AN INTERDISCIPLINARY AND MULTIDISCIPLINARY APPROACH BETWEEN MEDICAL EDUCATION AND POSITIVE TRANSCULTURAL PSYCHOTHERAPY TO LEAD SUICIDE PREVENTION STRATEGY FOR HEALTHCARE STUDENTS AND HEALTHCARE WORKERS

Suicidal ideation (SI), suicide attempts (SA), and completed suicides (CS), seem to be phenomena present globally and in heterogeneous growth. The objectives of this manuscript are to offer an overview of these phenomena related to mental health and mental well-being, focusing on the prevention of SI, SA, and CS, with multidisciplinary team (MDT) and interdisciplinary team (IDT) interventions that can be integrated into the daily activities of healthcare workers (HWs) and medical/healthcare students (MHSs). The role of medical education (MedEd) and counselling/psychotherapy, with particular interest in the PPT (Positive and Transcultural Psychotherapy), can become fundamental in intervention, identification, prevention activities, for MHSs and HWs.


Introduction
Globally, approximately 800000 suicides were estimated in 2012, around 11.4 suicides/100000 people, and this number appears to have grown by 6.7% between 1990 and 2016 reaching an average of 817000 suicides in 2016, an increase of 60% in the last 45 years.SAs are globally about 20 times higher than CSs (around 16 million), and SIs are about 100 times more frequent than CSs (Wasserman, 2016;Naghavi, 2019;Chehil, 2012;Falcone, 2018).Regarding the MHSs in the first year of study, a rate like that of the previously mentioned general population of 11.4 / 100000 is given and a worsening of the state of mental health during subsequent years of study is indicated (Coentre, 2018).Furthermore, the prevalence of SIs appear to be between 6% and 43% in medical students, and and for university students in general, an annual rate of CSs between 6.5 and 7.5/ 100000 is estimated over 20 years (Yusoff et al., 2012;Carson et al., 2000;Iarovici, 2014); regarding HWs, the suicide rate is 1.41 times higher for men and 2.27 times higher for women, compared to the general population (Latifi, 2019).While data relating to CSs, SAs, and SIs may be influenced by cultural, religious, ethnic, educational, or other biases related to personal belief (Mehmet Eskin, 2018), it is necessary to intervene through prevention systems that can be considered inclusive, and that avoid generating sociocultural barriers, and stigmatization.

Risk factors
The main risk factors in reference to MHSs and HWs are depression, burnout, excessive workload, occupation, dissatisfaction, lack of sense of belonging, alcohol consumption, stress, comorbid mental illness, post-traumatic stress disorder, feeling of isolation, previous SIs or SAs, anxiety, stressful personal events, gender, and race.With reference to the prevention of suicidality, there are wide-ranging difficulties that can compromise the necessary actions.Stigma of suicidal ideation and attempted suicide are a cultural factor that leads to isolation and discrimination (and self-isolation, selfdiscrimination, and self-stigmatisation) which makes it difficult to track down people in need of support.Poor awareness of possible support paths, poor knowledge of risk factors, behavioural signs, and symptoms make it difficult for the subject to be aware of the need for support, as well as lack of knowledge and awareness of suicidality as a multifactorial product, and perception of suicidality as a cultural taboo, due to possible communication and multidisciplinary/interdisciplinary activity deficiencies (Wasserman, 2016;Wasserman, 2021;Soper 2018).

The role of medical education
The primary role of MedEd relates to curriculum development and intervention, organization, leadership, assessment, of academic programs defined undergraduate, postgraduate, and continuing professional development.Deepening the role does not exclusively concern what is defined as "teaching and learning" but appears to have an important role in the development of wellbeing for MHSs and HWs, which will become well-being and safety for patients.The well-being of MHSs and HWs impact on their performance, on the acquisition of skills and competences, on personal and professional development, and on healthcare and educational providers.In this regard, medical education acts by planning and organizing support and monitoring systems for learners (MHSs, and HWs in lifelong learning), thus influencing the area concerning welfare and well-being (Meeks et al., 2019;Bishop et al., 2018), the pillar of education, and the pillar of community involvement and interaction, as visible from diagram 1.

The role of Positive and Transcultural Psychotherapy
The university and the healthcare workplaces are subject to high migration flows, which allow the structuring of multicultural, transcultural, and dynamic environments, in which it is necessary to understand and face the challenges deriving from the encounters and interactions of different cultures, habits, backgrounds, and relational modalities (Peseschkian, 1990;Kirmayer, 2022).In connection with the migratory dynamics and in line with the objectives of suicide prevention among MHSs and HWs, PPT describes characteristics and methods in line with the challenge.PPT turns out to be a humanistic psychodynamic modality, conflict-centred and resource-oriented, in which cognitivebehavioural aspects are integrated, based on a positive and transcultural approach.Among the objectives of PPT are the promotion and development of well-being and physical, mental, social health, awareness of human potential in its complexity.The PPT modality follows different objectives and can be applied in different areas, such as the treatment of psychosomatic and mental health disorders (therapeutic), counselling-preventioneducation (preventative and pedagogical), dissemination of transcultural understanding (Transcultural-societal approach), and use of different integrated modalities of therapeutic methodologies (interdisciplinary approach) (Peseschkian & Remmers, 2020;Cyrous, 2020), visible in Fig. 2. By multidisciplinarity we mean the interaction between different disciplines simultaneously, and by interdisciplinarity (or interprofessionalism) we mean the transfer of skills, abilities, knowledge, between different disciplines (Nima Rezaei & Amene Saghazadeh, 2022).Cooperation between MedEd and PPT can be considered through the establishment of multidisciplinary (MDT) and interdisciplinary teams (IDT), which can play active roles in suicide prevention, further interacting with different environments, stakeholders, and subjects (universities, educational providers, hospitals/clinics, communities).

