Mental health promotion and suicide prevention in …...Symposium “Suizidprävention in der...
Transcript of Mental health promotion and suicide prevention in …...Symposium “Suizidprävention in der...
Symposium “Suizidprävention in der Schule”
8 November 2016
der Baden-Württemberg Stiftung, Heidelberg, Germany
Mental health promotion and suicide
prevention in young Europeans
Good effects of the YAM program
Beeinflusse und verbessere deine Gefühle
Danuta Wasserman Professor of Psychiatry and Suicidology,
Karolinska Institute (KI), Stockholm, Sweden
Head of the National Centre for the Prevention of
Suicide and Mental Ill-health (NASP) at KI
Head of the WHO Collaboration Centre
EPA, Immediate Past President
National Centre for Suicide Research
and Prevention of Mental lll-Health (NASP), 1993
Karolinska Institutet
International
WHO Collaboration Centre for Research, Methods
Development and Training in Suicide Prevention
National (Sweden)
Regional (Stockholm)
11/14/2016 2 Danuta Wasserman
World Health Organization Preventing suicide: A global imperative
Suicide rates
An estimated 800 000 suicide deaths worldwide.
The annual global age-standardized suicide rate of 11.4 per 100 000
population (15.0 for males and 8.0 for females).
Suicide rates are highest in persons aged 70 years or over for both men
and women in almost all regions of the world.
In some countries, however, suicide rates are highest among the young.
Globally suicide is the second leading cause of death in 15−29-year-olds.
Suicide attempt rates
For each suicide there are many more people who attempt
suicide every year.
12-15/03/2016 Mental Health in EU Report, WHO Global Suicide Report, 2014
Danuta Wasserman 3
12-15/03/2016 Danuta Wasserman J Danuta Wasserman 4
Karta1. Självmordstal* i Europa, senast tillgängliga data.
Avser befolkningen över 15 år.
* Antal självmord per 100 000 invånare över 15 år
Mycket höga självmordstal
40,1 (Ungern) -58,0 (Litauen)
Höga självmordstal:
25,0(Moldavien) -35,8 (Vitryssland)
Medelhöga självmordstal:
11,9 (Nederländerna) -23,0 (Tjeckien)
Låga självmordstal:
3,4 (Albanien) -9,9 (Portugal)
Uppgift saknas
Suicide rates* in Europe, latest
available data from the WHO
15 years and over.
* The number of suicide estimated per 100 000 inhabitants
Very high suicide rates:
40,1 (Hungary) –58,0 (Lithuania)
High suicide rates:
25,0 (Moldavia) –35,8 (Belarus)
Low suicide rates:
3,4 (Albania) –9,9 (Portugal)
Average suicide rates
11,9 (The Netherlands) –23,0 (Czech Republic)
Suicide in Europe
4
Mental health in adolescents
One in five adolescents experience significant
symptoms of emotional distress.
10 - 15% suffer from mental disorders.
Depression
Severe suicide thoughts
Suicide attempts
Untreated mental health problems in youth lead
to poor mental health in the adulthood
11/14/2016 5 Danuta Wasserman
SEYLE Study sites Countries Onsite Leading
Investigators
Austria C. Haring
Estonia A. Värnik
France J.P. Kahn
Germany R. Brunner
Hungary J. Balazs
Ireland P. Corcoran
Israel A. Apter
Italy M. Sarchiapone
Romania D. Cozman
Slovenia V. Postuvan
Spain J. Bobes
Sweden
Coordinating
Center
D. Wasserman
11/14/2016
Principal Investigator D. Wasserman
Wasserman D et al. The Lancet, 2015; 385(9977):1536-1544
Coordinator V. Carli
Start prevention early!
6 Danuta Wasserman
Saving and Empowering Young Lives
in Europe (SEYLE)
FP7 EU funded project
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Gather information on European adolescents regarding: Mental health
Well-being
Health/Risk-behaviors
Suicidal behaviors
Test preventive interventions in schools
Danuta Wasserman
Objectives
SEYLE RESULTS
Screening of
health/risk-behaviors
and mental health
A two-stage professional screening approach was developed
by Heidelberg University and Karolinska Institute
I. A self-report questionnaire
II. Students deemed at-risk for mental health problems
were evaluated using a semi-structured clinical
interview performed by healthcare professionals.
III. 12.5% of students were found to require mental
healthcare.
11/14/2016 9 Kaess M. et al. Eur Child Adolesc Psychiatry, 2014 Jul;23(7):611-20 Danuta Wasserman
Risk Behaviors SEYLE (N=12,395 pupils)
Alcohol use
Drug use
Smoking
Sleep
Physical activity
Over/Underweight
Use of Internet/TV/video
games
Truancy
Bullying
11/14/2016 Danuta Wasserman 10 Carli V et al. World Psychiatry. 2014 Feb; 13(1): 78–86.
