Outcomes of the SEYLE project on school-based suicide prevention Mental health of European youth

Transcription

1 Meeting of the Group of Governmental Experts on Mental Health and Well-Being Luxembourg, 3-4 December 2014 DGSANCO LUX Programme Management and Diseases Outcomes of the SEYLE project on school-based suicide prevention Mental health of European youth President of the European Psychiatric Association (EPA) Professor of Psychiatry and Suicidology at Karolinska Institute (KI) Head of the National Centre for Prevention of Suicide and Mental Illhealth (NASP) Stockholm, Sweden Director for the WHO Collaborating Centre for Research, Methods Development and Training in Suicide Prevention

2 Mental health problems among adolescents One in five adolescents experience significant symptoms of emotional distress % suffer from mental disorders. The most common mental disorders among adolescents are: Depression Anxiety disorders Attention-deficit/ hyperactivity disorder Substance use disorder Suicide is the second leading cause of death among youth years worldwide Mental Health in EU Report 1/23/2015 2

3 Mental Health Problems and Health Risk-Behaviours (HRB) Depression, other psychiatric disorders and suicidal behaviours are strongly correlated with HRB, such as: Violence (Holmes & Sher 2013) Delinquency (Brent & Bridge 2007) Substance abuse (Schneider 2009) Bullying (Klomek et al 2009) Self harm(brunner et al 2014) 1/23/2015 3

4 How does the situation look for European youth? Health risk behaviours Mental health problems Preventability 1/23/2015 4

5 Saving and Empowering Young Lives in Europe (SEYLE) EU funded FP7 Program Objectives Gather information on European adolescents regarding: Socio-demographics Mental health Well-being Risk-behaviors Suicidal behaviors To test preventive interventions in schoolbased adolescents Wasserman D et al. BMC Public Health. 2010;10:192 1/23/2015 5

6 Study sites Countries Austria Estonia France Germany Hungary Ireland Israel Italy Romania Slovenia Spain Sweden Coordinating Center Onsite Leading Investigators C. Haring A. Värnik J.P. Kahn R. Brunner J. Balazs P. Corcoran A. Apter M. Sarchiapone D. Cozman V. Postuvan J. Bobes D. Wasserman Principal Investigator D. Wasserman Coordinator V. Carli Wasserman D et al. BMC Public Health. 2010;10:192 1/23/2015 6

7 SEYLE Evaluation of HRB Risk-behavior Excessive alcohol use Illegal drug use Heavy smoking Reduced sleep Overweight Underweight Sedentary behaviour Categorization Drinks 2 to 3 times a week or more Used illegal drugs at least three times during life Smokes more than 5 cigarettes per day Sleeps 6 hours per night or less BMI above 95 th percentile for that age BMI below 5 th percentile for that age Performs physical activity less than once a week High media use Internet, tv and videogames for non-school-related purposes for 5 hours or more per day Internet use Truancy Using the Internet for non-school-related purposes for 3 hours or more per day Skips school at least once a week without being ill or having another legitimate excuse Wasserman D et al. BMC Public Health. 2010;10:192 1/23/2015 7

8 SEYLE Psychometric Instruments Instruments WHO-5 Beck Depression Inventory-II (BDI-II) Zung Self-Rating Anxiety Scale (SAS) Paykel Suicide Ladder (PSS) Global School-Based Pupil Health Survey (GSHS) Strengths and Difficulties Questionnaire (SDQ) European Values Study Questionnaire (EVS) Deliberate Self Harm Inventory (DSHI) Young s Diagnostic Questionnaire (YDQ) Wasserman D et al. BMC Public Health. 2010;10:192 1/23/2015 8

9 High internal reliability of psychometric scales The internal reliability for the Z-SAS, BDI-II, WHO-5 and the SDQ was high. Z-SAS BDI-II WHO-5 SDQ Total Carli et al. BMC Public Health 2013, 13:479 1/23/2015 9

