Section Disorders of Personality Development Clinic of Child and Adolescent Psychiatry

1. School-based interventions to prevent suicidal behavior andrisk behaviors among adolescents in Germany: Results from the European Research Consortium SEYLER. Brunner, M. Kaess, P. Parzer, G. Fischer, J. Haffner, F. Resch and the SEYLE Consortium Section Disorders of Personality Development Clinic of Child and Adolescent Psychiatry Center for Psychosocial Medicine

2. Background Begin of psychiatric disorders in childhood and adolescence • Half of all psychiatric disorders emerge around the 14th year of life • Median age of onset for anxiety disorders and impulse control disorders: 11 years of age Kessler et al. 2005

3. Investigating in youth mental health is a best buy...(but) ...mental health care systems are weakest where they need to be strongest. Patrick McGorry, 2007

4. Overview • Study I: Heidelberg School Study 2004/5 • Prevalence and psychosocial correlates of suicidal behavior and risk behavior in a representative sample of adolescent from the general population in Germany • Study II: SEYLE Study 2010/11 • School-based intervention study to reduce suicidal behavior and risk behavior in adolescents: A randomized controlled study in 11 European countries • Results from baseline evaluation in Germany and 7 other countries • First results on the effectiveness

5. Epidemiology of suicidal behavior in adolescents • Suicide is the third leading cause of death among children and adolescents between 10 and 19 years (USA), in Germany second most common cause • Age of 15-19 years • 8.2 cases in 100.000 • 5 times more common in boys • Suicidal ideas: 10-19% • Suicidplans: 6-15% • Suicide attempts: 8% Gould et al., 2003

6. Epidemiology of Nonsuicidal Self-Injury (NSSI) in adolescents • 6-7% of all students 15 years of age • Female – male ratio: 7 - 3:1 • Minority receive professional help • Strong association with suicidal behaviour • Strong association with low self-esteem and substance abuse • esp. in girls mit depressive symptoms, anxiety and impulsiveness Hawton et al., 2002; De Leo & Heller, 2004

7. Heidelberg School Study 2005 • 15-16 year old students in Heidelberg and Rhein-Neckar district (116 of 121 schools) • Anonymous questionnaire in the class rooms • Approached: 6185 • Returned: 6085 (98,4%) • Analyzed: 5832 (94,3%) Brunner et al., Arch. Pediatr. Adolesc. Med., 2007

8. Definition and prevalence of occasional and repetitive forms of NSSI How often did you intentionally hurt yourself in the last year? (cutting, burning, ...)? Report of the students (n=5522) BOYS GIRLS Never 89.9% 80.1% 1-3 times a year 8.0% 14.0% (occasional NSSI) >3 times a year 2.1% 5.9% (repetitive NSSI)

9. Suicidality Suicidal ideation Boys Girls Never 90% 80% 1-3 times 8% 14% 4 and more times 2% 6% Suicide attempt Boys Girls Never 95% 89% One time 4% 8% 2 times and more 1% 3%

10. NSSI and Suicide Attempt NSSI Suicide attempt Never Once Several times n=5296 n=332 n=121 Never 89,3 41,6 20,7 1- 3 times a year 8,8 38,5 29,7 > 3 times a year 1,9 19,9 49,6 100% 100%100% N=5749, chi2(4)=1.3e+03, p<0.001/Cramer‘s V=0.34/Interaction Gender : chi2(4)=7.4, p=0.117

11. NSSI and YSR-scores1 YSR scales NSSI Anova Never 1-3 times a year >3 times a year R2 n=4900 n=630 n=229 n=5759 Withdrawn 2.8 3.9 4.6 3.9% Somatic complaints 2.6 4.5 5.6 9.0% Anxious/depressed 4.9 8.5 12.0 14.5% Social problems 2.0 2.3 2.6 0.6% Thought problems 1.3 2.1 3.8 7.6% Attention problems 4.3 5.9 7.0 6.6% Delinquent behaviour 4.1 6.3 8.5 11.4% Aggressive Behaviour 8.2 11.5 14.1 8.0% YSR: Youth Self-report 1Means of raw scores; 2Adjusted R2x100=explained variance

12. Prevalence of diagnostic criteria of borderline personality disorder (BPD) Total (%) BPD (%) • Feelings of abandonment - - • Instable relationships 3.9 34.0 • Identity disturbances 3.1 36.2 • Impulsivity 17.5 81.9 • Self-injurious/suicidal behav. 6.1 85.1 • Affective instability 17.0 88.3 • Feelings of emptiness 9.0 80.9 • Loss of anger control 7.5 59.6 • Dissociative symptoms 18.6 59.6 Dimensional assessment by items of the Youth self-report, n=5832, mean age 15.2 y

13. BPD-Symptomatology 60 54.39 40 per cent 24.66 20 11.45 5.25 2.64 1.01 0.38 0.15 0.07 0 0 1 2 3 4 5 6 7 8 Numbers of fullfilled diagnostic criteria n=5832, mean age 15.2 y

14. Suicide attempts Report of the students Report of the parents 99.5 98.6 100 100 95.0 89.1 80 80 60 60 Per cent Per cent 40 40 20 20 8.0 3.8 2.1 1.1 0.9 0.6 0.5 0.3 0.2 0.1 0.2 0.1 0 0 none oncel 2-3 timesl >3 times none once 2-3 times >3 times male female male female

