School-based Suicide Prevention Results from the SEYLE project

Vladimir Carli, M.D., Ph.D. Senior Lecturer in Prevention of Mental Ill-Health and Suicide

Swedish National Centre for Suicide Research and Prevention of Mental Ill-Health

Co-director, WHO Center for Research, Training and Methods Development in Suicide Prevention

Karolinska Institutet, Stockholm, Sweden

E-mail: vladimir.carli@ki.se

Structure of this presentation

The SEYLE project

Method

Epidemiological findings

Main results

The YAM Programme

Objectives

Structure

Materials

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

11/26/2015 3

Principal Investigator D. Wasserman

Wasserman et al, 2010; Carli et al, 2013

Project Manager V. Carli

SEYLE Objectives

Gather information on health and well-being of adolescents in Europe.

Implement school based suicide preventive interventions.

Evaluate the effectiveness of the interventions.

Recommend effective culturally adjusted models for promoting mental health and prevent suicide for adolescents in Europe.

Randomized Controlled Trial of

Mental Health Promotion and Suicide

preventive interventions that is

performed in the real world of

European High Schools.

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SEYLE

• Empowerment of teachers

–Question, Persuade and Refer (QPR), US gatekeeper training program, designed by the QPR Institute

• Empowerment of professionals –Professional Screening (ProfScreen), designed at

University of Heidelberg, Germany

• Empowerment of pupils

–Awareness increasing intervention (YAM, Youth Aware of Mental Health), designed at Columbia University and NASP, Karolinska Institutet

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Ask A Question, Save A Life

QPR Question, Persuade, Refer

• QPR is not a tool for mental health professionals

• QPR is not intended to be a form of counseling or treatment

• QPR is intended to offer hope through positive action

• General Information on Suicidal Behaviour

• Epidemiology of Suicidal Behaviour

• 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

Content of Teachers’ Training

• Multidisciplinary equipe sent in schools

• Positive cases identified through a

questionnaire

• Interviews to exclude false positives

• Referral to the local health care system

Professional Screening

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Prevalence of risk behaviours (stratified by age)

14 and below (n=4.007) 15 (n=5.350) 16 and above (n=2.955)

M %

F %

M+F

%

M %

F %

M+F

%

M %

F %

M+F

%

Alcohol abuse 6.4 4.1 5.2 10.0 5.3 7.3 17.7 10.2 14.1

Illegal drug user 3.2 2.0 2.6 5.8 2.7 3.9 8.6 7.8 8.2

Heavy smoking 4.6 6.1 5.4 10.5 8.0 9.0 25.0 16.7 21.0

Reduced sleep 9.7 14.6 12.3 11.4 17.6 15.1 19.9 21.4 20.7

Overweight 4.8 2.5 3.5 5.4 1.6 3.1 6.1 2.3 4.2

Underweight 3.0 2.8 2.9 3.6 2.4 2.9 4.1 3.4 3.8

Sedentary behaviour 9.4 16.8 13.5 14.2 23.4 19.6 17.7 29.3 23.5

Excessive media usage 10.8 7.2 8.8 10.6 8.8 9.6 14.1 11.3 12.7

Truancy 2.8 1.9 2.3 4.2 2.3 3.1 9.3 4.5 7.0

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Prevalence of psychiatric symptoms

(all age groups)

All age groups (n=12.328)

Male (n=5.529)

%

Female (n=6.799)

%

Both genders %

Subthreshold depressed (BDI_II<20 and positive on DSMIV-TR MDE) (sadness or loss of pleasure) 25.8 34.2 30.4

Depressed (BDI-II => 20) 4.9 10.6 8.1

Subthreshold Anxious (ZUNG-A <60 and ZUNG-A >=45) 15.8 29.5 23.3

Anxious (ZUNG-A >=60) 2.3 6.6 4.7

SDQ emotional symptoms 3.0 11.2 7.5

SDQ Conduct problems 12.5 8.4 10.3

SDQ hyperactivity 9.6 9.2 9.4

SDQ peer problems 4.4 2.9 3.6

SDQ prosocial (lack of prosocial behavior) 10.6 3.9 6.9

NSSI => 3 7.9 10.2 9.1

Suicidal ideation 24.5 38.7 32.3

Suicide attempter (lifetime) 3.0 5.1 4.2

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Latent class analysis of risk behaviours

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Main outcomes of

SEYLE-RCT

Incident cases of suicide attempts

Incident cases of severe suicidal ideation,

including having a suicidal plan

Incidence and prevalence of moderate or

severe depression

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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

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Wasserman D. et al. 2015

QPR intervention

Within group decrease in suicide attempts,

suicidal ideation and depression

Results in RCT:

Incident suicide attempts

Incident suicide thoughts/plans

Incidence and prevalence of depression

11/26/2015 20 Wasserman D. et al. 2015

QPR intervention Acceptance of the QPR intervention

in schools

Good reception in schools

The preparedness to help pupils is correlated

to teacher satisfaction with their work

conditions and well-being.

