Critical thinking about suicide prevention turkey by TeenMentalHealth

The IWK Health Centre in collaboration with the Sun Life Financial Chair in Adolescent Mental Health presents:

Critical Thinking about Suicide Prevention: Turkey

Professor Stan Kutcher

Sun Life Financial Chair in Adolescent Mental Health & Director, WHO Collaborating Center, Dalhousie University

Ankara, Turkey: October 22, 2009

Halifax, Nova Scotia, Canada

Suicide is an Emotional Issue: we need to do the right thing not just something â&#x20AC;˘ Perception of Risk (Peter Sandman)

Risk = Hazard + Outrage

Suicide is a Global Public Health Problem ½ of All Violent Deaths 1 Million Fatalities Every Year! 1.4% of the Global Burden of Disease More die by suicide than in armed conflicts Over 1,700 die DAILY Second leading cause of death in youth* “For every suicide death there are scores of family and friends whose lives are devastated emotionally, socially and economically” Dr Catherine Le Gales-Camus (WHO Assistant-Director General)

Evolution of Global Suicide Rates 1950-2000 (per 100,000)

WHO 2002

World map of suicide rates per 100,000.

 Rates: Eastern Europe  Rates: Latin America & Muslim Countries WHO, 2007

Suicide and Mental Disorder

â&#x20AC;&#x153;Suicide is in itself not a disease, nor necessarily the manifestation of a disease, but mental disorders are a major factor associated with suicide.â&#x20AC;? WHO Preventing Suicide: A Resource for General Physicians (2000)

Issues in Understanding Suicide and then dealing with it in the best and most informed manner • Emotional issues associated with suicide (including: stigma; religion; cultural; etc.) • The global crusade vrs the local reality (Suicide Prevention initiative of the WHO) • Complexities of addressing suicide and evaluating the effectiveness of interventions • Competing intervention models – public health vrs clinical care

Suicide: What the words mean

Suicidal Ideation: Suicidal ideation refers to thoughts, images or fantasies of harming or killing oneself. (INTENT, PLAN) Suicide Attempt: A suicide attempt is a purposeful self-inflicted act that is non-fatal and is associated with the intent to die. Suicide: Suicide is a purposeful self inflicted act that is fatal and is associated with the intent to die. Self Harm: Self harm refers to any self inflicted destructive behaviors not associated with the intent to die. * Suicidality: Suicidality refers to any thoughts or actions associated with an implicit or explicit intent to die.

Suicide Attempt or Non-suicidal self harm?

“the wards are full of kids who cut” – Shaffer, 2009 Current DSM – self harm only present as sub-feature with BPD Frequent admissions to hospital (ICD coding as suicide attempt) Confusing historical nomenclature: parasuicide; suicide gesture; self-harm Potentially creates substantive errors in understanding suicide statistics (Kutcher et al. JAACAP, 2009) : Public Health approaches?

Suicide Attempt or Non-suicidal self harm? Possible revisions to DSM - V “the wards are full of kids who cut” – Shaffer, 2009 Non Suicide Self Injury (NSSI) 5 or more events by day (duration?) Damage to body surface Not socially sanctioned Performed with the expectation of mild to moderate physical harm No suicide intent Not trivial

What do suicide rates actually mean?

Concerns pertaining to reliable capture of data regarding suicide (common Canadian approach is to enhance suicide rates over published rates: “how many of our young people who suicide are never counted? Many car accidents in teenagers are really suicide attempts.” – elsewhere: ideology; capacity) Concerns regarding coding of data on hospital admission – suicide attempt or self-harm Issues pertaining to secular trends (expression of rate over time: decline in rates regardless of national policy) Confusion between rates and raw numbers (Yenilmez et al, 2009) Denominator mis-interpretation (6/100,000 vrs 3/10,000) because of small demoninators Variability inherent in small numbers

What do suicide rates actually mean: Variability inherent in small numbers

Year

Region 1

Region 2

Region 3

2004

2005

3**

2006

2***

Suicide Rates by Gender and Country: examples (per 100,000)

Eastern Europe

50 Asia

40 30

Western Europe Latin America & Caribbean

Canada & USA

Oceania

20 10

Country

id a

ru gu

ag o

To b

hi le

SA U Tr in

U Po K n Fe lan d de ra tio C n an ad a us si a R

st ra

Z e lia al an d C hi na In di a Ja pa Be n lg iu m D en m ar k Fr an ce

Suicide Rates

Males Females

WHO 2007

Canadian Data: Variability by Place/Time Rate* of Suicide per 100,000 Provinces and Territories, 2000-2003 25

Rate per 100,000

2000 2001 2002 2003

0 BC

*Age-Standardized Mortality Rate

**Age-Standardized Mortality Rate per 10,000 Population

Data Source: Statistics Canada. (2006). Mortality, Summary List of Causes 2000, 2001, 2002, 2003. Ottawa, ON: Author.

NU**

Canadian Data: Variability by Age R ate* of S uicide by A ge G roup C anada, 2000-2003 25

Rate per 100,000

2000 2001 2002 2003

0 1014

1519

2024

2529

3034

3539

4044

4549

5054

5559

6064

6569

7074

7579

8084

85- 90+ 89

*A ge-S pecific M orta lity R ate

D ata S ou rce: Statistics C an a da. (20 06 ). M ortality, Su m m a ry L ist of C au ses 2 00 0 , 2 00 1, 2 00 2, 20 0 3. O ttaw a, O N : Au th or.

