Each year 63,000 people die by suicide in EU 27ec.europa.eu/health/sites/health/files/mental_health/docs/ev... · Suicide Prevention Health Care Perspective Treatment of schizophrenia

A menu of evidence-based actions

for preventing suicidal behaviour

Danuta Wasserman

Professor of Psychiatry and Suicidology

Head of the National Prevention of Suicide and Mental Ill-health (NASP) at Karolinska Institute, Stockholm, Sweden

WHO Collaborating Centre for Prevention of Mental Ill-Health and Suicide

The Thematic Conference on Prevention of Depression and Suicide

under the European Pact for Mental Health and Well-being

"Prevention of Depression and Suicide in a time of Crisis– Making it Happen"Budapest, 10-11 December 2009

15 december 2009Danuta Wasserman 2

Each year 63,000 people die by suicide in EU 27

Source: Eurostat, Statistical Book 2009

Males Females

Suicide in Europe

�� Every day, 172 persons die by suicide in Europe.Every day, 172 persons die by suicide in Europe.

�� This is equivilant to a devasting plane crash occuring This is equivilant to a devasting plane crash occuring

every day in the European Unionevery day in the European Union

2009-12-15Danuta Wasserman 3 2009-12-15Danuta Wasserman 4JDanuta 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 Suicide rates* in Europe, latest

available data from the WHOavailable data from the WHO

15 years and over.15 years and over.

* * The number of suicide estimated per 100 000 inhabitants The number of suicide estimated per 100 000 inhabitants

Very high suicide rates:Very high suicide rates:

40,1 (Hungary) 40,1 (Hungary) ––58,0 (Lithuania)58,0 (Lithuania)

High suicide rates:High suicide rates:

25,0 (Moldavia) 25,0 (Moldavia) ––35,8 (Belarus)35,8 (Belarus)

Low suicide rates:Low suicide rates:

3,4 (Albania) 3,4 (Albania) ––9,9 (Portugal)9,9 (Portugal)

Data not availableData not available

Average suicide ratesAverage suicide rates

11,9 (The Netherlands) 11,9 (The Netherlands) ––23,0 (Czech Republic)23,0 (Czech Republic)

2009-12-15Danuta Wasserman 5

Psychiatric inpatient population

N=7424

General population

N=1835

General population

N=6370

Main diagnosis

%

Main diagnosis

%

Multiple diagnosis

%

Mood disorders 20.8 44.4 34.3

Substance-related disorders 9.8 19.2 23.0

Schizophrenia 19.9 7.5 11.2

Organic mental disorders 15.0 2.1 0.9

Other psychotic disorders 10.4 2.3 0.0

Anxiety/somatoform disorders, Adjustment disorders

2.5 6.7 10.4

Other 6.2 2.7 5.6

Personality disorders 15.2 3.2 13.1

TOTAL 100.0 100.0 100.0

Psychiatric diagnoses Axis I & AXIS II and Psychiatric diagnoses Axis I & AXIS II and

suicidesuicide

Bertolote J, Fleischmann A, De Leo D, Wasserman D.Bertolote J, Fleischmann A, De Leo D, Wasserman D.

Suicide and Mental Disorders: do we know enough? British JournalSuicide and Mental Disorders: do we know enough? British Journal of Psychiatry, 2003;183:382of Psychiatry, 2003;183:382--383383


Health CareHealth CarePerspectivePerspective

Public HealthPublic HealthPerspectivePerspective

Antidepressant drugsAntidepressant drugs

LithiumLithium

NeurolepticsNeuroleptics

PsychotherapyPsychotherapy

Closing the existsClosing the exists

Alcohol reductionAlcohol reduction

MEDIA MEDIA

reportingreporting

Public Public

awarenessawareness

PsychoPsycho--socialsocial

measuresmeasures

EvidenceEvidenceStrategies in Suicide PreventionStrategies in Suicide Prevention

Model for Suicide PreventionModel for Suicide PreventionHealth care and public health Health care and public health

approachesapproaches

� Effective suicide prevention programs

should combine both approaches for

optimal impact.


Suicide PreventionSuicide Prevention

Health Care PerspectiveHealth Care Perspective

Treatment with antidepressants of depressionTreatment with antidepressants of depression

••SuicidalSuicidal thoughtsthoughts

Stone et al. BMJ. 2009

Barak et al. Neuropsychopharmacology. 2006

Angst et al.

J Clin Psych 1999

Möller 2009

Brent 2009

Oxford University

Press

••Suicide attemptSuicide attempt

••SuicideSuicide


Risks/BenefitsRisks/Benefits

Treatment of suicidal people with Treatment of suicidal people with

antidepressantsantidepressants

� Combine antidepressants with

psychotherapy

� Combine antidepressants with

anxiolytics

� Active follow up of treatment and side effects

2009-12-15Danuta Wasserman 9 2009-12-15Danuta Wasserman 10


EducationEducation

General practitionersGeneral practitioners’’ trainingtraining

The Gotland Study (Rutz, W.)The Gotland Study (Rutz, W.)