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Sisask et al 2013 Health Education Journal

11/26/2015

Professional Screening

intervention

Results in RCT:

Incident suicide attempts

Incident suicide thoughts/plans

Incidence of depression

Prevalence of depression

In the professional screening intervention arm:

3,070 students were screened

12.4% had such required referral to mental

healthcare

Half of the pupils (51.3%) refused to attend the

interview

22 11/26/2015

Kaess et al. 2014

Wasserman D. et al. 2015

Professional Screening intervention Help-seeking behaviours were increased in:

Younger pupils

Depressive and suicidal pupils

Peer victimized pupils

Best predictors for referral to mental healthcare were:

Depression

Suicidal behaviour

Substance abuse

External factors increasing help-seeking behaviour:

Parents positive attitude

Close proximity to the school for the professional clinical

interview

Short waiting time for the clinical interview

23 11/26/2015 Kaess et al. Eur Child Adolesc Psychiatry, 2014;23:611–620.

ProfScreen intervention Poor acceptance of the Professional Screening

De-stigmatize ProfScreen

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

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

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STIGMA

INCREASES

STIGMA

DECREASES

Kaess et al. Eur Child Adolesc Psychiatry, 2014;23:611–620.

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Results in RCT:

Incident suicide attempts

Incident suicide thoughts/plans

Incidence of depression

Prevalence of depression

Effects of YAM:

Incident suicide attempts

(OR: 0·45 [0·24 - 0·85]; p=0·014)

Incident severe suicidal ideation/plans

(OR: 0·50 [0·27 – 0·92]; p=0·025)

Incident moderate/severe depression

(OR: 0·71 [0·52– 0·97]; p=0·031)

Youth Aware of Mental Health (YAM)

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%).

11/26/2015 26 Wasserman D. et al., 2015

Youth Aware of Mental

Health (YAM) 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 new case of suicide attempt or

severe suicidal ideation by the YAM

intervention was 77.

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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 YAM,

displayed on posters in the classrooms

One can assume that the effect-sizes for the YAM are

probably underestimated

11/26/2015 28 Wasserman D. et al, 2015

SEYLE Strengths

A very large, multi-national effort involving ten

European countries

The largest number of adolescent participants

Good follow-up participation rates (>80%)

Standardised method

Active central oversight and centralized data

management

11/26/2015 29 Wasserman D. et al., 2015

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

11/26/2015 30 Aseltine et al. Am J Public Health, 2004

Aseltine et al. BMC Public Health, 2007

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

11/26/2015 31 Wilcox et al. Drug and Alcohol Dependent, 2008

Early Universal Suicide Prevention!

The school system is a suitable arena to introduce

programs to promote mental health and prevent

suicide.

Universal programs appear to be effective in

preventing suicide

Preventive efforts should start early

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is a culturally sensitive program promoting increased knowledge and discussion about mental health and the development of problem-solving skills and emotional intelligence for adolescents

www.y-a-m.org

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Let’s talk about mental health!

Engaging in non-judgmental conversation with teens about

everyday problems teens face; exploring empathy; how

actions affect not only themselves but also others;

discussing more than one solution to any given problem;

listening to and learning to support their peers, help

increase their control over and knowledge about their

mental health, assist them in adverse times and encourage

them to self-recognize the possible need for help.

YAM OBJECTIVES

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YAM offers

a hands-on approach to mental health issues

such as stress, crisis, bullying, depression and

suicide, allowing the personal experiences of the

participants to influence the content and

discussion.

continued effect over time, with the tools

acquired in YAM assisting the adolescents in

adverse times and encouraging them to

recognize the possible need for different kinds of

help.

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YAM empowers teens by:

boosting their confidence and knowledge about

mental health

enhancing their mental health literacy

tackling mental health stigma

increasing their coping skills

nurturing empathy and how to act on it

teaching them where and how to seek help if

needed

PEDAGOGY & STRUCTURE

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Integrating

cognitive learning through lectures, information in

booklet & posters and discussions

experiential & emotional learning through role-play

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Teens learn from both a professional and each other and try out their newly acquired knowledge by translating it to problem-solving and coping skills in carefully supervised role-play sessions

The opinions and experiences of the teens play a large role as they are taught to listen, learn from each other and respect each others individual histories.

YAM MATERIALS

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Role – play themes

Theme I: Awareness About Choices – Dilemmas and Conflict Resolution

Theme II: Awareness about Feelings and how to Manage Stress and Crises Situations

Theme III: Depression and Suicidal Thoughts

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Role-play provide the adolescents with an opportunity to

explore situations that could otherwise appear

threatening or difficult.

Integrating knowledge about new and complex topics

through everyday examples close to the teens.

An opportunity to think about the responsibilities of

adults, for example in the case of bullying.

A more tangible way to identify reasons for different

problems and to explore the effects they have on those

involved giving the adolescents knowledge and

tools for future use.