Understanding Suicide Rates: Variability • There is substantial variability in suicide rates over time. • There is substantial variability in rates geographically • What does variability in suicide rates mean for comparative analysis? • What is variability in suicide rates related to?

Critical thinking about suicide prevention Can rates help us decide about the type of approach? THEN THIS MAY MEAN…

IF SUICIDE RATE IS…

Factors apart from mental disorders are driving excess Therefore: identify substantive factors and intervene LOCAL FACTORS 15 per 100,000 Primarily associated with mental disorders Therefore: focus primarily on the identification and treatment of mental disorders 4 per 100,000



Suicide rate, Turkey

Data may not be reliable



Male Female

NationMaster.com (18/10/09)

Suicide Rates: What do the statistics really tell us? •

“Be careful when reading a medical book. You could die of a misprint” – Mark Twain

•

“You can not determine the depth of a well by measuring the length of the pump handle” – unknown Correlations do not equal causality If you choose one explanation for a complex factored observation you are likely to be wrong

• •

Percent of all deaths due to suicide, by age and sex, Canada, 2003: emotional impact of the cause of death statistic + age activity focus impact

Mortality rates due to suicide per 100,000, by age and sex, Canada, 2003

Suicide in Canada, 1950 to 1992 â&#x20AC;&#x201C; duration of time curve and data impact

Source: Suicide in Canada (1994) - accessed 2008

Year 20

age-specific rate per 100,00 population

Suicide in Canada, 1979 to 2003 â&#x20AC;&#x201C; change the duration and change the impact 20

10 10-14

15-19

8 All ages

U.S. suicide rate by age group (1970 â&#x20AC;&#x201C; 2002): duration and impact

McKeown et al. Am J Pub Health Oct 2006

Conclusion – about the statistics of suicide

• We need to be very careful in our interpretation of reported statistics • Studies of interventions are even more problematic • The potential exists for statistics to be used for “a priori” purposes

Understanding Suicide Prevention: what are the issues and how do we address them critically? • Multiplicity of ideas based approaches • Enthusiasm to “do something” • Essential yet confusing basic concepts (NSSI) • Quality of the literature • Research to action – the path to policy and operations

Critical thinking about suicide prevention

Level of â&#x20AC;&#x153;certaintyâ&#x20AC;? in conclusions related to type of study (best evidence or best practice?)

Critical thinking about suicide prevention Level of “certainty” in conclusions PERCENTAGE OF RESEARCH

TYPE OF RESEARCH Hypothesis testing

Explanatory modeling (? variables)

95%

Epidemiological correlations No PM

Small sample descriptions

Case descriptions

What does this literature issue mean?

• If most of our literature is at a low standard of evidence how certain can we be that what we are doing or plan to do is likely to be less wrong? • Best Evidence Informed Practice vrs Evidence Informed Best Practice • Essential to move ahead and invest in the highest level of evidence research • Stop publishing research at low levels of evidence apart from hypothesis generation work

Two Approaches to Addressing Suicide Prevention • Public Health Models – Focus on populations – Use risk factor approach – Can be evaluated

• Clinical Care Models – Focus on individuals or groups – Use risk factor approach – Can be evaluated

Public Health Model Approaches

• Public Health Approaches: –

Promotion – Entire community framework, utilizes all possible factors approach, does not discriminate between causality or correlation, does not seek out or measure contributory proportional effects, often uses a social marketing or educational model (does an advertisement change your life?), often promote “protective” factors – wellness fallacy (enhancing wellness does not stop onset of illness) - CAST – Intervention - Universal; Targeted (selective or indicated): highly dependent on rate, strength and causal impact of factors), may include legislation and regulation – School Based Suicide Prevention Programs

Types of Mental Health Prevention Programs: Public Health Risk Factor Model •

•

Universal – efforts that target the whole population (not to an “at risk” population) – purpose is to reduce incidence of identified mental disorder – not useful with low incidence Selective – efforts that target individuals or a population subgroup whose risk for developing the disorder is significantly higher than average (risk may be immediate or life-long) – useful if risk factors are causal or strongly deterministic and interventions effective Indicated – efforts that target high risk individuals who are identified as having minimal but detectable signs or symptoms of the mental disorder but do not meet criteria for the disorder – useful if indicators strongly predictive

Prevention: Primary or Secondary?

• Stop the event from ever happening • Stop negative events resulting from the initial event from happening • Modify or change the nature of the event when it happens • Decrease the impact of the event when it happens

What is a Risk Factor?