10 Socio-demographic characteristics of the SEYLE sample N=12,395 Socio-demographics N Age Gender (% Male) 12, ± Males (%) Females (%) Both Genders (%) Not born in the country Parents not born in the country Doesn t belong to a religious denomination Someone in the family lost job last year Single parent household Carli et al. World Psychiatry, 2014;13(1): /23/

11 HEALTH RISK-BEHAVIOURS

12 Alcohol Drink containing alcohol (at least 2-3 times per week) % Males Females had lower prevalences than males (M= 10.5% vs. F= 5.8%; p<0.0001) 1/23/

13 Alcohol consumption patterns and family structure There is a statistically significant difference in adolescent alcohol consumption whether the adolescent lives in a family with both birth parents, in a single-parent family or in a family with one birth parent and one step-parent. Abstaining from alcohol percentage among adolescents is greater in families with both birth parents compared to other family types. The more often adolescents see their family member drunk the more they drink themselves (quantity, frequency). 1/23/ Rüütel et al 2014, accepted in Intern. J Environmental Res in Public Health

14 Drugs At least one time in life used illegal drugs (%) Males Use of drugs significantly differs among genders (M=12.5% vs. F=9.3%; p<0.001) 1/23/

15 Sleep Hours of sleep among adolescents Approx. 7.7±1.3 hours per night during a school week Hours of sleep: Decrease with age Lower among females Sarchiapone M, et al Sleep Medicine, 15(2): /23/

16 Sleep Sleep and emotional and behavioral problems among adolescents Diminished hours of sleep were significantly associated with: Emotional problems Hyperactivity Conduct problems Conflict with peers Total difficulties Suicidal ideation Sarchiapone M, et al Sleep Medicine, 15(2): /23/

17 Measuring pathological Internet use Young s Diagnostic Questionnaire (YDQ) During the past 6 months, when using the Internet for non-essential purposes (e.g. NOT school work, academically, etc.), please answer the following questions by checking the box for Yes or No for each item. ITEM YES NO 1. Do you feel preoccupied with the Internet (i.e. think about previous online activity or anticipate next online session)? 2. Do you feel the need to use the Internet with increasing amounts of time in order to achieve satisfaction? 3. Have you repeatedly made unsuccessful efforts to control, cut back, or stop Internet use? 4. Do you feel restless, moody, depressed, or irritable when attempting to cut down or stop Internet use? 5. Do you stay online longer than originally intended? 6. Have you jeopardized or risked the loss of significant relationship, job, or educational opportunity because of the Internet? 7. Have you lied to family members, therapist, or others to conceal the extent of involvement with the Internet? 8. Do you use the Internet as a way of escaping from problems or of relieving a dysphoric mood (e.g. feelings of helplessness, guilt, anxiety, or depression)? 1/23/

18 Internet According to the Young s Diagnostic Questionnaire for Internet Addiction (YDQ), Internet users were classified into three groups: Adaptive users (YDQ score: 0-2) Maladaptive users (YDQ score: 3-4) Pathological users (YDQ score: 5) Young, K.S. (1996). CyberPsychology and behaviour, 1(3), /23/

19 Internet Prevalence of Maladaptive and Pathological Internet use by gender All countries Males Females Mean Maladaptive use Mean Pathological use hours (n=1,608) hours (n=525) Total Total Total Total n % n % Both genders , Durkee et al Addiction; 107(12): /23/

20 Internet Mental health of pathological Internet users Pathological Internet use was associated with: Depression Suicidal ideation Suicide attempts Bullying Poor parental monitoring (Great impact on boys) Kaess et al. Eur Child Adolesc Psychiatry, 2014 Nov;23(11): /23/

21 Truancy Prevalence of truancy by gender and age-group 14 and below (n=4.007) M % F % M+F % M % 15 (n=5.350) F % M+F % 16 and above (n=2.955) M % F % M+F % Truancy Boys 1/23/

22 Truancy and HRB Truancy is associated with: Smoking cigarettes Drinking alcohol Drug use Physical fights 1/23/

23 Truancy and mental health problems Truancy is associated with: Depressive symptoms Anxiety Suicidal ideation Suicide attempts 1/23/

