Positive Psychiatry Preventing suicide through happiness. Prof Yoram Barak, MD, MHA

Positive PsychiatryPositive Psychiatry

Preventing suicide through Preventing suicide through happinesshappiness..

Prof Yoram Barak, MD, MHA.

Cloninger CR. The science of well-being: an Cloninger CR. The science of well-being: an integrated approach to mental health and its integrated approach to mental health and its

disorders. disorders. World Psychiatry. 2006World Psychiatry. 2006

Despite vast expenditures on psychotropic drugs and extensive

efforts to manualize psychotherapy methods, there has been as yet no

substantial improvement in average levels of happiness and well-being in

general populations.



The practical failure of psychiatry to improve well-being is not surprising for several reasons.

First, the focus of psychiatry has been on mental disorders, not on the understanding or development of positive mental health.

Morbidity and mortality are more strongly related to the absence of positive emotions than to the presence of negative emotions.



Second, psychiatric methods of assessment and treatment often require prolonged training with complex jargon for psychotherapy or expensive medications and equipment for biological therapies.

These cost and distribution characteristics limit the availability of effective treatments around the world.

Integrative psychobiological treatments can be highly effective and inexpensive, harnessing the spontaneous resilience of human beings in a therapeutic milieu that can be provided by a wide range of mental health workers with varying levels of professional expertise.



Randomized controlled trials of therapies to enhance well-being in patients with mental disorders show improvements in happiness and character strengths that increase treatment adherence and reduce relapse and recurrence rates when compared to cognitive-behavioral therapy or psychotropic medication alone.

Randomized controlled trials showed that interventions to enhance well-being are also effective in samples of students and volunteers from the general population.



Fava GA, Rafanelli C, Grandi S et al. Prevention of recurrent depression with cognitive behavioral therapy: preliminary findings. Arch Gen Psychiatry 1998;55:816-20.

Fava GA, Ruini C, Rafanelli C et al. Well-being therapy of generalized anxiety disorder. Psychother Psychosom 2005;74:26-30.

Fava GA, Ravanelli C, Cazzaro M et al. Well-being therapy: a novel psychotherapeutic approach for residual symptoms of affective disorders. Psychol Med 1998;28:475-80.

D’Souza RF, Rodrigo A. Spiritually augmented cognitive behavioral therapy. Australasian Psychiatry 2004;12:148-52.

Emmons RA, McCullough ME. Counting blessings versus burdens: an experimental investigation of gratitude and subjective well-being in daily life. J Person Soc Psychol 2003;84:377-89.

Happiness and Suicide:Happiness and Suicide:a “case” in focusa “case” in focus

20032003- - 0404נתוני התאבדות בישראל בשנים נתוני התאבדות בישראל בשנים ממוצע שנתי ממוצע שנתי100,000100,000שיעור ל – שיעור ל –

גיל זכרים נקבותגיל זכרים נקבות

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7575 + +23.823.8 7.27.2

Suicide rates Israel 1998per 100,000 population

0

20

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60

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65-74

55-64

45-54

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Published DataPublished Data J Affect Disord. 2007J Affect Disord. 2007 Dietary tryptophan intake and suicide rate in industrialized nationsDietary tryptophan intake and suicide rate in industrialized nations.. Voracek & Tran Voracek & Tran Soc Psychiatry Psychiatr Epidemiol. 2006 Soc Psychiatry Psychiatr Epidemiol. 2006 Suicide rates, life satisfaction and happiness as markers for populationSuicide rates, life satisfaction and happiness as markers for population mental healthmental health.. Bray & GunnellBray & Gunnell Arch Suicide Res. 2006Arch Suicide Res. 2006 National differences in predictors of suicide among young and elderlyNational differences in predictors of suicide among young and elderly citizens: linking societal predictors to psychological factorscitizens: linking societal predictors to psychological factors.. Wu & BondWu & Bond Soc Psychiatry Psychiatr Epidemiol. 2003 Soc Psychiatry Psychiatr Epidemiol. 2003 Self-reported happiness in life and suicide in ensuing 20 yearsSelf-reported happiness in life and suicide in ensuing 20 years.. Koivumaa-Honkanen et-alKoivumaa-Honkanen et-al Psychol Rep. 2002 Psychol Rep. 2002 National ratings of happiness, suicide, and homicideNational ratings of happiness, suicide, and homicide.. Lester DLester D.. Am J Psychiatry. 2001 Am J Psychiatry. 2001 Life satisfaction and suicide: a 20-year follow-up studyLife satisfaction and suicide: a 20-year follow-up study.. Koivumaa-Honkanen et-alKoivumaa-Honkanen et-al

Soc Psychiatry Psychiatr Epidemiol. 2006 Soc Psychiatry Psychiatr Epidemiol. 2006 Suicide rates, life satisfaction and happiness as markers for Suicide rates, life satisfaction and happiness as markers for

populationpopulation mental healthmental health.. Bray & GunnellBray & Gunnell

There is a growing interest amongst health policy makers in measuring life satisfaction and happiness as indicators of population well-being.

From a public health perspective these measures may be useful indicators of population mental health.

We note that the various definitions of mental health extend beyond the absence of illness and many include the notion of well-being, ‘‘when individuals feel that they are coping, fairly in control of their lives, able to face challenges, and take on responsibility’’.



Although suicide rates are often used to measure population mental (ill) health in national health strategies, international variations and temporal trends in suicide rates are influenced by a range of factors, including some which are not themselves directly related to mental health such as differences in the cultural acceptability of suicide, the completeness of reporting and availability of means of suicide.