• When present, increases the probability of a particular outcome - correlations • What is probability and how good are we at determining that? • What is the difference between causal (attributable) and co-relational risk factors? • What is the difference between a “trigger factor” or “precipitant” and a risk factor? (eg: family conflict)

Risk Factors and Prevention

Likely Causal

Modifiable

Not modifiable

Unlikely to be Causal

Suicide: moderate to strong “risk factors” – probably “causal”? • Mental Illness – especially MDD (OR: 11-27) • Substance abuse • Prior suicide attempt (~ 35% completers – especially males) • FH suicide/suicide attempts (5x mother, 2x father)

Problems with correlation reasoning – drawing incorrect conclusions • Most common “reasoning” is correlational • Most common “reasoning” is wrong • Simple probability reality – with many probabilities the chance of being correct decreases with the number of possibilities • Many so called “causes” are actually outcomes (depression and life events) • Proximity often confused with causality – the recent Natalie Morton case in the UK – cervical cancer vaccine caused the death? • Fear of the less known and the need to “understand” – autism and MMR vaccination

Confusion of Causal Reasoning – Turkish Examples (overgeneralization) “Constant change is a permanent aspect in most Turkish families. Some of this change is reflected in national statistics, but some is not. Change has also rearranged family values and priorities, to the extent that suicides, for example, rose because more people simply could not cope with modern life.” Turkey- Changes in Family Life http://family-jrank.org/pages/1720/Turkey-Changes-in-Family-Life.html

Confusion of Causal Reasoning – Turkish Examples (inferential assumption plus no testing of alternative hypotheses) “The finding that individuals attempting suicide tended to be younger and more often women can be explained by the fact that young people and women are more prone to encounter life crises and be more economically dependent” Report on the Mamak study: CJP. 2003

Suicide Prevention can be evaluated as to effectiveness and cost effectiveness • Suicide prevention programs can be evaluated using well validated scientific/statistical approaches – this includes: public health (health promotion and population health methods) and clinical approaches • Studies of suicide prevention programs must be properly designed, properly applied and the data properly evaluated • Conclusions must be based on data included in the study or from related studies (culture causes everything)

Suicide Prevention can be evaluated as to effectiveness and cost effectiveness

Common problems include: poor study design; small sample sizes; lumping different variables â&#x20AC;&#x201C; ideation, self-harm, suicide); use of proxy outcome measures; inadequate follow-up time; provider:evaluator conflict; confounding effects of secular trends; lack of control for known factors (for example: bullying and depression)

Oxford Levels of Evidence

GRADE: Quality Assessment Profile # of studies (n) Consistency Directness Precision Publication Bias Study Limitations Lack of allocation concealment Lack of blinding Large loss to follow up (≥20%) Failure to adhere to intention to treat analysis Study stopped early for benefit Failure to report outcomes

“What Works Repository” Classification Framework RCT No known harmful side effects Adequately addressed threats to internal validity Random assignment Large sample (Sufficient power?) Intervention described Independent evaluation Adequate outcome measure Differences described Modest attrition (≤20%) Intent‐to‐treat analysis Accurate interpretation of results Statistically significant positive effect of program Effect sustained for ≥1 year post‐program ≥1 external replication (RCT)

Scientific Standard for Certifying Programs as Effective – based on quality studies! – what works framework • • • • • •

Experimental Design/ RCT Statistically significant and substantive positive effect Effect sustained for at least 1 year post-intervention At least one external replication with RCT (fidelity) RCTs adequately address threats to internal validity No known health-compromising side effects

Source: Working Group for the Federal Collaboration on What Works. (2004). Hierarchical Classification Framework for Program Effectiveness. In Elliot, D. (2007). Evidence-Based Violence Prevention Programs. Presented at Strengthening Mental Health Research Capacity in Latin America and Caribbean Conference: Kingston, Jamaica. December 4.

Applying the methodology to evaluate common suicide prevention strategies – the example of school based suicide prevention – is it effective or not?

Schools and Youth Suicide Prevention • •

Plethora of school based suicide prevention programs Common perception that they are effective in preventing youth suicide • Very popular in North America and elsewhere • Recommended by respected international agencies

•

“Schools are the preferred areas for public health interventions on suicide prevention …” WHO: Suicide Prevention in Europe (2002)

SearchÂ Results Primary search keywords: 1. 2. 3. 4. 5. 6.

suicid* OR self*harm school* youth* OR teen* OR adolescen* prevent* OR intervent* OR postvent* OR treat* screen* OR curricul* OR program* OR gatekeeper* effective* OR efficac* (and com binations thereof)

PubMed

Secondary search: Manual search of reference lists of selected studies

PsycINFO

NREPP

ERIC

Cochrane

Articles sent to clipboard 495

Articles retrieved 205

Program evaluations of school-based suicide prevention programs 42

Studies with measure of suicide and/or suicide attempt and/or suicidal ideation and/or depression and/or hopelessness 23

Example of “weak” methodology Houck GM, Darnell S, Lussman S. A support group intervention for at‐risk female high school students. Journal of School Nursing 2002, 18:212.