The Estonian Study (VThe Estonian Study (Väärnik, A.)rnik, A.)

The Hungarian Study (Hendin, H. et al. &Mann, J.)The Hungarian Study (Hendin, H. et al. &Mann, J.)

The German (NThe German (Nüürenberg) study (Hegerl, U.)renberg) study (Hegerl, U.)

Suicide in femalesSuicide in females

Suicide in malesSuicide in males

AntidepressantsAntidepressants

AnxiolyticsAnxiolytics

HospitalHospital carecare


Outcome with lithiumOutcome with lithium Outcome without lithiumOutcome without lithium

SuicidesSuicides

RateRate 0.1670.167 0.7930.793

(95% CI)(95% CI) (0.109(0.109--0.224)0.224) (0.592(0.592--0.995)0.995)

SubjectsSubjects 14,30814,308 1,3701,370

AttemptsAttempts

RateRate 0.4070.407 4.0214.021

(95% CI)(95% CI) (0.154(0.154--0.660)0.660) (2.040(2.040--6.003)6.003)

SubjectsSubjects 898898 651651

All actsAll acts

RateRate 0.1970.197 2.5702.570

(95% CI)(95% CI) (0.128(0.128--0.266)0.266) (1.751(1.751--3.3893.389

SubjectsSubjects 15,15715,157 1,9981,998

Estimated rates of suicidal acts with and without lithium Estimated rates of suicidal acts with and without lithium

maintenance treatmentmaintenance treatment

Möller HJ (2009). Pharacological and other biological treatments of suicidal behaviours. In D. Wasserman and C. Wasserman, eds. The Oxford

Textbook of Suicidology and Suicide Prevention: A Global Perspective. Oxford University Press, Oxford.

Lithium levels in drinking water and Lithium levels in drinking water and

risk of suicide risk of suicide

� Lithium levels in tap water were examined in the 18 municipalities of Oita prefecture in Japan in relation to the

suicide standardized mortality ratio (SMR) in each municipality

� Lithium levels were significantly and negatively associated with

SMR averages for 2002-2006

� Conclusion: even very low levels of lithium in drinking water may play a role in reducing suicide risk within the general population

(Ohgami et al. Br J Psychiatry 2009)



Health Care PerspectiveHealth Care Perspective

Treatment of schizophreniaTreatment of schizophrenia

Neuroleptics Neuroleptics –– Clozapine (Leponex)Clozapine (Leponex)

N= 102 000N= 102 000

SuicideSuicide by 75%by 75%

Attempted suicideAttempted suicide

Meltzer et al.Meltzer et al.

Arch. Gen. Psych 2003Arch. Gen. Psych 2003

Hennen et al. Schiz. Res. Hennen et al. Schiz. Res.

20052005

Pompili et al. 2008Pompili et al. 2008

Expert Rev Neurother

Tiihonen J, et al. Tiihonen J, et al.

Lancet 2009Lancet 2009

2009-12-15Danuta Wasserman 132009-12-15Danuta Wasserman 14

PsychotherapyPsychotherapy

••CBTCBT(Cognitive behavioural therapy)(Cognitive behavioural therapy)

Tarrier et al. Meta-analysis, Behav Modif 2008

••DBTDBT(Dialectal behavioural therapy)(Dialectal behavioural therapy)

Linnehan et al.Arch Gen Psych, 2006

Attempted suicideAttempted suicide

Repetition of att.Repetition of att.

suicidesuicide

New approach:

Cognitive-Behavioral

Therapy for Suicide

Prevention (CBT-SP)

Stanley et al. J

Am Acad Child Adolesc Psychiatry, 2009

Rudd et al. IN: D. Wasserman and

C. Wasserman, eds. Oxford University Press 2009


Health Care/ Public Health Care PerspectiveHealth Care/ Public Health Care Perspective

TeleTele--CheckCheck

TeleTele--HelpHelp

Mental wellMental well--beingbeing

SuicideSuicide

Hospital admissionsHospital admissions

De Leo et al. Br J Psych. 2002

Krysinska KE and De Leo D, Review

Omega, 2007


WHO/EU (MONSUE) multiWHO/EU (MONSUE) multi--centre centre

study on attempted suicide in 26 study on attempted suicide in 26

European countriesEuropean countries

� A high percentage of suicide

attempters have up to 20

contacts with at least 5

treatment providing facilities


� The continuity of treatment of suicide attempters

is poor

Critical points in care

� Leaving the care setting is often a critical point for the patient

� Patients are often discharged without clear follow up plans


WHO SUPRE-MISS

Follow-up of suicide attempters:

RCT across 5 countries

Subjects:

� Suicide attempters identified in emergency units in 5 countries:� Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic

Republic of Iran; and Yuncheng, China

Fleischmann et al. (2008). Bulletin of the World Health Organization


1867Suicide attempters

TAU

n=945TAU + BIC

n=922

WHO SUPRE-MISS

Brief intervention and contact

� Brief intervention and contact (BIC):

� 1-hour individual information session after suicide attempt

� nine follow-up contacts after discharge (phone calls or visits);

1, 2, 4, 7, 11 week(s)

4, 6,12, 18 months

� Information sessions conducted by a person with clinical experience (e.g. doctor, nurse, psychologist).