24 Truancy and bullying 1/23/

25 Truancy and bullying 1/23/

26 Start prevention at an early age HRB increases with age 14-year-olds already have: High alcohol use Drug use Smoking Need improvement in sleep Need improvement in physical activity 1/23/

27 Cluster analyses in SEYLE Health Risk Behaviours n=12,395 Carli et al. World Psychiatry, 2014;13(1): /23/

28 Psychopathology in three HRB clusters Depression Anxiety Lifetime Suicide attempts N=6,054 (M/F: 2,557/3,497) No/Low risk >60% N=1,796 (M/F: 687/1,109) Invisible risk 29% N=1,184 (M/F: 622/562) High risk 10% 4.2% 13.4% 14.7% 2.5% 8.0% 9.2% 1.7% 5.9% 10.1% Carli et al. World Psychiatry, 2014;13(1): /23/

29 PSYCHOPATHOLOGY

30 Evaluation of depression and anxiety Psychiatric symptom Categorization Depression BDI-II score 20 Sub-threshold depression BDI score <20 and positive (>0) on items assessing core symptoms of depression (sadness and loss of pleasure) Anxiety ZUNG-A score 60 Sub-threshold anxiety 44 ZUNG-A score < 60 1/23/

31 Prevalence of adolescent depression and anxiety 10.5% Depression 29.2% Subthreshold-depression 5.8% Anxiety 32% Subthreshold-anxiety Balázs et al J Child Psychol Psychiatry 2013 Jun;54(6): /23/

32 Anxiety and Physical Comorbidity in Adolescents Self-rated health: 2.8% Poor 2.8% Physical disability 15% Chronic illness Adolescents who rated their health as poor, had a physical disability or chronic illness had significantly higher levels of anxiety. 1/23/ Balazs et al 2014, submitted

33 AFFECTIVE DISORDERS IN ADOLESCENTS Merikangas, K. R., He, J., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., Benjet, C., et al. (2010). Lifetime Prevalence of Mental Disorders in U.S. Adolescents: Results from the National Comorbidity Survey Replication Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49(10), /23/

34 Prevalence of psychopathology by age 1/23/

35 Psychopathology increases with age and differs between gender Females Depression Anxiety Self harm Suicidal ideation Suicide attempts Males Conduct disorders Hyperactivity 1/23/

36 Lifetime Suicide Attempts Have you ever tried to take your own life? Males: 2,9% Females: 5,1% Total: 4.2% Females had attempted suicide more often than males (p<.001) Carli et al. World Psychiatry, 2014;13(1): /23/

37 Different preventive strategies are needed for boys and girls Prevention strategies for girls need to address: Depression Anxiety Self harm Suicide attempts Sleep Sedentary behavior Prevention strategies for boys need to address: Conduct disorders Peer problems Hyperactivity Sedentary behavior Sleep Alcohol, drugs, cigarettes Carli et al. World Psychiatry, 2014;13(1): /23/

38 SEYLE INTERVENTIONS

39 Saving and Empowering Young Lives in Europe (SEYLE) The SEYLE project is a randomized controlled trial (RCT) testing mental health promoting interventions for adolescents in European schools. The SEYLE project is registered at the German Clinical Trials Register (DRKS ). Wasserman D et al. BMC Public Health. 2010;10:192 1/23/

40 Three different theoretical approaches are used in the preventive interventions to empower: 1. Professionals: Profscreen was designed by Heidelberg University, Germany with Karolinska Institutet, Sweden. 2. Teachers: QPR, US gatekeeper training program. 3. Pupils: Awareness intervention designed to increase awareness of health risk-behaviours and mental health. It was designed by Columbia University and Karolinska Institutet. 4. Control/Minimal intervention Wasserman D et al. BMC Public Health. 2010;10:192 1/23/

41 Saving and Empowering Young Lives in Europe (SEYLE) The SEYLE sample consisted of 11,110 adolescent pupils Recruited from 168 randomly assigned schools in ten European Union countries Median age 15 years Wasserman D et al. BMC Public Health. 2010;10:192 1/23/

