each year 63,000 people die by suicide in eu 27 · pdf filethe hungarian study (hendin, h. et...
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A menu of evidence-based actions
for preventing suicidal behaviour
Danuta Wasserman
Professor of Psychiatry and Suicidology
Head of the National Prevention of Suicide and Mental Ill-health (NASP) at Karolinska Institute, Stockholm, Sweden
WHO Collaborating Centre for Prevention of Mental Ill-Health and Suicide
The Thematic Conference on Prevention of Depression and Suicide
under the European Pact for Mental Health and Well-being
"Prevention of Depression and Suicide in a time of Crisis– Making it Happen"Budapest, 10-11 December 2009
15 december 2009Danuta Wasserman 2
Each year 63,000 people die by suicide in EU 27
Source: Eurostat, Statistical Book 2009
Males Females
Suicide in Europe
�� Every day, 172 persons die by suicide in Europe.Every day, 172 persons die by suicide in Europe.
�� This is equivilant to a devasting plane crash occuring This is equivilant to a devasting plane crash occuring
every day in the European Unionevery day in the European Union
2009-12-15Danuta Wasserman 3 2009-12-15Danuta Wasserman 4JDanuta 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 Suicide rates* in Europe, latest
available data from the WHOavailable data from the WHO
15 years and over.15 years and over.
* * The number of suicide estimated per 100 000 inhabitants The number of suicide estimated per 100 000 inhabitants
Very high suicide rates:Very high suicide rates:
40,1 (Hungary) 40,1 (Hungary) ––58,0 (Lithuania)58,0 (Lithuania)
High suicide rates:High suicide rates:
25,0 (Moldavia) 25,0 (Moldavia) ––35,8 (Belarus)35,8 (Belarus)
Low suicide rates:Low suicide rates:
3,4 (Albania) 3,4 (Albania) ––9,9 (Portugal)9,9 (Portugal)
Data not availableData not available
Average suicide ratesAverage suicide rates
11,9 (The Netherlands) 11,9 (The Netherlands) ––23,0 (Czech Republic)23,0 (Czech Republic)
2009-12-15Danuta Wasserman 5
Psychiatric inpatient population
N=7424
General population
N=1835
General population
N=6370
Main diagnosis
%
Main diagnosis
%
Multiple diagnosis
%
Mood disorders 20.8 44.4 34.3
Substance-related disorders 9.8 19.2 23.0
Schizophrenia 19.9 7.5 11.2
Organic mental disorders 15.0 2.1 0.9
Other psychotic disorders 10.4 2.3 0.0
Anxiety/somatoform disorders, Adjustment disorders
2.5 6.7 10.4
Other 6.2 2.7 5.6
Personality disorders 15.2 3.2 13.1
TOTAL 100.0 100.0 100.0
Psychiatric diagnoses Axis I & AXIS II and Psychiatric diagnoses Axis I & AXIS II and
suicidesuicide
Bertolote J, Fleischmann A, De Leo D, Wasserman D.Bertolote J, Fleischmann A, De Leo D, Wasserman D.
Suicide and Mental Disorders: do we know enough? British JournalSuicide and Mental Disorders: do we know enough? British Journal of Psychiatry, 2003;183:382of Psychiatry, 2003;183:382--383383
2009-12-15Danuta Wasserman 6
Health CareHealth CarePerspectivePerspective
Public HealthPublic HealthPerspectivePerspective
Antidepressant drugsAntidepressant drugs
LithiumLithium
NeurolepticsNeuroleptics
PsychotherapyPsychotherapy
Closing the existsClosing the exists
Alcohol reductionAlcohol reduction
MEDIA MEDIA
reportingreporting
Public Public
awarenessawareness
PsychoPsycho--socialsocial
measuresmeasures
EvidenceEvidenceStrategies in Suicide PreventionStrategies in Suicide Prevention
Model for Suicide PreventionModel for Suicide PreventionHealth care and public health Health care and public health
approachesapproaches
� Effective suicide prevention programs
should combine both approaches for
optimal impact.