� Primary outcome measure: suicide at 18 month follow-up

Fleischmann et al. (2008). Bulletin of the World Health Organization


Status TAU TAU + BIC X2 P-Value

(n) % (n) %

Died by suicide 18 2.2 2 0.2 13.83 <0.001

Died of any cause 22 2.1 11 1.3 4.36 0.037


Results and Conclusion

Conclusion:

This low-cost brief intervention may be an important part of

suicide prevention programmes for under-resourced low-

and middle-income countries as well as for developed

countries.

The role of attitudes: an example The role of attitudes: an example

Attempted suicide Attempted suicide –– an important risk factor an important risk factor

for future suicidesfor future suicides

� A risk factor can be the health care personnel’s attitude to whom treatment should be given.

� In Italy, Spain, Switzerland and Germany all young boys who have attempted suicide get treatment, but not all the girls.

� In the Nordic countries, the opposite was the case.

Hultén, A. Wasserman, D et al. Repitition of attempted suicide among teenagers in Europe.European Child and Adolescent Psych, 2001;10:161-169


Training of trainers in psychiatric Training of trainers in psychiatric

clinical workclinical work

� The knowledge can be improved - obvious

� The negative attitudes towards suicidal patients can

be modified

� The climate in the work place can be improved

� The professional status can also be

improved

Ramberg I-L, and Wasserman D. 2004


PUBLIC HEALTH APPROACH IN SUICIDE PREVENTION



Public Health PerspectivePublic Health Perspective

Closing the exitsClosing the exits

•• Availability of toxic medicationsAvailability of toxic medications

•• Gun controlGun control

•• PesticidesPesticides

Leenaars et al. Death stud 2003

Gunnel et al. Int. J. Epidemiol, 2007

Simkin et al. QJM 2005

•• BridgesBridges Beautrais et al. Aust N Z J

Psychiatry, 2009



Media reportingMedia reporting

Chen YY. et al. Soc Psychiatry Psychiatr

Epidemiol 2009; Schmidtke et al. Psychol Med

1988


Public Health PerspectivePublic Health Perspective


Restrictions in alcohol consumptionRestrictions in alcohol consumption

““PerestroikaPerestroika”” in the former USSR: historyin the former USSR: history’’s most effective s most effective

suicidesuicide--preventive program for men 1984preventive program for men 1984--19861986

Wasserman, D., Värnik, A. Acta Psych Scand. 1998

•Suicides for men decreased by 40%

•Suicide decreased most for males in the workforce ages 24-54

•Decline of suicide in all 15 republics of the former USSR

•In Europe during the same time period suicide decreased

for men by only 3,0%!

0

10

20

30

40

50

60

70

0 2 4 6 8 10 12

Russia Belarus Ukraine

Annual suicide rates per 100 000 males and consumption of Absolute alcohol in litres per capita in the Slavic republics, 1984 and 1986.


Alcohol restrictions and attitude Alcohol restrictions and attitude

changes towards alcohol during changes towards alcohol during

perestroika 1984perestroika 1984--19861986

� Suicide

� Death from undetermined causes, either accidental or intentional

� Homicide

� Death due to cardiovascular diseases

� Death due to respiratory diseases

� Violent death due to external injuries

� Death due to accidental alcohol poisoning(Leon, D. et al. The Lancet 1997)

(Wasserman, D. et al. Acta Psych. Scand. 1998)


Strategies for intervention in schools: SEYLE

EU funded 7 � � framework program

� Increasing mental health awareness among pupils (Wasserman Camilla et al. 2009)

� Screening: 60% of suicides identified at high school –mainly depression and

anxiety (Shaffer et al. 2004)

� Gate-keeper training: training key persons to identify risks

and encourage treatment.


Projektet SEYLE –

EU funded 7 � � framework program

(Saving and EmpoweringYoung Lives in Europe)



T h a n k y o uT h a n k y o u


Publisher: The Oxford University Press (www.oup.com)

Printed in English

This paper was produced for a meeting organized by Health & Consumers DG and represents the views of its author on thesubject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of the Commission's or Health & Consumers DG's views. The European Commission does not guarantee the accuracy of the dataincluded in this paper, nor does it accept responsibility for any use made thereof.

Documents

Each year 63,000 people die by suicide in EU 27ec.europa.eu/health/sites/health/files/mental_health/docs/ev... · Suicide Prevention Health Care Perspective Treatment of schizophrenia