42 ARM I Professional Screening Psychiatric Disorders and HRB 4-week intervention Positive cases identified through the baseline questionnaire (detection) Interviews by mental health professionals to exclude false positives (diagnostics) Referral to the local health care system (treatment) Kaess et al. Eur Child Adolesc Psychiatry, 2014;23: /23/

43 ARM II Gatekeepers (teachers, school staff) identify suicidal students at school (QPR) 4-week intervention 3-hours training Q Question P Persuade R Refer Quinette, P: Question, Perceive, Refer (QPR) in Suicide Prevention [ 1/23/

44 ARM II Gatekeepers identify suicidal students at school (QPR) Recognition Communication Referral to professionals Quinette, P: Question, Perceive, Refer (QPR) in Suicide Prevention [ 1/23/

45 ARM III Awareness of HRB and mental health intervention for pupils 4-week 5 hours intervention Pedagogical booklet about lifestyles, health risk behaviours, suicidal behaviours and mental health problems. Lectures with role-play Posters in the classroom Manual for instructors Wasserman Camilla, et al BMC Public Health, 12:776 1/23/

46 ARM III Awareness Program Booklet for pupils (25 pages) Part 1: Awareness of Mental Health and Health Risk Behaviours Part 2: Self-Help Advice Part 3: Stress and Crisis Part 4: Depression and Suicidal Thoughts Part 5: Helping a troubled friend Part 6: Getting advice Who to contact Wasserman Camilla, et al BMC Public Health, 12:776 1/23/

47 Role-play examples HRB It s getting late and you are going home from a party. You realize that your friend s sister who is driving you is drunk. Physical violence You suddenly see a bruise on your friend s arm. When you ask what happened, she/he says that her/his mother hit her/him. Crises Situations A break-up with the girl-friend/boy-friend. A family member is seriously ill. A parent becomes unemployed or can t work any longer. Exclusion/Bullying Maria is not always allowed to be around Sofia and Luisa. Sometimes she is allowed to come along, sometimes she is not. Sometimes they tell her she has ugly clothes or a bad hair style etc. Depression and Suicidal Thoughts Eric fights with his parents, he thinks that everyone is horrible; he sleeps badly, starts to drink alcohol and stays away from school. Role-play: One student should play Eric and should show how he may feel, other students play people that can help him (friends, family members, teachers, etc.). What should Eric do? Wasserman Camilla, et al BMC Public Health, 12:776 1/23/

48 ARM III Awareness Program Manual for instructors performing the interventions Psychologist, public health experts, social workers (31 pages) Text about mental health problems and health risk behaviours Role-play examples Posters Wasserman Camilla, et al BMC Public Health, 12:776 1/23/

49 Design of Awareness Intervention 1/23/

50 ARM IV Control/minimal Intervention 4-week duration Posters in the classroom, the same as in the Awareness Arm Contact information for healthcare services Contact information for community supported healthy lifestyle groups 1/23/

51 SEYLE INTERVENTION RESULTS

52 Main outcomes of SEYLE interventions Incident cases of suicide attempt Incident cases of severe suicidal ideation, including having a suicidal plan 3-month and 12-month follow-up 1/23/

53 Statistical analyses Generalized linear mixed models (GLMM) with a logistic link, a random effect to account for clustering of pupils within schools, and a nested random effect to account for repeated (3- and 12-month) measures within pupils, were used to test for intervention group differences. The GLMMs for each outcome included fixed effects for intervention group, categorical month, a group-by-month interaction, and controlled for individual characteristics: age gender country of residence not living with both biological parents not born in the country of residence parent lost employment in the previous year Wasserman D. et al. The Lancet, 2014, in press. 1/23/

54 Awareness intervention Significant results in RCT At 12-month follow-up, a significant effect of the Awareness intervention, compared with controls was observed with reduction of: Incident suicide attempts (OR: 0 45 [ ]; p=0 014) Severe suicidal ideation/plans (OR: 0 50 [ ]; p=0 025) Wasserman D. et al. The Lancet, 2014, in press. 1/23/