Study Characteristics Support Group Intervention Author Year Title Strategy Subjects Control Random Program duration F/U -Time Outcome Measures Effect-S Effect-SA Effect-SI Effect attitude, skills, knowledge

SI: Suicidal ideation ST: Suicidal threat SA: Suicide attempt

Houck et al. 2002 A support group intervention for at-risk female high school students support group Females only n=14; effective sample size n=8 no no 45 min/1x week/14 weeks immediate SI, SA, ST, emotional distress, stress, drug use, risk behaviours, personal resources, social resources, likelihood of dropout NA Nonsig decrease sig decrease for SI (used p<0.05) and SI, drug related (used p<0.10); sig decrease for past month ST (used p<0.10) *effective sample size n=8 sig reduction in perceived stress and family distress (used p<0.10); sig reduction in likelihood of dropout (used p<0.10)

NA: Not measured Tx: Treatment Sig: Statistically significant

Quality of Evidence Support Group Intervention

Oxford Levels of Evidence

Author Year Level Type of study

Houck et al 2002 Quasi-experimental design with post hoc control group 2c(-)

Oxford Levels of Evidence Scale: 1a – 1b – 1c – 2a – 2b – 2c – 3a – 3b – 4 – 5 highest

lowest

Quality of Evidence Support Group Intervention Houck et al., 2002 # of studies (n) Consistency Directness Precision Publication Bias

2 studies, 2004(n)=2100; 2007(n)=4133 NA No comparison Very small sample, no control group Possible

Study Limitations Lack of allocation concealment Lack of blinding Large loss to follow up (≥20%) Failure to adhere to intention to treat analysis Study stopped early for benefit Failure to report outcomes

No internal control group; results compared to "norms" established during validity testing of questionnaire N/A Yes: 6/14 dropped out (43%) No ITT; present data for 8 students only No All outcomes reported

GRADE Quality Scale: HIGH – MODERATE – LOW – VERY LOW

Quality of Evidence Support Group Intervention

Houck et al., 2002

RCT No known harmful side effects

 ?

Adequately addressed threats to internal validity through:

Random assignment Large sample (Sufficient power?) Intervention described Independent evaluation Adequate outcome measure Differences described Modest attrition (≤20%) Intent-to-treat analysis Accurate interpretation of results

Statistically significant positive program effect

Effect sustained for ≥1 yr post-program ≥1 external replication (RCT)

  n=14      (43%)  effective sample size n=8  Used p <0.10 significance level however, noted that results must be viewed with caution  Alcohol use  Suicidal ideation  Hard drug use  Suicidal ideation, Drug  Adverse drug consequences related  Drug use control problems  Suicidal threats, Last month  Risk Behaviours  Suicidal threats, Last year  Self-esteem  Suicidal threats Indirect  Self-efficacy, Personal  Suicide attempt, Last year control  Suicide attempt, Last month  Problem solving & Coping  Depression  Family functioning, Support  Hopelessness  Parent support  Anxiety  Best-friend support  Anger  Classmate support  Perceived stress  Favourite teacher support  Family distress  Likelihood of dropout  Effectiveness measured immediately after program conclusion (14 weeks) 

“What Works Repository” Rating: EFFECTIVE–EFFECTIVE W/ RESERV’NS–PROMISING–INCONCLUSIVE EVIDENCE–INSUFFICIENT EVIDENCE–INEFFECTIVE

Quality of Evidence Support Group Intervention • Weak evaluation – – – – –

Very small sample; Females only Pre‐/post‐test design No control group No intention to treat analysis No follow‐up

• Used p <0.10 to determine significant program effect

Examples of “strong” methodology

Aseltine RH, James A, Schilling EA, Glanovsky J. Evaluating the SOS suicide prevention program: A replication and extension. BMC Public Health 2007, 7:161.

Aseltine RH & De Martino R. An outcome evaluation of the SOS suicide prevention program. American Journal of Public Health 2004, 94:446.

Study Characteristics SOS: Signs of Suicide Author Year Title Strategy Subjects Control Random Program duration F/U -Time Outcome Measures Effect-S Effect-SA Effect-SI Effect attitude, skills, knowledge

Aseltine & De Martino 2004 An outcome evaluation of the SOS suicide prevention program curriculum + screening 2100 yes yes 2 days 3 months self-report SI, SA; knowledge & attitudes test; help-seeking behaviour NA Tx group less likely to report SA not sig sig greater increases in knowledge, attitudes, not help-seeking

SI: Suicidal ideation SA: Suicide attempt NA: Not measured

Aseltine et al. 2007 An evaluation of a school-based suicide prevention program curriculum + screening 4133 yes yes 2 days 3 months self-report SI, SA; knowledge & attitudes test; help-seeking behaviour NA Tx group less likely to report SA not sig sig greater increases in knowledge, attitudes, not help-seeking

Tx: Treatment Sig: Statistically significant

Oxford Levels of Evidence SOS: Signs of Suicide

Oxford Levels of Evidence

Author Year Type of study Level

Aseltine & De Martino 2004 RCT 1b

Aseltine et al. 2007 RCT, replication of 2004 1a(-)

Oxford Levels of Evidence Scale: 1a – 1b – 1c – 2a – 2b – 2c – 3a – 3b – 4 – 5 highest

lowest

GRADE Quality Scale SOS: Signs of Suicide # of studies (n) Consistency Directness Precision Publication Bias Study Limitations Lack of allocation concealment Lack of blinding Large loss to follow up (≥20%) Failure to adhere to intention to treat analysis Study stopped early for benefit Failure to report outcomes

Aseltine & De Martino, 2004 / Aseltine et al., 2007 2 studies, 2004(n)=2100; 2007(n)=4133 Main findings same magnitude and similar direction Yes: Comparison of SOS vs. nothing Large samples, Small CIs Not likely Computerized scheduling program Self-report questionnaire 2007=8% completed survey at 3mo; 2004=7% completed survey at 3mo ITT No Reported all outcomes; Measured SI, SA directly

GRADE Quality Scale: HIGH – MODERATE – LOW – VERY LOW

“What Works Repository”SOS: Signs of Suicide

RCT No known harmful side effects

Aseltine & De Martino, 2004 / Aseltine et al., 2007  ?