Team Modality Function Multidisciplinary
Interaction between professions Interdisciplinary Transfer of skills/abilities between professions

Preventative interventions and activities
Curriculum intervention and workload organization, programming a compulsory personal therapy (counselling/psychotherapy) for MHSs and HWs, constant over time (personal therapy cyclic sessions and supervision), which allows the development of self-awareness, emotional development, selfreflexivity, as well as direct monitoring of mental well-being, and it can also find its application in favour of students who decide to opt for study paths offered with distance learning / online modality with the possibility of carrying out personal therapy in the same methodology (Gentile & Roman, 2009;Søvold et al., 2021).In addition, peer support activities should be organised with supervised mental well-being monitoring activities carried out by counselling / psychotherapy students (Moe 2020;Chester, 2006).These activities involve supervision by expert personnel, MDT, and IDT, with reference to the therapies carried out by counselling / psychotherapy trainees towards MHSs and HWs.These activities may offer many advantages: − Cost reduction for MHSs and HWs for mandatory personal therapy, delivered as a supervised internship.− Distance counselling / psychotherapy activities, also in support of distance learning students, organized through university structures or providers (monthly or three-month evaluation).

− Establishment of MDTs and IDTs involving
MHSs and HWs in the cooperation of MedEd and PPT.− Generation of the awareness of the real existence of the practitioner-patient. − Increase in the number of peers (MHSs and HWS) available for the training in counselling/psychotherapy for students (with and without supervision).− Increase in the number of mental well-being practitioners (in departments or areas at risk, and in university departments).− Increase in the use of PPT in environments with a high migratory flow or multicultural environments.− Increased use of technology and monitoring and self-monitoring tools (artificial intelligence, face/emotions analysis, performance analysis, reflective journal).
− Integration intervention of counselling/psychotherapy skills training for all programs of the health professions (medical and non-medical).− Support to MHSs and HWs in the monitoring phase and support of mental wellbeing and suicide prevention.A further step in suicide prevention is to train and educate HWs and MHSs on epidemiological data, on the prevention supports present in institutions and workplaces, on education to recognise the possible signs of stress or mental illness, education on emotions and feelings, and to educate on the challenge against the stigmatization of mental disease due to social and cultural barriers.MHSs and HWs must thus be informed of the absence of possible disputes or participate in their study path and career path (Klein, 2022;Kusumadewi et al., 2021;Hrovat et al., 2012).Academic and workplace activities useful for the prevention of suicide are identifiable in the following activities: − Reflective journal.− Performance analysis.− Surveillance survey.− Formal and informal feedback.− PPT (counselling/psychotherapy).
The reflective journal (reflective practice) is a monitoring tool mainly used in the development of professional practice, knowledge, and skills, in the planning of corrective actions or improvement of the professional / academic path and is a useful tool to increase the level of self-awareness and self-knowledge, which thus allows constant monitoring of oneself also in relation to sensations and emotions (Richard et al., 2010;Cooper, 2019).Peer feedback (formal and informal), survey, and performance analysis (academic and professional), in the context of suicide prevention, can be useful tools for monitoring suicidality, both in MHSs and HWs (Bowersox et al., 2021;Andreotti et al., 2020;Chadha, 2021).MedEd in cooperation with universities and the managerial areas of the workplaces have the task of supporting the organization and methods of using feedback and surveys, making them clear, executable, and interpretable; in support of these three tools that may be used in suicide prevention, artificial Intelligence and facial/emotions analyser software could be proposed (Bernert et al., 2020;Laksana et al., 2017).

Conclusion
In the objective of the prevention of CSs, SAs, and SIs, MDTs and IDTs based on MedEd and PPT, fit a fundamental role in identifying the best monitoring and preventative systems in a high-risk group such as MHSs and HWs (Hoppen & Morina, 2021;Birni & Eryilmaz, 2022).From what has been described, the mental health of subjects at risk can be monitored to prevent the risk of suicide through the integration of different areas as illustrated in diagram 2: − Technologies.− Environment.− Education/dissemination activities.− Preventative counselling/psychotherapy modalities.− Peer activities.The aims of the interventions and of the organization of support to the MHS and HW, in addition to prevention as a primary objective, are also the generation and monitoring of mental health, interdisciplinary and multidisciplinary support, training, dissemination, and information on mental health and emotions, and against discrimination and stigmatization of mental illness and suicide.

Limits of the manuscript
What is proposed in the manuscript does not evaluate the possible cost-effectiveness ratio, ROI, and the peculiarity of the different academic and health systems, their legislation, their financing, and any preventive pathways already active..

1 .
Fig. 2: interdisciplinary and multidisciplinary role of MedEd and PPT