“Invisible” group of adolescents
Latent class analysis of health/risk-behaviors N=12,395 pupils
11/14/2016 11 Danuta Wasserman Carli V et al. World Psychiatry. 2014 Feb; 13(1): 78–86.
Psychopathology in low, high and invisible
risk groups
Pupils in the "invisible" risk group, compared with the high-
risk group, had a similar prevalence of:
Anxiety (8% vs. 9.2%)
Subthreshold depression (33.2% vs. 34%)
Depression (13.4% vs. 14.7%)
Suicidal thoughts (42.2% vs. 44%)
11/14/2016 12 Carli V et al. World Psychiatry. 2014 Feb; 13(1): 78–86, Danuta Wasserman
Suicide attempts in low, high and invisible
risk groups
The prevalence of suicide attempts was:
1.7% in the low-risk group
5.9% in the "invisible“ group
10.1% in the high-risk group
11/14/2016 Danuta Wasserman 13
Sleep Hours of sleep among adolescents
SEYLE (N=11,788)
Approx. 7.7±1.3 hours per night during
a school week
Hours of sleep:
Decrease with age
Lower among females
11/14/2016 14 Sarchiapone M, et al 2014. Sleep Medicine, 15(2):248-254 Danuta Wasserman
Sleep Emotional and behavioral problems
among adolescents
Diminished hours of sleep were
significantly associated with:
Emotional problems
Hyperactivity
Conduct problems
Conflict with peers
Suicidal ideation
Total difficulties
11/14/2016 15 Sarchiapone M, et al 2014. Sleep Medicine, 15(2):248-254 Danuta Wasserman
Physical activity Physical activity and mental health
SEYLE (N=11,110 pupils)
A minority of adolescents met the criteria of the
WHO guidelines: at least 60 minutes of moderate
to vigorous-intensity physical activity daily:
17.9% of boys
10.7% of girls
Physical activity and sports participation:
Increased well-being
Reduced depression and anxiety
11/14/2016 16 McMahon E et al 2016, Accepted, ECAP. Danuta Wasserman
Pathological Internet Use (PIU)
PIU is defined as excessive or poorly controlled
preoccupations, urges or behaviors regarding
Internet use that leads to impairment or distress
(Shaw and Black 2008).
Males:
PIU: 5.2%
Females:
PIU: 3.8%
11/14/2016 Danuta Wasserman 17
Pathological Internet use Demographic and social factors
SEYLE (N= 11,956 pupils)
Pathological Internet use is significantly higher among:
Males
Older adolescents
Those not living with a biological parent or relative
Adolescents who have a parent or guardian that
are unemployed
Adolescents with parents who do not pay attention
to them or do not know what adolescents do with
their free time
11/14/2016 18 Durkee et al. Addiction, 2012 Dec;107(12):2210-22 Danuta Wasserman
Pathological Internet users Online activities
Highest ranked online activities:
Watching videos
Frequenting chat rooms
Social networking
Males:
Playing single-user games
Females:
Social networking
11/14/2016 19 Durkee et al. Addiction, 2012 Dec;107(12):2210-22
Danuta Wasserman
Psychopathological risk factors for PIU and problematic alcohol use
(PAU) German SEYLE sample (N=1,444 pupils)
Prevalence rates:
PIU: 4.8%
PAU:5.6%
Conduct problems and depressive symptoms are
significantly associated with both PIU and with PAU.
11/14/2016 20 Wartberg L et al. Psychiatry Research, 2016 Jun 30;240:272-7. Danuta Wasserman
Pathological Internet use
Psychopathology and suicidal behavior
SEYLE (N=11,356 pupils)
is associated to:
11/14/2016 21 Kaess et al. Eur Child Adolesc Psychiatry, 2014 Nov;23(11):1093-102. Danuta Wasserman
Depression
Conduct problems
Hyperactivity and/or inattention
Suicidal Ideation
Suicide attempt
Protective Factors
Reading books and watching films were
protective factors for serious suicidal
ideation (SSI)
11/14/2016 Danuta Wasserman 22
This was especially
true in individuals
with the lowest
levels of social
belonging
Kasahara-Kiritani et al. Int. J. Environ. Res. Public Health. 2015;12, 15937-15942
Smoking in European adolescents
SEYLE (N=12,328 pupils)
30.9% of adolescents report daily
smoking.
58% of those reported the onset of
smoking under the age of 14 years.
