and accepted medical guidelines. The modules have been formulated using strong lived experience input, accepted medical and psychological standards as well as using established Eastern philosophies of mindfulness, meditation and thought control. The new “Positive Mindfulness Cognition” are the active steps created to control and eliminate negative thoughts and the ability to control one’s own thoughts was fully proven [13].and shared in other publications [14, 15].
Further research into these processes occurred when the processes were made available as a free smartphone program and online to allow universal access through a Not for Profit entity as the TUFMINDS program and these research documents now extend to involving 551 people in 3 studies [16, 17, 18].These studies all show consistent improvements in the mental health and suicide prevention parameters studied. This study is to consolidate that research and measure the impact over time with and without reinforcement of the TUFMINDS techniques.
In this study, the TUFMINDS program was run in three 2 hour sessions in the business over 3 weeks, with a total of 6 hours training. During this time the participants were exposed to video modules from the TUFMINDS program, each of which is around 10-15 minutes. The participants watched each video once in the group setting with 15 videos being seen (out of the total of 30 videos in the full TUFMINDS program). The program was approved by the managers and it was their choice to make participation compulsory.
The aim of this research was to assess if universal suicide prevention strategies in the workplace and community along with active mental health intervention strategies can actively improve mental health scores, skills and willingness to assist a person in suicidal or emotional distress and actively moves individuals away from the point of suicidal action. The late follow up of participants allowed the number of suicidal risk recognitions and active interventions to be measured as well as seeing if the initial benefit seen after the initial training is sustained over time.
The Following Hypotheses Were Tested:
Study Design
The impact was assessed with a pre-test and post-test questionnaire with the initial TUFMINDS training and a follow up with a single retrospective post- and pre-questionnaire being used 8 months later. The questionnaires at the time of the initial training and the retrospective questionnaires were both stand alone and assessed independently of each other.
After the initial training the participants were also given the option of reviewing the TUFMINDS techniques again online using a free smartphone app called TUFMINDS where those modules already seen could be revisited and other modules could also be seen for more information about mental wellbeing, mental illness and personal development. This participation was voluntary so created two groups to be assessed separately to measure the impact of using the TUFMINDS program after the initial training.
Participants
Participation in the initial training was compulsory and all staff attended the training. The business involved was a heavy industrial metal construction plant, so the workers were generally unskilled heavy labourers with a few managers and administration staff.
After the initial training the participants were offered access to the ongoing TUFMINDS program online through the free smartphone application and use of this was voluntary.
All participants signed an informed consent and only those that completed the questionnaires were included in the evaluation.
Intervention
Participants underwent the training by watching the 15 video modules of the TUFMINDS program over the 6 hours and the time was split up evenly between “Positive Mindfulness Cognition” / mindset (2 hours), suicide awareness training (2 hours) and mental wellbeing and mental illness sessions (2 hours).
Each group presented 15-20 people and there was discussion within the group and was facilitated by TUFMINDS trainers. As all the content was in the video format, the content was standard in each training so no variation in content or presenter skill would impact the outcome. For safety, the TUFMINDS trainer’s onsite also were trained and psychologically skilled with to address any emotional issues arising.
There was no structured reinforcement of the TUFMINDS techniques although the participants did have the ability to access the program using the TUFMINDS program using the free TUFMINDS smartphone app and this was voluntary. The follow up study tracked which participants did get this reinforcement of the program and this allowed comparison of the individuals in each group to be compared with each other. This is a very useful aspect to see how individuals do over the months with and without any ongoing TUFMINDS training.
Measures
Participants completed the questionnaires immediately prior to starting the program and immediately on completing the 6 hour of training sessions. They then also completed the single retrospective post- and pre-questionnaire 8 months later. The questionnaires measured optimism, resilience, mental health stigma (initial only), mood levels (depression, anxiety and stress), workplace parameters and perceived stress at home and work (initial only).