15 december 2009Danuta Wasserman 7
Suicide PreventionSuicide Prevention
Health Care PerspectiveHealth Care Perspective
Treatment with antidepressants of depressionTreatment with antidepressants of depression
••SuicidalSuicidal thoughtsthoughts
Stone et al. BMJ. 2009
Barak et al. Neuropsychopharmacology. 2006
Angst et al.
J Clin Psych 1999
Möller 2009
Brent 2009
Oxford University
Press
••Suicide attemptSuicide attempt
••SuicideSuicide
2009-12-15Danuta Wasserman 8
Risks/BenefitsRisks/Benefits
Treatment of suicidal people with Treatment of suicidal people with
antidepressantsantidepressants
� Combine antidepressants with
psychotherapy
� Combine antidepressants with
anxiolytics
� Active follow up of treatment and side effects
2009-12-15Danuta Wasserman 9 2009-12-15Danuta Wasserman 10
Suicide PreventionSuicide Prevention
EducationEducation
General practitionersGeneral practitioners’’ trainingtraining
The Gotland Study (Rutz, W.)The Gotland Study (Rutz, W.)
The Estonian Study (VThe Estonian Study (Väärnik, A.)rnik, A.)
The Hungarian Study (Hendin, H. et al. &Mann, J.)The Hungarian Study (Hendin, H. et al. &Mann, J.)
The German (NThe German (Nüürenberg) study (Hegerl, U.)renberg) study (Hegerl, U.)
Suicide in femalesSuicide in females
Suicide in malesSuicide in males
AntidepressantsAntidepressants
AnxiolyticsAnxiolytics
HospitalHospital carecare
2009-12-15Danuta Wasserman 11
Outcome with lithiumOutcome with lithium Outcome without lithiumOutcome without lithium
SuicidesSuicides
RateRate 0.1670.167 0.7930.793
(95% CI)(95% CI) (0.109(0.109--0.224)0.224) (0.592(0.592--0.995)0.995)
SubjectsSubjects 14,30814,308 1,3701,370
AttemptsAttempts
RateRate 0.4070.407 4.0214.021
(95% CI)(95% CI) (0.154(0.154--0.660)0.660) (2.040(2.040--6.003)6.003)
SubjectsSubjects 898898 651651
All actsAll acts
RateRate 0.1970.197 2.5702.570
(95% CI)(95% CI) (0.128(0.128--0.266)0.266) (1.751(1.751--3.3893.389
SubjectsSubjects 15,15715,157 1,9981,998
Estimated rates of suicidal acts with and without lithium Estimated rates of suicidal acts with and without lithium
maintenance treatmentmaintenance treatment
Möller HJ (2009). Pharacological and other biological treatments of suicidal behaviours. In D. Wasserman and C. Wasserman, eds. The Oxford
Textbook of Suicidology and Suicide Prevention: A Global Perspective. Oxford University Press, Oxford.
Lithium levels in drinking water and Lithium levels in drinking water and
risk of suicide risk of suicide
� Lithium levels in tap water were examined in the 18 municipalities of Oita prefecture in Japan in relation to the
suicide standardized mortality ratio (SMR) in each municipality
� Lithium levels were significantly and negatively associated with
SMR averages for 2002-2006
� Conclusion: even very low levels of lithium in drinking water may play a role in reducing suicide risk within the general population
(Ohgami et al. Br J Psychiatry 2009)
2009-12-15Danuta Wasserman 12
Suicide PreventionSuicide Prevention
Health Care PerspectiveHealth Care Perspective
Treatment of schizophreniaTreatment of schizophrenia
Neuroleptics Neuroleptics –– Clozapine (Leponex)Clozapine (Leponex)
N= 102 000N= 102 000
SuicideSuicide by 75%by 75%
Attempted suicideAttempted suicide
Meltzer et al.Meltzer et al.