11/14/2016 23 Banzer et al. European Psych. 2015;30(1):515 Danuta Wasserman
Smoking
Adolescent smoking is significantly associated with:
Anxiety
Emotional symptoms
Conduct problems
Hyperactivity
Excessive alcohol use
Illegal drug use
Previous suicide attempts
11/14/2016 24 Banzer et al. European Psych. 2015;30(1):515
Danuta Wasserman
Alcohol Drink containing alcohol* (2 or more times per week) %
Females had lower prevalences than males (M= 10.5% vs. F= 5.8%; p<0.0001)
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Males
Danuta Wasserman Kaess et al. Eur Child Adolesc Psychiatry. 2014;23(7):611-20
*defined as one bottle of beer, one glass of wine, or 4 cl of hard liquor
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Alcohol use Alcohol consumption patterns among adolescents are related to
family structure and exposure to drunkenness within the family
SEYLE (N=12,115 pupils)
Ruutel et al. Int. J. Environ. Res. Public Health. 2014;11(12),12700-12715 Danuta Wasserman
The more adolescents
see their family member
drunk - the more they
drink themselves.
Reproductive health N=11,406
Sexual debut was reported by 18.8% of the total
population.
Ages ≤15 and >15 years old
(13.2% vs 38.0%)
Significant differences were found between:
Boys and girls
(21.3% vs 16.9%)
11/14/2016 27 Gambadauro P et al 2016, Submitted Danuta Wasserman
Early sexual debut was associated with:
Anxiety
Depression
Severe suicidal ideation
Suicide attempts
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Reproductive health and psychopathology
N=11,406
Gambadauro P et al 2016, Submitted Danuta Wasserman
5% of students reported having concerns regarding their sexual
orientation.
Compared with their peers, they had higher levels of:
Physical assault (40% vs. 8%),
Attempted suicide (29% vs. 2%),
Frequent alcohol use (20% vs. 1%)
Sexual assault (16% vs. 1%)
Almost all of those (90%) with sexual orientation concerns
reported having had sex compared to just 4% of their peers.
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Sexual orientation and mental health
problems among adolescents Irish SEYLE (N=1,112 pupils)
Cotter P et al. Ir Med J. 2014 Nov-Dec;107(10):310-3. Danuta Wasserman
Forms of bully victimization in the SEYLE
adolescent sample (N=11,110)
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Social exclusion
Spreading
rumours
Left out of
activities
Name calling
Teasing in an
hurtful way
Making fun
of one’s
looks
Hitting
Kicking
Pushing
Mean text via
messages or emails
Spreading rumors
via email or social
networking sites
Embarrassing
pictures, videos, or
fake profiles made
Barzilay S et al. 2016, Submitted.
Relational victimization was directly
associated with increased likelihood
for suicide attempt.
11/14/2016 Danuta Wasserman 31 Barzilay S et al. 2016, Submitted.
Adolescent Mental Health Depression and anxiety
SEYLE (n = 12,395)
Depression:
10.5% depression
29.2% subthreshold-depression
Anxiety:
5.8% anxiety
32% subthreshold-anxiety
Subthreshold-anxiety, anxiety and depression are
correlated to functional impairment and suicidality.
11/14/2016 32 Balazs J et al. J Child Psychol Psychiatry. 2013 Jun;54(6):670-7. Danuta Wasserman
Direct self-injurious behavior (D-SIB) refers to the
intentional self-inflicted damage of the surface of an
individual’s body by self cutting, -burning, -hitting, -
biting, and skin damage by other methods.
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Direct Self-Injurious behavior
D-SIB
Brunner R et al. J Child Psychol Psychiatry. 2014 Apr;55(4):337-48. Danuta Wasserman
Lifetime prevalence of D-SIB in Europe
27.6%
19.7% occasional D-SIB
7.8% repetitive D-SIB
Lifetime prevalence ranges from 17.1% to 38.6%
across countries.
Estonia, France, Germany, and Israel had the
highest lifetime rates of D-SIB.
11/14/2016 34 Brunner R et al. J Child Psychol Psychiatry. 2014 Apr;55(4):337-48. Danuta Wasserman
D-SIB cessation reduces risk for suicidal
thoughts and behaviour in adolescence.
11/14/2016 Danuta Wasserman 35 Kaess M et al. ECAP, 2016. Submitted
Immigration and mental
health in Europe
Significantly poorer self-perceived health than
natives.
Non-European adolescent migrants, regardless of
migrant generation, had higher externalized
symptom levels than natives.
11/14/2016 Danuta Wasserman 36 McMahon E et al. 2016, Submitted.
Mental Health of Youth in Europe
SEYLE RCT (Randomized controlled trial)
To test preventive interventions in school-based
adolescents.
