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: [email protected]
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
11/26/2015 19
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.
11/26/2015 25
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.