Adequately addressed threats to internal validity through:

Statistically significant positive program effect Effect sustained for ≥1 yr post-program ≥1 external replication (RCT)

 (by class)  2004(n)=2100; 2007(n)=4133     (no baseline data)  2007=8% completed survey at 3mo; 2004=7% completed survey at 3mo    Suicide attempt  Knowledge Adaptive attitudes re: depression & suicide  Suicidal ideation  Help seeking behaviour  (3 month follow-up)  Aseltine et al., 2007 = Replication of Aseltine & De Martino, 2004

“What Works Repository” Rating: EFFECTIVE–EFFECTIVE W/ RESERV’NS–PROMISING–INCONCLUSIVE EVIDENCE–INSUFFICIENT EVIDENCE–INEFFECTIVE *LACKS SUSTAINED EFFECT REQUIRED FOR PROMISING CLASSIFICATION

Quality of Evidence: Taking a closer look SOS: Signs of Suicide • High quality evaluation – RCT with replication – Large sample

• Statistically significant effect on self reported suicide attempts, knowledge about suicide, and attitudes towards suicide and depression (but did not measure primary outcome and no differences in help seeking behavior)

Quality of Evidence SOS: Signs of Suicide Some major concerns… • Randomization of class rather than school opens study to contamination – Especially since a program goal is to increase help‐seeking behaviour on behalf of friends

• No pre‐test (baseline) data – Excluding data from screening program, screening only treatment group leaves out crucial information re: change in depression status, change in severity of suicidality, etc.

• Follow‐up period (3 months) too short to demonstrate long‐term effects of program. • Use of proxy measures – primary outcome not measured (completed suicide) – no measures of harm • Variability in statistical significance of selected proxy measures (positive for self‐reported SA but not for SI or HSB) – QUERY HAWTHORNE EFFECT?

Conclusions SOS: Signs of Suicide

In spite of the authors contention that the SOS program is an effective suicide prevention program, given the absence of suicide itself as a reported outcome and the studyâ&#x20AC;&#x2122;s methodological and design problems it is not possible for an independent third party to conclude that SOS: Signs of Suicide is an effective suicide prevention program

Overall Assessment • Of 42 evaluations of school‐based suicide prevention programs identified in this review, 23 measure direct outcomes • Of those, only 11 are RCTs • No study shows effectiveness of any program for suicide prevention • No study shows promising evidence for suicide prevention of any program

Postvention in Youth Suicide (CISD)

• CISD developed to prevent onset or reduce severity of PTSD (or other psychiatric disorder) after a traumatic event • Critical Incident Stress Management (CISM) – cousin of CISD • CISD/CISM very common in school based suicide postvention (including grief counselors) • Strong adherents to CISD and financial investment in programs and training

Postvention Evaluation • Key systematic reviews (2000 – 2008) of CISD all demonstrate: not effective in improvement of long term outcomes, no decrease in any disorder or any symptoms, no functional improvements, often worsen symptoms and outcomes • Search of: PsychInfo; PubMed; ERIC; Cochrane Library could not identify any RCT of any school based suicide CSID postvention program or any outcome evaluation of any school based suicide postvention CISD program

Current Status of Evidence – school based suicide prevention programs

• Of the 23 studies identified in the global literature less than ½ were RCT’s • No study met criteria for either of the following status recommendations: “effective”, “effective with reservations”, or “promising”. • Only one program met criteria for the status recommendation of “inconclusive evidence” (SOS) • No studies of school based CISD postvention found – systematic reviews of other CISD note no positive and some noxious effects

BOTTOM LINE

• High quality, consistent, and scientifically valid evaluation is necessary so that stakeholders – parents, educators, politicians, and the community – do not invest in programs that are either ineffective or even harmful. • But, we have already built and implemented programs with little substantive evidence of positive effect and unknown potential harm

BOTTOM LINE • Future research should include – Standardization of suicide‐related terms and assessment protocols for identifying at‐risk groups – Use of outcome measures that are reliable, valid, and useful for evaluation of program effectiveness – Sufficient statistical power to allow for reasoned inferences to be drawn from results – Control populations – An end to the reliance on surrogate measures such as knowledge of or attitude towards suicide.