55 Awareness intervention Significant results in RCT When the analysed sample included pupils who participated in all waves of data collection (N=8,282), the Awareness intervention showed even stronger effects for: Incident suicide attempts (OR: 0 36 [0 18, 0 72]; p=0 004) Severe suicidal ideation/plans (OR: 0 46 [0 24, 0 88]; p=0 018) Wasserman D. et al. The Lancet, 2014, in press. 1/23/

56 Awareness Intervention The observed reduction in incident suicide attempts was more than 50%. 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%). Wasserman D. et al. The Lancet, 2014, in press. 1/23/

57 Awareness intervention How many pupils need to be approached in order to prevent suicidal ideation and attempts? Combining the two outcomes, the number needed to be intervened upon in order to prevent one suicidal outcome by the Awareness intervention was around 91. 1/23/

58 ProfScreen intervention No significant results in RCT Incident suicide attempts Incident suicide thoughts/plans In the professional screening intervention arm: 3,070 students were screened 12.4% had such a high degree of HRB or severe mental health problems that they required mental healthcare Wasserman D. et al. The Lancet, 2014, in press. Kaess et al. Eur Child Adolesc Psychiatry, 2014;23: /23/

59 ProfScreen intervention Help-seeking behaviours were increased in: Younger pupils Depressive and suicidal pupils Peer victimized pupils Best predictors for referral to mental healthcare were: Low Body Mass Index (BMI) Depression Suicidal behaviour Substance abuse Increased help-seeking behaviour: Parents postive attitude Close proximity to the school for the professional clinical interview Short waiting time for the clinical interview Kaess et al. Eur Child Adolesc Psychiatry, 2014;23: /23/

60 ProfScreen intervention Poor acceptance of the Professional Screening De-stigmatize ProfScreen DE-STIGMATIZING FACTORS Discretely approaching the pupil One-on-one interaction with pupil Provide mental health information to pupil/parent Addressing stereotypes of mental illness Empowering pupils to seek help Promoting self-esteem and self-efficacy STIGMA INCREASES STIGMA DECREASES STIGMATIZING FACTORS The name Screening Approaching the student in front of teachers/peers Performing clinical interview in indiscrete locations Not addressing prejudices of mental illness Showing disinterest in helping pupil Kaess et al. Eur Child Adolesc Psychiatry, 2014;23: /23/

61 QPR intervention No significant results in RCT Incident suicide attempts Incident suicide thoughts/plans QPR designed to act on overt behaviours, accessible to observation QPR intervention is not designed to influence pupils internal perceptions of negative life events, depression and suicidality. Wasserman D. et al. The Lancet, 2014, in press. 1/23/

62 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. Sisask et al 2013 Health Education Journal 1/23/

63 SEYLE Limitations Reliance on self-report, as in similar studies For ethical reasons the control group was exposed to the same mental health information as in YHMAP, displayed on posters in the classrooms One can assume that the effect-sizes for the YHMAP are probably underestimated Wasserman D. et al. The Lancet, 2014, in press. 1/23/

64 SEYLE Strengths The largest number of adolescent participants, by far Good follow-up participation rates Standardised Active central oversight Centralized data management A very large, multi-national effort involving ten European countries 100 personnel trained Wasserman D. et al. The Lancet, 2014, in press. 1/23/

65 Summary Efficacy of the intervention in the RCT 12 month follow up Awareness Question, Persuade and Refer Professional Screening Suicide attempts Significant decrease N.S. N.S. Suicidal ideation Significant decrease N.S. N.S. Wasserman D. et al. The Lancet, 2014, in press. 1/23/

66 Discussion Awareness intervention Cognitive, Emotional and Communicative learning. Lectures and written materials support pupils knowledge and skills acquired during the program (cognitive learning). Role play provides an opportunity to discuss feelings, solutions and improve skills (emotional learning and training skills). The written material is also a facilitator in communicating with parents and others about feelings, worries, mental health and HRB (communication and interactive learning). Wasserman Camilla, et al BMC Public Health, 12:776 1/23/