In relation to suicide, the measures were suicide knowledge (warning signs, how to ask, refer and assist the person), confidence, skill, and willingness to help a suicidal person and understanding levels about mental illnesses. Additionally, in the follow up questionnaire the individuals were asked if they recognised anyone with suicidal risk, how often they intervened to assist and if they watched the TUFMINDS program after the training.
In the retrospective (later) questionnaire, the participants filled in the same questions for “NOW” and “BEFORE TUFMINDS” with each of the questions asked. This allowed the retrospective questionnaire to stand alone and to compare with the initial results.
Demographics
The participants name, age, gender and indigenous status were collected. A code was then created for confidentiality of data.
Mental Health
Optimism was measured with the Life Orientation Test – Revised (LOT-R). Resilience was measured using the Brief Resilience Scale (BRS), mental health stigma using the Internalized Stigma of Mental Illness Inventory and the mood scores were measured using the Depression Anxiety Stress Score (DASS21).
The mental health stigma questions were dropped from the follow up questionnaire due to their length and complexity in order to keep the questionnaire manageable as the follow up questionnaire required two answers for each question for “Now” and “Before TUFMINDS”.
Suicide and Mental Illness Knowledge
A 10 point Likert scale ranging from 1 (Very Low) to 10 (Very High) was used and these 7 items. “Please rate your knowledge of” and the items included: “Facts about suicide prevention”; “Suicide warning signs”; “How to ask someone who may be suicidal”; “How to persuade someone to get help”; “How to get help for someone who may be suicidal”; “General information about mental illness” and “How willing are you help someone who is suicidal”.
Suicide Risk Recognition and Assistance Given
To assess suicidal recognition and action taken before and after the training, the participants were asked to score themselves “After the TUFMINDS training” and “In the 6 months before TUFMINDS” with the following three question - “How many times have you thought another person’s behaviour may indicates/he was considering suicide?”; “How many times have you asked another person whether s/he was considering suicide?” and “If yes, how would you rate the person’s risk of suicide?” on a 0-5 Likert scale.
Participants Evaluation of Program
Using a 5 point Likert scale, participants were asked to rate the TUFMINDS program with 3 items: “Usefulness of the TUFMINDS Program”; “Do you believe the training will help you in helping someone who is suicidal?”; “Would you recommend this training to others?”
There was also an open comment section at the end to allow for any other feedback.
Case Detection
During each training session, the trainers observed the participants for any signs of emotional upset or distress and offered assistance immediately. The questionnaires were assessed to check for any significant mood disorders or individuals that may be at risk from the DASS21 scores and would speak confidentially to those individuals to ensure safety and follow up care was in place.
Data Analysis
Data was analysed directly from the pre and post questionnaires and change in levels assessed. This was performed using mean values for each outcome, standard deviation, 95% confidence levels, significance levels with p values and percentage change in actual numbers using linear regression.
The significance levels and percentage changes were measured separately after the initial training and at the late follow up. The two groups within the participants using or not using the TUFMINDS program were compared directly to assess any impacts in the 8 months until the retrospective questionnaire.
There were around 34 participants in the initial training sessions and 30 participants completing the follow up questionnaires. Participants were 90% male (27) and 10
Key Findings
This study reinforces previous TUFMINDS research where optimism, mental resilience and mood scores improved and the longer term improvement is tracked here showing ongoing and increasing benefit. This improvement occurs without any reinforcement of the TUFMINDS program and the reason for this is probably because the participants practice the Positive Mindfulness Cognition techniques over time and as they improve their technique, their mindset, mood and resilience improve further.
The other very significant impact is that use of the TUFMINDS program (available as a free smartphone app or online) magnifies the benefits significantly, resulting in 10-30% further improvement compared to non-users of TUFMINDS.
The improvement of 37% in optimism (LOT-R ) scores and mental resilience (BRS) scores of 22% have enormous proven benefits to physical health, mental health and coping.