NHS – Health Development Agency (2004): teen suicide prevention programs review • • • • •

Strong evidence – none Moderate evidence – none Weak evidence – contact cards*, SSRI’s (?) Limited evidence – responsible media reporting; DBT; CBT No evidence or harmful – every other teen suicide prevention program studied “Based on the available evidence…we are unable to recommend any specific [public health] approach to youth suicide prevention”

Sun Life Financial Chair In Adolescent Mental Health

New Panacea – Lets all stop suicide together As other public health approaches have not demonstrated effectiveness nor safety (usually never measured) the net has become spread wider – the assumption now is that the entire community must work together to prevent suicide in young people – no longer “prevention” but “promotion”

Community Model for Youth Suicide Prevention –opinion unencumbered by evidence: Public Health Agency of Canada (web site accessed Feb 19, 2007)

“increase both the individual’s and the community’s capacity to improve youth mental health – using strategies that foster supportive environments and individual resilience … not only do we target youth but we target the entire community itself”

Community Model for Youth Suicide Prevention –opinion unencumbered by evidence: Public Health Agency of Canada (web site accessed Feb 19, 2007)

•

• •

Tragic response counseling; critical incident debriefing; educating parents on youth mental health issues; community forum on youth suicide; public education about youth suicide; youth mental health speakers; youth service providers lists; pars and stars golf tournament; business community engagement – teen assistance fund; community resource center; community helpers program; parent education; police involvement; media kit responses Model has been presented at “numerous provincial and national conferences” VERY NICE, BUT DOES IT PREVENT YOUTH SUICIDE?

Sun Life Financial Chair In Adolescent Mental Health

Suicide Prevention in Nova Scotia â&#x20AC;˘ Newly established (Feb 2006) Ministry of Health Promotion and Protection identified 20% reduction in suicide by 2009-2010 as target in 2006-2007 HPP Business Plan â&#x20AC;˘ Youth suicide rate in NS is 4.0 per 100,000 population

Sun Life Financial Chair In Adolescent Mental Health

CAST • Program philosophy encapsulated in this quotation found on CAST publicity material: “Suicide is most often the result of pain, hopelessness and despair. It is almost always preventable through caring, compassion, commitment and community.” (Canadian Association for Suicide Prevention, 2004)

Sun Life Financial Chair In Adolescent Mental Health

CAST What will be offered? • Community Suicide Prevention Tool Kit (expected in 2007- still not ready) • Community Toolkit Orientation Training • Community Coalition Building & Support • Networking & Communications No evidence for the effectiveness of any of these activities to prevention of suicide

Sun Life Financial Chair In Adolescent Mental Health

Self-education and Suicide â&#x20AC;˘ An important component to addressing mental health issues is that of mental health literacy â&#x20AC;˘ Can improvement of mental health literacy related to suicide make any impact on suicide rates in young people?

Sun Life Financial Chair In Adolescent Mental Health

The Internet & Mental Health â&#x20AC;˘ Particularly important vehicle for sourcing information regarding stigmatized illness, such as mental disorders (Berger et al., 2005). â&#x20AC;˘ Mental health is one of the main topics of interest for youth looking for health information on the web (Rideout, 2002.

Sun Life Financial Chair In Adolescent Mental Health

Rank of website vs. Number of statements supported by evidence (red) and not supported by evidence (yellow)

Website Rank Website Rank

Source: Szumilas & Kutcher, 2007

Recent Extensive Reviews: there is hope for some approaches – lets use them

New Zealand • • •

identification and effective treatment of mental disorders especially depression Restriction of lethal means Gatekeeper training

Global (USA lead consensus) •

Identification and effective treatment of mental disorders

Prevention of Suicide: Clinical Approaches • Clinical approaches include interventions that occur within the context of health or associated health service delivery • Useful if health providers have necessary knowledge and competencies for identification, assessment and treatment • Require “visit” of at risk individual or active outreach to individuals known to be at risk • Demonstrated effectiveness

Sun Life Financial Chair In Adolescent Mental Health

Healthcare-based prevention programs •

Two factors have been identified most helpful during crisis by suicidal patients (Eagles et al., 2003) – Rapid accessibility to appropriate services – Decreasing stigmatization

• • •

Many youth say they would seek out their primary care physician as the first point of contact if they were distressed (Davidson & Manion, 1993) Only 1 in 10 family physicians involved in a Canadian study reported adequate training in the treatment of youth depression (Kotowycz et al., 2003) Just 2% said they felt comfortable treating depression in youth

Sun Life Financial Chair In Adolescent Mental Health

Healthcare-based prevention programs •

Research suggests that training primary care physicians to recognize, treat, and refer patients who are suffering from mental illness, especially depression can (Beautrais et al., 2007) – Increase physician identification of suicidal patients – Improve treatment of depression – Decrease suicide rates

•

Training should be based on a continuing education model, since attenuation of the intervention effect was seen within 3 years of one training program. (Rutz et al., 1992)

Sun Life Financial Chair In Adolescent Mental Health

Healthcare-based prevention programs â&#x20AC;˘ Treatment of depression (e.g. use of selective serotonin re-uptake inhibitors) is associated with decreased suicide rates and suicide attempts in young people (Gibbons et al., 2005; Simon & Savarion, 2007). â&#x20AC;˘ Thus, effective early treatment of depressed youth is a promising approach.

Suicide attempt rates in 3 months before and antidepressant treatment

Simon et al. Am J Psychiatry 2006

6 months after starting

Antidepressants and Suicide Attempts

â&#x20AC;˘ Treatment associated with decrease in suicide attempts â&#x20AC;˘ Especially evident with antidepressant Rx from psychiatrist OR psychotherapy

Am J Psychiatry 164 (7): A46

Association between suicide rate and SSRI use in youth aged 5-14 Ecological Analysis

1996-1998

U.S. suicide rate in 5-14 year olds: 0.8 per 100,000 Poisson regression: negative association between SSRI use and suicide (p<0.004)

Gibbons Am J Psychiatry Nov 2006

Counties with lowest SSRI use

Counties with highest SSRI use

Impact of warnings: Rx rates within 30 days after diagnosis

Libby AM, et al . Am J Psychiatry 2007;164:884-891

Impact of warnings:

Gibbons RD, et al. Am J Psychiatry 2007 Sep;164(9):1356-63.