The RCT was performed in 10 European Union countries.
The adolescent sample size in the SEYLE RCT
was N=11,110
The SEYLE project is registered at the
German Clinical Trials Register
(DRKS00000214).
11/14/2016 38 Wasserman D et al. BMC Public Health. 2010;10:192 Danuta Wasserman
Saving and Empowering Young Lives
in Europe (SEYLE) RCT
11/14/2016
11,110 adolescents
168 randomly assigned schools
10 European Union countries
Median age 15 years
39 Wasserman D et al. The Lancet, 2015; 385(9977):1536-1544 Danuta Wasserman
Multidisciplinary equip sent in schools.
Positive cases identified through a questionnaire.
o Detection
Interviews to exclude false positives.
o Diagnostics
Referral to the local health care system.
o Treatment
11/14/2016 40 Danuta Wasserman
ARM I Professional Screening
4-week intervention
Kaess et al. Eur Child Adolesc Psychiatry, 2014;23:611–620.
Designed by the University of Heidelberg & Karolinska Institutet
ARM II
Gatekeepers (teachers, school staff) identify
suicidal students at school (QPR)
4-week intervention
Q Question
P Persuade
R Refer
Quinette, P: Question, Perceive, Refer (QPR) in Suicide Prevention
[http://www.hopes-wi.org/qpr.htm]
41 11/14/2016 Danuta Wasserman
General Information on Suicidal behavior
Training on risk factors and warning signs
for suicide
Myths and facts about suicide
How to ask / not ask questions
How to provide support
Referral
Arm II
QPR Training
11/14/2016 42 Danuta Wasserman
Pedagogical booklet about lifestyles, health/risk behaviors, suicidal behaviors and mental health problems.
Lectures with role-plays
Posters in the classroom
Manual for instructors
ARM III
YAM (Youth Aware of Mental Health)
for pupils
Beeinflusse und verbessere deine Gefühle
4-week 5 hours intervention
43 11/14/2016
Wasserman Camilla, et al 2012. BMC Public Health, 12:776 Danuta Wasserman
ARM III
YAM (Youth Aware of Mental Health)
Program Booklet for pupils (25 pages)
Part 1: Bewusstsein für seelische Gesundheit
Part 2: Hilfe zur Selbsthilfe
Part 3: Stress und Krise
Part 4: Depression und Selbstmordgedanken
Part 5: Freunden helfen, die Probleme haben
Part 6: An wen kann ich mich wenden,
wenn ich Hilfe benötige?
44 Wasserman Camilla, et al 2012. BMC Public Health, 12:776 11/14/2016 Danuta Wasserman
ARM III
YAM Program Beeinflusse und verbessere deine Gefühle
Role-play themes
45
• Awareness About Choices • Dilemmas and Conflict Resolution Theme I
• Awareness about Feelings and how to Manage Stress and Crises Situations
Theme II
• Awareness about Depression and Suicidal Thoughts and what to do
Theme III
11/14/2016 Danuta Wasserman Wasserman Camilla, et al 2012. BMC Public Health, 12:776
YAM intervention timeline
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1 week prior: Baseline screening for ”Emergency cases” referral for treatment
Age group: 14 – 16 years
Emergency cases*
*Emergency cases: Pupils who during last two weeks tried to attempt suicide or have serious suicide thoughts with plans.
x2
x2
x1
Arm IV
Control/minimal Intervention 4-week duration
Posters in the classroom, the same as in YAM
Contact information to healthcare services
Contact information to community “healthy
lifestyle” groups
47 11/14/2016 Danuta Wasserman
Main outcomes of SEYLE
interventions
Incident cases of suicide attempt.
Incident cases of severe suicidal ideation,
including having a suicidal plan.
Incidence of moderate and severe
depression.
48 11/14/2016 Danuta Wasserman
Professional Screening
intervention
Results in RCT No preventive effects were observed on:
Incident (new) suicide attempts
Incident (new) suicide thoughts/plans
Incident (new) depression
In the professional screening intervention arm:
Significantly good effects on treatment of
prevalent cases of depression 12.5% required referral to mental healthcare
49 11/14/2016 Kaess et al. Eur Child Adolesc Psychiatry. 2014 Jul;23(7):611-20
Wasserman D et al. The Lancet. 2015;18;385(9977):1536-44 Danuta Wasserman
Treatment
Help-seeking behavior following
school-based screening
Help-seeking is associated with the locality of the interview and the
simplicity to schedule appointments:
The greater the travel time to the interview, the lower the attendance
rate.
Arranging interviews within 1 week of contacting the student
increased compliance.