Arch. Gen. Psych 2003Arch. Gen. Psych 2003
Hennen et al. Schiz. Res. Hennen et al. Schiz. Res.
20052005
Pompili et al. 2008Pompili et al. 2008
Expert Rev Neurother
Tiihonen J, et al. Tiihonen J, et al.
Lancet 2009Lancet 2009
2009-12-15Danuta Wasserman 132009-12-15Danuta Wasserman 14
PsychotherapyPsychotherapy
••CBTCBT(Cognitive behavioural therapy)(Cognitive behavioural therapy)
Tarrier et al. Meta-analysis, Behav Modif 2008
••DBTDBT(Dialectal behavioural therapy)(Dialectal behavioural therapy)
Linnehan et al.Arch Gen Psych, 2006
Attempted suicideAttempted suicide
Repetition of att.Repetition of att.
suicidesuicide
New approach:
Cognitive-Behavioral
Therapy for Suicide
Prevention (CBT-SP)
Stanley et al. J
Am Acad Child Adolesc Psychiatry, 2009
Rudd et al. IN: D. Wasserman and
C. Wasserman, eds. Oxford University Press 2009
Suicide PreventionSuicide Prevention
Health Care/ Public Health Care PerspectiveHealth Care/ Public Health Care Perspective
TeleTele--CheckCheck
TeleTele--HelpHelp
Mental wellMental well--beingbeing
SuicideSuicide
Hospital admissionsHospital admissions
De Leo et al. Br J Psych. 2002
Krysinska KE and De Leo D, Review
Omega, 2007
2009-12-15Danuta Wasserman 15
WHO/EU (MONSUE) multiWHO/EU (MONSUE) multi--centre centre
study on attempted suicide in 26 study on attempted suicide in 26
European countriesEuropean countries
� A high percentage of suicide
attempters have up to 20
contacts with at least 5
treatment providing facilities
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� The continuity of treatment of suicide attempters
is poor
Critical points in care
� Leaving the care setting is often a critical point for the patient
� Patients are often discharged without clear follow up plans
2009-12-15Danuta Wasserman 17
WHO SUPRE-MISS
Follow-up of suicide attempters:
RCT across 5 countries
Subjects:
� Suicide attempters identified in emergency units in 5 countries:� Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic
Republic of Iran; and Yuncheng, China
Fleischmann et al. (2008). Bulletin of the World Health Organization
2009-12-15Danuta Wasserman 18
1867Suicide attempters
TAU
n=945TAU + BIC
n=922
WHO SUPRE-MISS
Brief intervention and contact
� Brief intervention and contact (BIC):
� 1-hour individual information session after suicide attempt
� nine follow-up contacts after discharge (phone calls or visits);
1, 2, 4, 7, 11 week(s)
4, 6,12, 18 months
� Information sessions conducted by a person with clinical experience (e.g. doctor, nurse, psychologist).
� Primary outcome measure: suicide at 18 month follow-up
Fleischmann et al. (2008). Bulletin of the World Health Organization
2009-12-15Danuta Wasserman 19
Status TAU TAU + BIC X2 P-Value
(n) % (n) %
Died by suicide 18 2.2 2 0.2 13.83 <0.001
Died of any cause 22 2.1 11 1.3 4.36 0.037
2009-12-15Danuta Wasserman 20
Results and Conclusion
Conclusion:
This low-cost brief intervention may be an important part of
suicide prevention programmes for under-resourced low-
and middle-income countries as well as for developed
countries.
The role of attitudes: an example The role of attitudes: an example
Attempted suicide Attempted suicide –– an important risk factor an important risk factor
for future suicidesfor future suicides
� A risk factor can be the health care personnel’s attitude to whom treatment should be given.
� In Italy, Spain, Switzerland and Germany all young boys who have attempted suicide get treatment, but not all the girls.
� In the Nordic countries, the opposite was the case.