15. Only 10-12% of the students with suicidal behavior received professional help!

16. Study II: Aims of SEYLE Study„Saving and Empowering Young Lives in Europe“ (SEYLE) To reduce risky, self-destructive and suicidal behavior in adolescents To evalute the effectiveness of different intervention programs To implement the most effective intervention program adapted to the individual countries

17. Participating centers: 10 European countries and Israel Coordination: Karolinska Institute, Stockholm, Sweden Supervision: Columbia University, New York, USA SavingandEmpowering Young Lives in Europe (SEYLE)

18. Recruitment and Procedure 11.000 adolescents aged between 14 and 16 years (n=1.000 per country) t0 (baseline) t1 (three months) t2 (12 months after t0 ) Intervention Four Interventions Gatekeeper-Training (n= 250) Awareness-Training (n= 250) Professional Screening (n= 250) Control condition (n= 250)

19. Intervention programs (I) Program 1: Gate-keeper training Teachers are trained on how to recognize and refer students at-risk of suicide to professional services, how to help students with depression and risk-behavior Program 2: Awareness training Educational program for students, teaching about mental illness and suicide; awareness about feelings and how to manage stress and crisis situations; helping friends raise willingness to seek professional help

20. Intervention programs (II) Program 3: Professional Screening Screening of students on self-destructive and risk-taking behavior via baseline evaluation. Adolescents screened at-risk in accordance to the cut-off criteria are referred for professional clinical assessment and subsequent referral to mental health professionals Program 4: Control condition (Minimal Intervention) Educational posters in classrooms, basic information how to contact healthcare providers (self-referral)

21. 37 schools of the Rhein-Neckar district had been approached 11 schools declined participation, 26 schools took part in the study 1857 students and their caretakers had been approached (written and informed consent)

22. The „Heidelberg“ sample Approx. 70 % of the initially approached students were included Schooltyp Interventions | HS RS GY | Total --------------------------------------------------------------------------------------------------------- Gate-keeper | 178 73 79 | 330 Awareness | 134 104 130 | 368 ProfScreen | 114 140 169 | 423 Control condition | 97 132 94 | 323 ----------------------------------------------------------------------------------------------------- Total | 523 449 472 | 1,444 HS: Hauptschule, 9 years elementary schools RS: Realschule, secondary school level 1 certificate GY: Gymnasium, qualification for university entrance

29. Prevalence and gender differences of internet use Young‘s Diagnostic Questionnaire (YDQ) asks symptoms according to the DSM-IV diagnostic criteria of „pathological gambling“

30. Suicidal behavior and internet use

31. Suicidal behavior and excessive internet usePaykel Suicide Scale

32. Baseline in 8 European countries (I)

33. Baseline in 8 European countries (II)

34. Baseline in 8 European countries (III)

35. Difference of prevalence rates of NSSI and depressive symptoms

36. Professional Screening Professional Screening designed by Kaess, Parzer & Brunner 2009 Drop-out < Cut-off Screening • - Baseline questionnaire • Defined cut-offs > Cut-off • Structured clinical interview by (trained psychologist and psychiatrists) Drop-out < Cut-off Interview > Cut-off Referral Evaluation of the referrals

37. Results of the screening (stage I) • Eating behaviour 4.2 % • Substance abuse47.0 % • Excessive use of media 15.8 % • Sensation seeking & delinquent behaviour11.1 % • School attendance 2.6 % • Peer victimization 8.3 % • Social relationships 6.4 % • Anxiety 8.4 % • Depression20.6 % • NSSI21.7 % • Suicidal behaviour19.1 % In total, 68.5 % of the sample was screened as being at-risk by the questionnaire!

38. Results of the interview (stage II) Students could not be contacted: 34 Risk cases defined by questionnaire: 293 (out of 423) Students contacted: 259 Students refused to take part in the interview: 164 Students not at-risk (false positives): 64 Students took part in the interview: 95 At-risk students referred: 31

39. Predictors after minimizing Bayes Information Criteria(BIC) • Predictors for attending the interview • negative: excessive use of media • positive: peer victimization, suicidal behavior • Predictors for being referred to mental health care • positive: suicidal behaviour

40. Another predictor for attending the interview: Distance to professional institutions

43. Gender and response of intervention Specific types of intervention programs as • Awareness Program • Professional Screening showed significant better response in female students

44. Summary and Conclusions • High prevalence rates of NSSI and suicidal behavior in adolescents • Striking differences between European countries • Strong association with several risk behaviors • Seeking for professional help very seldom • Schools based intervention program can effectively reduce suicidal behavior • Open question which intervention program is the most effective one • Early recognition and early intervention concepts are urgently needed • Role model: Orygen Mental Health Center

45. Thanks to… … the Heidelberger SEYLE-Team • Michael Kaess • Peter Parzer • Katja Klug • Gloria Fischer • Judith Frisch • Lisa Göbelbecker • Sarah Schneider • Nassrin Schönbach • Christoph Lenzen • Franz Resch … and all members of the SEYLE-group