This study revealed a number of barriers in providing appropriate care to young people with mental health problems in PHC in Nicaragua. At the same time the interviewed PHC professionals suggested different ways to improve the treatment, and they acknowledged that they lacked sufficient knowledge and competence. Our informants agreed that they were not properly prepared to handle mental health problems, and they felt this as a challenge to their professional identity. Frustration made them at times ignore signs of mental health problems in their patients and sometimes even reject help-seeking young people.
Misconceptions among staff about suicidal behaviours have been reported in several studies [12, 22–24]. Milton and co-authors showed that only one out of 52 general practitioners considered suicide to be preventable . Our study also shows constricted thinking to be common. Some of our informants were also occupied by the contradiction between being trained to save lives and having to cope with young and seemingly healthy people who wish to die.
The barriers preventing health professional from being able to help were reflected in feelings of frustration, powerlessness and sadness. Similar findings have been described by, for example, Anderson and co-workers, who reported experiences of frustration to be important obstacles in dealing with young people with suicidal behaviour . The informants were concerned about difficulties in openly discussing sensitive matters with their young patients, in accordance with the findings of Taylor and co-workers , who found that despite variations in health care systems and settings, communication between patients and staff was everywhere a key issue in improving services, user satisfaction and treatment adherence.
Overall, the health professionals in our study called for more training, similar to what has been reported by, among others, Slaven and Kesely . Numerous studies have concluded that continuous training, adapted to different settings and resources, is a core aspect for health care professionals in order to perform better in the area of mental health and suicide prevention [26, 27]. Huband and Tantam  specifically suggest training in counselling or psychotherapy, allowing staff to modify their attitudes by reducing defensive attribution and improving control of their own anxiety. Our informants also called for guidelines on how to manage patients with suicidal problems, and they even had suggestions for a stepped-care model to improve management of these patients. Strangely enough, none of the health care professionals in our study were aware of the existence of the national guidelines for the management of suicidal patients that was launched in 2003 . Unfortunately, this gap between publishing programs and guidelines and having them implemented is a well-known problem worldwide.
Many informants held the view that reasons for young people attending PHC were confined to reproductive health issues. When the vignette was introduced in the interviews, they started to reflect more openly on other possible health problems among young people. Interestingly, our informants expressed few negative feelings towards young people with suicidal problems, in contrast to what has been reported in other studies (see for example: [9, 11]. Instead, reluctance to deal with suicidal problems seemed more likely to stem from feelings of incompetence rather than from negative attitudes.
Taken together, feelings of incompetence and constricted thinking among the health care professionals made them prone to refer any young person with mental health problems to some other member of staff; this was evident with both among nurses and doctors. We used in our analysis the metaphor of a “hot potato” to illustrate this flow of internal referrals.
Studies have shown that suicide victims are likely to make contact with health care professionals shortly before they commit suicide. One study found that 87% of cases made contact with a health care professional within one month prior to suicide . Another study has shown that such contacts increase in frequency throughout the months prior to committing suicide . Despite their limitations, doctors and nurses acknowledged the benefits that a well-functioning PHC-system could have for patients with suicidal problems. They felt that they as PHC staff should be able to providing the “first help” for young people with suicidal thoughts must be a priority. They compared this situation with other medical emergency situations and felt that suicidal behaviour should be perceived as a similar emergency situation.
One limitation of this study was that we did not interview hospital staff about their perceptions of young people showing suicidal behaviour. However, there are reasons to believe that they share similar difficulties with those working at a PHC level. Evidence from a study conducted in United Kingdom showed that hospital staff also experienced frustration and mixed feelings in managing suicidal patients . From our research findings theoretical generalizations can be drawn and they might be applicable in settings with similar characteristics as ours, such as LMIC, urban area and free services at PHC.
A review of mental health systems in low- and middle-income countries concerning management at PHC level argued that mental health services in primary health care should include diagnosis and treatment, but also strategies to prevent mental disorders and ensure that primary health care workers are able to apply psychosocial and behavioural skills, for example interviewing, counselling and interpersonal skills .