Hultén, A. Wasserman, D et al. Repitition of attempted suicide among teenagers in Europe.European Child and Adolescent Psych, 2001;10:161-169
2009-12-15Danuta Wasserman 21
Training of trainers in psychiatric Training of trainers in psychiatric
clinical workclinical work
� The knowledge can be improved - obvious
� The negative attitudes towards suicidal patients can
be modified
� The climate in the work place can be improved
� The professional status can also be
improved
Ramberg I-L, and Wasserman D. 2004
2009-12-15Danuta Wasserman 22
PUBLIC HEALTH APPROACH IN SUICIDE PREVENTION
2009-12-15Danuta Wasserman 23
Suicide PreventionSuicide Prevention
Public Health PerspectivePublic Health Perspective
Closing the exitsClosing the exits
•• Availability of toxic medicationsAvailability of toxic medications
•• Gun controlGun control
•• PesticidesPesticides
Leenaars et al. Death stud 2003
Gunnel et al. Int. J. Epidemiol, 2007
Simkin et al. QJM 2005
•• BridgesBridges Beautrais et al. Aust N Z J
Psychiatry, 2009
2009-12-15Danuta Wasserman 24
2009-12-15Danuta Wasserman 25
Media reportingMedia reporting
Chen YY. et al. Soc Psychiatry Psychiatr
Epidemiol 2009; Schmidtke et al. Psychol Med
1988
Suicide PreventionSuicide Prevention
Public Health PerspectivePublic Health Perspective
2009-12-15Danuta Wasserman 26
Restrictions in alcohol consumptionRestrictions in alcohol consumption
““PerestroikaPerestroika”” in the former USSR: historyin the former USSR: history’’s most effective s most effective
suicidesuicide--preventive program for men 1984preventive program for men 1984--19861986
Wasserman, D., Värnik, A. Acta Psych Scand. 1998
•Suicides for men decreased by 40%
•Suicide decreased most for males in the workforce ages 24-54
•Decline of suicide in all 15 republics of the former USSR
•In Europe during the same time period suicide decreased
for men by only 3,0%!
0
10
20
30
40
50
60
70
0 2 4 6 8 10 12
Russia Belarus Ukraine
Annual suicide rates per 100 000 males and consumption of Absolute alcohol in litres per capita in the Slavic republics, 1984 and 1986.
2009-12-15Danuta Wasserman 27
Alcohol restrictions and attitude Alcohol restrictions and attitude
changes towards alcohol during changes towards alcohol during
perestroika 1984perestroika 1984--19861986
� Suicide
� Death from undetermined causes, either accidental or intentional
� Homicide
� Death due to cardiovascular diseases
� Death due to respiratory diseases
� Violent death due to external injuries
� Death due to accidental alcohol poisoning(Leon, D. et al. The Lancet 1997)
(Wasserman, D. et al. Acta Psych. Scand. 1998)
2009-12-15Danuta Wasserman 28
Strategies for intervention in schools: SEYLE
EU funded 7 � � framework program
� Increasing mental health awareness among pupils (Wasserman Camilla et al. 2009)
� Screening: 60% of suicides identified at high school –mainly depression and
anxiety (Shaffer et al. 2004)
� Gate-keeper training: training key persons to identify risks
and encourage treatment.
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Projektet SEYLE –
EU funded 7 � � framework program
(Saving and EmpoweringYoung Lives in Europe)
2009-12-15Danuta Wasserman 30
15 december 2009Danuta Wasserman 31
T h a n k y o uT h a n k y o u
15 december 2009Danuta Wasserman 32
Publisher: The Oxford University Press (www.oup.com)
Printed in English
This paper was produced for a meeting organized by Health & Consumers DG and represents the views of its author on thesubject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of the Commission's or Health & Consumers DG's views. The European Commission does not guarantee the accuracy of the dataincluded in this paper, nor does it accept responsibility for any use made thereof.