The health benefits from an improved LOT-R scores are well researched showing reduced heart attacks (19 Giltay et al 2006), strokes (20 Kim et al 2011), 9 years longer life (21 Danner et al 2001) and improved mental health (22 Conversano et al 2010).
The improvements in depression, anxiety and stress scores (45%, 37%, 39% respectively) using these techniques are also dramatic considering the low cost and relatively fast timeframes to learn them.
The magnitude of these changes is also significant because the minimal time required to learn the techniques, the ease of access 24/7 to the content and lack of need for face to face training with professionals. It also means that the program is accessible to anyone with a smartphone or internet access especially important to underserviced rural and remote individuals.
Suicide knowledge was increased by 45% and self-efficacy to help others at 30
The limitations of this study need to be considered when interpreting the results. Firstly, the study was performed without a control group although a control group has been used in previous TUFMINDS research [17].Secondly, the instruments for some measures like suicide skill, willingness and knowledge and workplace parameters were designed for this study and have not been evaluated. Thirdly, the numbers of participants in the study are low and from only one workforce and while the results did show statistical significance across the board, further studies to increase the numbers overall is recommended.
Further workplace and community studies are therefore recommended to increase the overall numbers seen and ensure that the results are effective across industry types and different social groups.
Implications
TUFMINDS presents a possible universal mental wellbeing and suicide prevention program for use in the community and workplaces. Despite the limitations listed above, this evaluation shows very strong support for the positive effects of the TUFMINDS program to improve mental wellbeing and reduces mental illness scores of depression, anxiety and stress. There is also significant improvement in optimism, mental resilience, suicide knowledge and self-efficacy. The evidence is that these individuals are willing, skilled and confident to recognise and do assist individuals at risk of suicide. It would therefore be important to promote TUFMINDS across the broad populations to help prevent suicide and self-harm.
The implications of a passively delivered mental wellness and suicide intervention program are enormous. There are both health cost savings and better health outcomes because this is a passive program and can be available 24 hours a day, seven days a week. The cost savings to the health budget would be made by reduced payments for professionals or speakers, facility costs and trainer training and additionally the training could be done at the person’s convenience at any time.
This information can also be accessed anywhere with internet access and it does not require the individual to talk or communicate with anyone in any way. It is known from Lifeline that many individuals are not willing to speak to a person (face to face or online) and some prefer to use SMS messaging so that service is now offered. There are still others who will not reach out for help at all and are unwilling to communicate in any way.
This process provides solutions to this group who are not willing to reach out or accept that there may be a problem because it allows them to passively gather information and understanding relevant to them without any need to accept that they have a problem, including to themselves. Once they start to watch the modules, they are likely to start to recognise their mental health patterns as unhealthy, understand that the treatment processes can be effective and change their perspective to having hope and solution focussed knowledge.
Another implication with significant impact is that this process may provide an intervention to protect individuals at the point of suicidal ideation and provide some protection before professional help can be obtained. The studies on impulsivity show that intervention needs to be in place with very little delay so having this information in an electronic form that is available 24 hours a day may provide protection to reduce the suicidal action steps and further research should be put into place to assess if this benefit is seen.
This study measured the impact of the program delivered in a form that can be easily shared online, though social media and electronically, without any need for trainers, professionals or facility costs. The benefits are potentially very significant to change the way community education is delivered to improve the mental health and resilience of the community in an effective, safe and economically sustainable way.
Further research needs to be performed to increase numbers and industries assessed and to measure the impact of the TUFMINDS app in the community to measure all parameters as performed in this study to confirm similar results without the initial training program.
This study was performed by the creators of the TUFMINDS program, Dr John and Elizabeth McIntosh in the process of developing and accessing the program content and acknowledge the conflict of interest.
The study was done without funding or support from external parties. The authors would like to acknowledge the assistance of the company that participated in the study, their managers and owners who approved the delivery of the program and the organisers who coordinated each of the in-house training sessions.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