CDC Report on Child and Adolescent Suicide: Feb. 2007

• SSRI prescriptions to young people across the USA fell by 18% in 2003 – 2004 • For the first time in a decade, the suicide rate in youth (1 – 19) in the USA INCREASED – by 20% over the same period of time (Hamilton, Pediatrics. 119: 345-360, 2007).

Suicide per 1000

Number of Completed Suicides per 1000 0.25 0.2

8-17 years

0.15 19-24 years

0.1 0.05 0 1999 2000 2001 2002 2003 2004 2005 Year

Warning was administered in 2004

Katz et al. Canadian Medical Association Journal, April 2007

Impact of warnings: Prescribing patterns shift â&#x20AC;Ś to bupropion?

Nemeroff CB, et al. Arch Gen Psychiatry 2007;64:466-72

Suicide Prevention Strategies – Results of the International Systematic Review “ Physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates. Other interventions need more evidence of efficacy. Ascertaining which components of suicide prevention programs are effective in reducing rates of suicide and suicide attempt is essential in order to optimize use of limited resources.” Mann et al. JAMA. 2005

Suicide Prevention: What Can Be Done?

• Think of both public health and clinical care models • Learn what public health approaches have been used in a location or situation similar to yours – AND MODEL A LOCAL APPROACH TO THOSE WHICH HAVE BEEN PROVEN TO BE USEFUL IN DECREASING SUICIDE • Learn what clinical care approaches have been used in locations or situations similar to yours – TRY TO REPLICATE THOSE WITH PROVEN EFFICACY

Suicide Prevention: Some Possible Public Health Strategies to Consider in your Location •

Increasing the identification of and access to effective treatment for those people who have mental illnesses – requires enhancement of clinical service capacity – clinical approach

•

Restriction of common lethal means (such as firearm control; safe storage of poisons and gasoline; etc.)

•

Media training (not to sensationalize reports about suicide)

•

Birds of a feather flock together – not well tested but may be useful approach to deal with the issue of cluster, contagion or “copy-cat” suicides

•

Gatekeeper models – for example: teachers, guidance counselors training may be helpful in identifying youth at higher risk

The IWK Health Centre in collaboration with the Sun Life Financial Chair in Adolescent Mental Health presents:

Understanding Youth Depression and Suicide: Addressing these Issues by Educators (R)

Professor Stan Kutcher

Sun Life Financial Chair in Adolescent Mental Health & Director, WHO Collaborating Center, Dalhousie University

Dr. Sonia Chehil

Associate Professor in Psychiatry. Dalhousie University

February 17, 2008

The IWK Health Centre in collaboration with the Sun Life Financial Chair in Adolescent Mental Health presents:

Understanding Adolescent Depression - Education Upgrading Program for Health Professionals (R2)

Professor Stan Kutcher Sun Life Financial Chair in Adolescent Mental Health & Director, WHO Collaborating Center, Dalhousie University Dr. Sonia Chehil

Associate Professor in Psychiatry. Dalhousie University Copyright ÂŠ Kutcher & Chehil: March 29, 2008

The Clinical Approach to Addressing Suicide

• Clinical interventions have evidence to support their use in the prevention of suicide • All health providers are in a unique situation to be able to address individual suicide risk – especially in primary care • Training is needed

Identification of the Higher Risk Individual in Primary Care: Family History • Family history of mental disorder • Family history of suicide • Family history of substance abuse

Identification of the Higher Risk Individual in Primary Care: Personal History • Previous suicide attempt (especially in males) • Mental disorder (including anxiety disorder) • Substance misuse or abuse • Impulsivity • Legal – justice system involvement

Identification of the Higher Risk Individual in Primary Care: Clinical Profile • • • •

• • •

Psychiatric symptoms (depression, psychosis) Substance abusing or misusing Hopelessness Major life event with negative consequences (burden of illness) Poor social supports Declining work or school performance Physical pain (elderly)

Clinical screening for suicide risk – the SAD PERSONS model (* denotes domain of concern) • • • • • • • • • •

Sex (male)* Age (<19, >60)** Depression Previous Attempt Ethanol (alcohol abuse) Rational thinking (psychosis)*** Social supports lacking Organized plan No spouse**** Sickness (chronic or uncontrolled pain)

Identification of Depression in Primary Care: HAMD â&#x20AC;&#x201C; 7 (McIntyre et.al. Int. J. Clin. Practice, 2007)

Kutcher Adolescent Depression Scale (available in Turkish)

Kutcher Adolescent Depression Scale

Tool for Assessment of Suicide Risk (TASR â&#x20AC;&#x201C; A)

Addressing Suicidal Behaviors in the General Hospital Setting

• Uniform, stepped approach training in suicide risk assessment for all health providers – consultation capability (ready response) • Policy guidelines for the further assessment and immediate care for patients deemed to be at high risk following initial screening – safe environment (limit access to means) • Policy guidelines for intervention, followup and monitoring for patients deemed to be at high risk following consultation assessment

Issues in Physician Address of Suicide Risk Evaluation: Training during Training â&#x20AC;˘ Many training programs for physicians do not adequately provide training in recognition, assessment and interventions for the suicidal person â&#x20AC;˘ USA study (Sudak et al., 2007): - less than half the program directors surveyed reported that teaching about suicide was adequate; - majority indicated need for standardized curriculum materials on suicide training â&#x20AC;˘ Psychiatry residents?