67 Acceptance of the SEYLE Awareness intervention in schools The Awareness intervention was popular among pupils and instructors. Adolescents enjoyed the role-play session in this intervention. Adolescents learned about health risk behaviours, mental health and suicidal behaviours. Improved skills in talking about suicide. Camilla Wasserman et al BMC Public Health; 12:776 1/23/

68 Discussion QPR and ProfScreen interventions Adult-driven interventions, which adolescents might be reluctant to accept Helping pupils with mental health problems is dependent on teachers subjective psychological well-being QPR requires teachers to identify observable signs of suicide risk; being that suicidality is primarily an internal process Many warning signs are well hidden 1/23/

69 Discussion Other Universal Suicide Preventive Interventions A classroom-based intervention, Signs of Suicide (SOS), involving 2,100 pupils in 5 North American high schools, showed a reduced risk of suicide attempts at 3-month follow-up, although there were no differences in suicidal ideation Similar findings were reported based on an extension of this programme carried out with 4,133 pupils in 9 US high schools, where again, there was a significantly lower incidence of suicide attempts at 3-month follow-up, but no improvement regarding suicidal ideation compared to controls Aseltine et al. Am J Public Health, 2004 Aseltine et al. BMC Public Health, /23/

70 Discussion Other Universal Suicide Preventive Interventions A RCT of a classroom-based behavioural intervention called the Good Behaviour Game, involving two cohorts of approximately 1000 and 2000 North American first grade pupils found a reduced incidence of suicidal ideation and suicide attempts when followed up at ages 21 to 22 years in the first cohort, but not in the second cohort. 1/23/ Wilcox et al. Drug and Alcohol Dependent, 2008

71 Prevention is needed Suicide among adolescents Suicide is the second leading cause of death among youth years worldwide. Suicide attempts are predictors of future suicides. Suicide attempts HRB Mental health Poor impulse control Externalizing psychopathology Depressive/anxiety Internalizing psychopathology Barzilay S & Apter A. Arch Suicide res. 2014;18(4): /23/

72 Early Universal Suicide Prevention HRB and Mental Health Problems increase with age. The school system is a suitable arena to introduce programs to promote mental health and prevent suicide. However, programs require: Further adaptation Testing Establishing policies and procedures that can be adopted by the school system 1/23/

73 Acknowledgments The SEYLE project was supported through the European Union Seventh Framework Program (FP7) 3 million Funded 60% of total costs Principle Investigator Prof. : Karolinska Institutet, Stockholm, Sweden Project Manager Ass. Prof. Vladimir Carli: Karolinska Institutet, Stockholm, Sweden Site leaders and their teams (approx. 150 researchers and assistants) Prof. Christian Haring: University for Medical Information Technology, Austria Prof. Airi Varnik: Estonian-Swedish Mental Health & Suicidology Institute, Estonia Prof. Jean- Pierre Kahn: University of Nancy, France Prof. Romuald Brunner: University of Heidelberg, Germany Prof. Judit Balazs: Vadaskert Child and Adolescent Psychiatric Hospital, Hungary Dr. in Epidemiology Paul Corcoran: National Suicide Research Foundation, Ireland Prof. Alan Apter: Schneider Children's Medical Centre of Israel, Tel-Aviv University, Tel Aviv, Israel Prof. Marco Sarchiapone: University of Molise, Italy Prof. Doina Cosman: Iuliu Hatieganu University of Medicine and Pharmacy, Romania Dr. Vita Postuvan: University of Primorska, Slovenia Prof. Julio Bobes and Pilar Saiz: University of Oviedo, Spain External consultants Prof. Christina Hoven: Columbia University, New York, USA Medical and Social Anthropologist Camilla Wasserman: Columbia University, New York, USA Prof. in Biostatistics Melanie Wall: Columbia University, New York, USA Ethical advisor Prof. Stella Reiter-Theil: Basel University, Switzerland 1/23/

74 Thank you 23 januari