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

11/14/2016 7

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)

11/14/2016 25

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

11/14/2016 26

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

11/14/2016 28

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.

11/14/2016 29

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)

11/14/2016 Danuta Wasserman 30

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.

11/14/2016 33

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.

PREVENTION

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

11/14/2016 Danuta Wasserman 46

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

11/14/2016 Danuta Wasserman 56

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:

11/14/2016 58

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.

11/14/2016 59

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

11/14/2016

Thank you!

62 Danuta Wasserman