11/14/2016 50 Cotter P et al. Soc Psychiatry Psychiatr Epidemiol, 2015 Jun;50(6):973-82.
Adolescents attended the interview more often than
their peers, when: Severe depressive symptoms
Recent suicide attempt
Bullied students
Danuta Wasserman
QPR intervention
Results in RCT: Incident suicide attempts
Incident suicide thoughts/plans
Incident and prevalent cases of
depression
11/14/2016 51 Wasserman D et al. The Lancet. 2015;18;385(9977):1536-44 Danuta Wasserman
QPR intervention Acceptance of the QPR intervention in
schools
Good reception in schools.
But the preparedness to help
pupils is correlated to teacher
satisfaction with their work
conditions and well-being.
52 Sisak M et al Health Education Journal, 2013 Vol. 73(4) 382–393
11/14/2016 Danuta Wasserman
http://www.allthingsprivatepractice.c
om/wp-
content/uploads/2011/02/Checking-
the-Time-2.jpg
The observed reduction in incident suicide attempts was
more than 50%. (OR: 0·45 [0·24 - 0·85]; p=0·014)
The observed reduction in incident severe suicide
thoughts/plans was 50%. (OR: 0·50 [0·27 – 0·92]; p=0·025)
This effect is higher than those seen in other successful
universal public health interventions regarding:
Bullying and bully victimization (17-23%)
Certain types of school-based interventions addressing
smoking cessation (14%).
53 Wasserman D et al. The Lancet. 2015;18;385(9977):1536-44 11/14/2016 Danuta Wasserman
YAM - Beeinflusse und verbessere deine Gefühle
Preventive effects
How many pupils need to be approached in
order to prevent suicidal ideation and attempts?
To prevent one suicidal event (suicide
attempt or severe ideation) 91 pupils need to
be exposed to YAM (Beeinflusse und
verbessere deine Gefühle)
11/14/2016 54 Danuta Wasserman Brent and Brown. Commentary. The Lancet, 2015;385(9977):1489-1491.
Preventive effects:
The observed reduction in incident
cases of moderate/severe depression
is 30%.
(OR: 0·71 [0·52– 0·97]; p=0·031)
11/14/2016 Danuta Wasserman 55 Hoven C, Carli V et al. 2016. In preparation.
Depressed boy
after being
bullied
YAM - Beeinflusse und verbessere deine Gefühle
Intervention
Qualitative interviews with pupils about
SEYLE YAM intervention (N = 32)
(Italy, Spain, Estonia and Romania)
Interested
One foot in the door
Careful
Respect for authority
Not my topic
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Give me a little time!
Let me speak the way I like!
Can I trust you?
Am I doing it right?
Let silence speak!
Wasserman C, Postuvan V, et al 2016. Submitted.
Suicide prevention Experts’ Opinions on Ethical Issues in Mental Health Research
with Minors: Results of a Delphi Study in SEYLE
Research with minors, especially
for preventive purposes,
investigating risk behaviors
such as deviance, drug abuse,
or suicidal behavior, is ethically
sensitive.
11/14/2016 57 Hiriscau EI,... Reiter-Theil S and colleagues. Int J Environ Res Public Health. 2016;13:0000
Danuta Wasserman
Ethical needs considered relevant for
Mental Health Research with minors were
the following:
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Suicide prevention Experts’ Opinions on Ethical Issues in Mental Health Research
with Minors
Hiriscau E et al. Int J Environ Res Public Health. 2016;13 pp. 1 - 20
Confidentiality of sensitive data
in relation to school.
Competence for consenting
alone when 15 years or older.
How, when or whom to contact
in emergency cases.
Avoidance of risk for harm and
stigma.
Secrecy in handling the
information about family
members.
Feedback about research
Danuta Wasserman
YAM (Beeinflusse und verbessere deine Gefühle)
has the lowest incremental cost per QALY vs.
Control.
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Suicide prevention Incremental cost-effectiveness ratios (ICERs) analysis
of SEYLE interventions in comparison with the control group
Ahem S et al. Manuscript submitted. 2016 Danuta Wasserman
The YAM was cheapest in
comparison to other
interventions versus
control.
ICERs for YAM are €15,992 per
QALY gained for suicide attempt.
Suicide can be prevented!
Evidence-based strategies of suicide
prevention in mental health care and in public
health approaches
12-15/03/2016 Danuta Wasserman 61
G. Zalsman et al. Lancet Psychiatry, 2016;3(7):646–659.
10-years follow-up of systematic review of evidence based strategies in
suicide prevention, Mann J et al. JAMA 2005, 294(16):2064-74
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Thank you!
62 Danuta Wasserman