Studies to date suggest the relationship between national levels of life satisfaction, happiness and suicide is complex.

For example, people below the age of 35 tend to be ‘happier’ than those above the age of 75 yet less satisfied with their lives.

This may suggest that expectations change over a lifetime or between successive cohorts.

The nations with the highest happiness scores in ecological surveys tend to have the highest levels of suicide, and this is thought to be due to the individualistic nature of these societies .

This theory is in keeping with Durkeim’s division of suicide into different types. Egoistic suicide results from lack of integration of the individual into society.



Little is known about the association between markers of population well-being, such as life satisfaction and happiness, and population mental health.

The aim of this paper is to use data from the 1999/2000 European Values Survey (EVS) to examine the association of population levels of life satisfaction and happiness with suicide rates and other markers of population mental health in Europe.



European Values Survey

The European Values Survey (EVS) [9] is a collaborative, longitudinal survey.

In 1999/2000, representative samples of the populations of 33 European countries responded to a wide range of questions on social and economic issues.

Response rates range from 25 to 95% (median 66%, inter-quartile range 50–73%).

Here we use the results obtained from a total of 39,678 respondents in 32 countries (Turkey was excluded due to lack of suicide data).

The number of respondents per country was between 967 and 2,500.



For the following two survey questions, data were extracted from the CD-ROM EVS 1999/2000:

1. ‘‘All things considered, how satisfied are you with your life as a

whole these days?’’ The response was given on a Likert scale

1 (Dissatisfied) to 10 (Satisfied), resulting in the variable ‘life satisfaction’ (median score

in country). 2. ‘‘Taking all things together, would you say you are (a)

very happy, (b) quite happy, (c) not very happy or (d) not at all happy?’’ The percentages of respondents in the first two categories

were summed, resulting in the variable ‘happiness’.



Here, we compare two possible indicators of mental health with measures of population well-being (EVS 1999/2000):

Suicide rates are calculated from the WHO Mortality Database for 1999. For 4 of the 32 countries, mortality data for 1999 were not available and so the most recently published data were used (ranging from 1996 to 1998)

Rates of hospital discharges for mental and behavioural disorders are available from the WHO Regional Office for Europe for 21 of the EVS countries for 1999. Coding differences between countries (e.g., whether transfer

to another department in the same hospital is recorded as a discharge, date of introduction of ICD-10) make these data of limited comparability between countries.



MHI (Mental Health Index)-5 data are available for 16 of the EVS countrie.

MHI-5 comprises questions about mood over the past month, measuring the experience of psychological well-being and the absence of psychological distress.

“During the past month, how much of the time (1) were you a happy person? (2) have you felt calm and peaceful? (3) have you been a very nervous person? (4) have you felt downhearted and blue? (5) did you feel so down in the dumps that nothing could cheer you up?”

Questionnaires were administered in 2002. Response rates range from 23 to 84% (median 51%, inter-

quartile range 42–71%). Analysed here are percentages of respondents classed as

cases according to MHI-5.



Data on the prevalence of mental disorders (based on the cumulative number of ‘‘registered mental patients’’ (Chapter V ICD-9/10) at the end of the calendar year) are available for 1999/2000 from the WHO Regional Office for Europe for 12 of the EVS countries.

Data collection methods vary between countries (e.g. some exclude out-patients, while others include drug and alcohol abuse patients).

RESULTSRESULTS

Suicide rates and hospital discharge rates for mental and behavioral disorders are relatively strongly associated (n = 23; r = 0.68; 95% CI: 0.37, 0.85).

Given that hospital discharge rates are subject to coding differences between countries, this is a surprisingly robust association.


population mental healthpopulation mental health.. Bray & GunnellBray & Gunnell



There is good evidence of an inverse association between suicide and both:

life satisfaction r2=0.44; 95% CI: (0.68,0.11) happiness r2=0.42; 95% CI: (0.67, 0.08). The magnitude of the correlation is greater for

men than women. Associations with hospital discharge data

suggest similar patterns, though the correlations are based on a smaller number of countries and were weaker r2=0.31; 95% CI: (0.64, 0.12) and r2= 0.35; 95% CI: (0.67, 0.07 respectively).

Scatter plot of suicide rate per 1,000,000 against (a) median lifesatisfaction scores and (b) % very or quite happy using data from the

European Values Survey 1999/2000, for 32 European countries .

DISCUSSIONDISCUSSION

Life satisfaction and happiness were associated, in the expected direction, with most of the indicators of population mental health we assessed, suggesting that they may be useful measures of population mental well-being.

Mental well-being is a component of commonly used definitions of mental health.

Whilst most of the associations we found were relatively modest (all correlations were smaller than 0.55) This does not necessarily undermine the usefulness of

these two variables, as the measures we were comparing them with in turn have several limitations.

CONCLUSIONCONCLUSION

Perhaps the best approach for policy makers and health strategists to assess trends is a cluster of indicators, including surveys of life satisfaction and happiness, population surveys of psychiatric morbidity, suicide rates and rates of psychiatric hospitalisation.

Our results suggest that survey questions on life satisfaction and happiness are measuring similar but different aspects of well-being.

It is possible that other variables such as community trust and feeling in control of one’s life could also contribute valuable information to an assessment of population mental health.

Future DirectionsFuture Directions

Increasing Happiness:Increasing Happiness:

Possible ? Feasible ? Validated Possible ? Feasible ? Validated ??

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Positive Psychiatry Preventing suicide through happiness. Prof Yoram Barak, MD, MHA