Issues in Primary Care Address of Depression and Suicide

• Educational interventions can increase the recognition of depression and suicide symptoms • Increased recognition of depression and suicide symptoms does not necessarily translate into increased effective treatments – LINKS NEEDED • Regulatory body warnings can limit primary care physicians use of effective treatments (SSRI medications)

Conclusions: Decreasing suicide rates by doing the right thing not just doing something • Suicide is an important public health AND clinical problem (especially in primary care and community mental health care) • It should be addressed with a solid understanding of the complexities of issues pertaining to suicide and suicide prevention • We should use those interventions that we have good evidence for efficacy and subject promising interventions to solid scientific scrutiny • Partnerships amongst multiple stakeholders: health providers, NGO’s; educators; public health; etc. are needed

Suicide Resource: recommended for use by health providers

â&#x20AC;˘ Kutcher S., Chehil S., Suicide Risk Management: A Manual for Health Professionals. Blackwell Publishing Ltd., Oxford Uk., 2007

Sun Life Financial Chair In Adolescent Mental Health For more information visit

WWW.TEENMENTALHEALTH.ORG

Cross-national Comparisons of the Onset of Psychiatric Disorders

Age of onset distributions of any anxiety disorders*

Age of onset distributions of any mood disorders*

Age of onset distributions of any substance use disorders*

*Data for Germany were omitted because of the narrow age range of the sample

Psychiatric Diagnosis & Completed Suicide Rates

Depression

14.6

Bipolar Disorder

15.5

Mixed Drug Abuse

14.7

Dysthymia

8.6

Obsessive Compulsive Disorders

8.2

Panic Disorder

7.2

Schizophrenia

6.0

Personality Disorders

5.1

Alcohol Abuse

4.2

Adapted from: Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors. American Psychiatric Association, 2003.

Suicide Rates: A Local Issue

•

There is substantial variation in suicide rates across states, across regions within states and across jurisdictions within regions Must understand the local issues associated with suicide – are global or national approaches going to be effective if local realities are not addressed? Must address LOCAL factors

Rutz & Wasserman, 2004. Trends in Adolescent suicide mortality in the WHO European Region.

Other Essential Concepts in Understanding Suicide Prevention • Rare event • Possible random distribution over time • Secular trends and impact of intervention difficult to establish without long evaluation periods • Proximal and distal causality – prodrome effect • Cost to investment issues (health sector investment)

School Screening Programs for Youth at Suicide Risk

• • • •

Most at risk not present Fluctuation of ideation Cost to Return Ratio Linkages to mental health services – what to do with those you find • Low adherence to treatment recommendations • No evidence rates reduced

Youth suicide and preventive interventions Gould (2003) JAACAP

• • • • • • • • • •

Suicide awareness curriculum – weak or negative Skills training – weak Screening – potential if interventions provided Gatekeepers – no known positive effect Peer Helpers – no evidence (? Negative) Post-vention – weak (? Type) Crisis hotlines – no evidence Restrict firearms – equivocal Media education – equivocal Primary care training – no documented effect

Teen suicide prevention programs Burns and Patton (2000): ANZJP

•

Clinical; Indicated; Selective; Universal Programs

•

Twelve categories (eg: parental psychopathology; enhancing resilience; crisis intervention and hot-lines; Rx non-fatal suicidal behavior; etc.)

•

Only two programs had “evidence of effect in non-experimental studies” – firearm restriction and responsible media reporting

•

No program demonstrated cost – effectiveness “Lack of investment in research designs that can demonstrate effectiveness”

Canadian Commentary

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Breton et al (2002): “none of the school programs had a demonstrated impact on suicidal behavior”

•

Guo and Harstall (2002): “ there is insufficient evidence to either support or not to support curriculum-based suicide prevention programs in schools ,,, sponsor and design a good quality Canadian study in the area of suicide prevention programs for children and youth.”

•

Nova Scotia (2006): “research to date has provided very little clear evidence of the effectiveness of these activities [prevention programs] in reducing suicide rates”

•

Canadian Task Force on Preventive Health Care (1993): curriculum or school based programs which focus on increasing awareness, risk identification and community resources are not effective, and may, in fact, stimulate imitative suicidal behaviour.”

Impact of warnings: â&#x20AC;&#x153;Spilloverâ&#x20AC;? into adult depression treatment

Have the warnings impacted your treatment of adults? Valuck RJ, et al. Am J Psychiatry 2007;164:1198-1205

Public Health Principles Underlying Suicide Prevention Strategies

• • • •

Apply good and effective interventions Avoid ineffective interventions Eliminate harmful interventions Facilitate public accountability » NHS: Health Development Agency (2004)