basic principles and best practices in prevention of suicides among adolescents

1. basic principles and best practices in prevention of suicides among adolescents Marco Sarchiapone Department of Health Sciences, University of Molise marco.sarchiapone@me.com

2. I declareno conflict of interest regarding this presentation Master Class

3. introduction • Suicidal behaviour includes: • suicidal thoughts (suicidal ideation) • attempted suicide • suicide • Suicide can occur at any age • Youth suicide is an increasingly important public health issue that impacts many adolescents, their families and communities • In order to develop effective prevention programs we need to know on what risk and protective factors we can act Master Class

4. Suicidal Behaviour is Multidetermined • Suicidal behaviour, as well as other human behaviours and psychiatric disorders, is a complex phenomenon determined by the action of several bio-psycho-social factors • A useful model for describing and studying suicidal behaviors is the Multifactorial Model of diseases • This will lead us to define outline a “map” of risk and protective factors of a subject towards suicide Master Class

5. STRESS-DIATHESIS MODEL • Predisposing or distal risk factors for suicidal behaviours constitute a basis on which potentiating or proximal risk factors act as a trigger for suicidal behaviours (Mośckici, 1997) PROTECTIVE FACTORS SUICIDE POTENTIATING FACTORS SUICIDAL THRESHOLD SURVIVAL RISK FACTORS Master Class

6. Suicidal threshold LIFE EVENT OTHER TRIGGER LIFE EVENT OTHER TRIGGER SUICIDE Non vulnerable subject Vulnerable subject Master Class

7. Magnitude ofthe problem • Almost one million people die each year of suicide • Annual global mortality rate of about 14.5 per 100,000 or one death about every 40 seconds • For every completed suicide, there are estimated 10-20 suicide attempts made • The real number of suicides is higher than the statistics show Master Class

8. Magnitude ofthe problem • According to WHO, suicidal thoughts and behaviours are increasing in Western countries, especially in Europe Master Class

9. Magnitude ofthe problem • The frequency of suicidal behaviour escalates steeply from childhood through middle to late adolescence and into adulthood, with suicide rates peaking in the 19- to 23-year-old population • At least 100,000 adolescents commit suicide every year • The act of deliberate self-harm in children and adolescents is frequently impulsive, and in many cases, they do not intend to die • Youth frequently explain their actions in terms of wanting to stop unbearable feelings or escape from a painful situation Master Class

10. Suicidal ideation • Between 3.5% and 52.1% of adolescents report suicidal thoughts (Diekstra et al., 1995) • 13.8% of students had seriously considered attempting suicide and about 10.9% had made a plan to attempt suicide, during the 12 months before the survey (Youth Risk Behaviour Survey, 2009) • Suicidal ideation is both associated with and predictive of psychopathology, especially mood, anxiety, and substance use disorders, among adolescents as well as older age groups (Reinherz et al., 2006) • Adolescent suicidal ideation has been linked to deficits in behavioural and emotional functioning (e.g., low self-esteem, depressive symptoms) in adolescence, extending into young adulthood (Reinherz et al., 2006) Master Class

11. Suicidalideation • Precursors of suicidal ideation (McGee et al., 2001): • Boys: hopelessness, dependence, and poor social/emotional adjustment • Girls: family discord, early behavioural problems, and poor perception of family roles • Substance use or separation anxiety may provoke adolescent ideators of both sexes to attempt suicide • Mood and anxiety disorders increase the risk of suicidal ideation: panic attacks are a risk factor for ideation or attempt in females, while aggressiveness increases the risk of suicidal ideation or attempt in males • In contrast to other adolescents with suicidal ideas, those who attempt suicide have more severe feelings of hopelessness, isolation, and suicidal ideation and are reluctant to discusstheirsuicidalthoughts(Shaffer et al., 2001) Master Class

12. Attempted suicide • Non-fatal suicidal behaviour is more prevalent among younger people than among older people • The ratio of fatal to non-fatal suicidal behaviour in people under 25 years is usually estimated to be of the order of 1:100–200(McIntire et al., 1981) • 6.3% of students had attempted suicide one or more times and 1.9%reported a suicide attempt that required medical care, during the 12 months before the survey (YRBS, 2009) • More than half of those attempting suicide made more than one attempt • Over 10% of teenagers have made repeated suicide attempts within the first year after an attempt and the repetition rate increases to 20% over 7 years (Hultén et al., 2002) Master Class

13. Attempted suicide • A previous suicide attempt is in itself the strongest predictor of future suicide • Previous suicidal experience sensitizes suicide-related thoughts and behaviours, such that these later become more accessible and active • Attempts by unusual methods and medically serious attempts are predictive of further suicide attempt behaviour and seem to be predictive of completed suicide (Beck et al., 1974) • Local rates of attempted suicide and regional and national suicide rates in young people are strongly correlated (Hawton et al., 1998) • There is an association between repeated suicide attempts and completed suicide, particularly in males and when a violent method has been used (Hawton, 1993) Master Class

14. suicide • Suicide ranks as the second cause of death after traffic accidents and other injuries in the ages 15-19 • In Europe each year, approximately 13,500 young men and women aged 15-24 years die by suicide • Several birth cohort analyses have reported an increase in risk for later birth cohorts, particularly among young males • Suicide in adolescence is estimated to be under-reported by around 30% or more Master Class

15. trends in suicide rates in adolescents Shaffer, D., Gould, M., & Hicks, R. (2007). Teen Suicide Fact Sheet. Master Class

16. Sociodemographic characteristics Adolescent suicide attempters who are at greater risk for suicide are: • Older (16 to 19 years old) • Male • Adolescents (of either sex, regardless of age) with a current mental disorder • Especially when complicated by comorbid substance abuse, irritability, agitation, or psychosis • Those who have made previous suicide attempts and persist in wanting to die (Shaffer, 2001) Master Class

17. Gender differences • Suicide is much more common in adolescent and young adult males than females (5.5:1 in 15- to 24-yearolds) • Suicide attempts are more common in girls than boys (1.6:1) • Completed suicide is more common in the male population in the United States, western Europe, Australia, and New Zealand, but suicide rates are equal between the sexes in some countries in Asia and more common in the female population in China and India (Gould et al., 2003; IASP, 1999) • Sex differences between completed suicides and suicide attempts can be explained by sex differences in methods (Beautrais, 2003) • There may be gender-specific patterns of early risk factors and/or developmental pathways associated with suicidal ideation and behaviour in adolescence and young adulthood Master Class

18. Risk factors for suicide in Adolescents PREDISPOSING RISK FACTORS POTENTIATING RISK FACTORS • Neurobiological risk factors • Family history of suicide • Psychiatric disorders • Substance use/abuse • Impulsive/aggressive behaviours • Childhood trauma • Stressful life events • Availability of means • Physical illness • Grief • Acute phases of psychiatric disorders • Risk taking behaviours Master Class

19. IMPULSIVITY AND SEROTONINERGIC SYSTEM Asberg et al., 1976 5-HIAA in the cerebrospinal fluid. A biochemical suicide predictor? Arch Gen Psychiatry 33(10):1193-7 Linnoila & Virkkunen, 1992 Aggression, suicidality, and serotonin J Clin Psychiatry 53:46-51 Virkkunen et al., 1995 Low Brain Serotonin Turnover Rate (Low CSF 5-HIAA) and Impulsive Violence J Psychiatry Neurosci 20(4): 271-5 Low brain serotonin turnover, as indicated by low cerebrospinal fluid (CSF) 5-hydroxyindoleacetic acid (5-HLAA), is associated with increased impulsiveness, impaired control of aggressive behaviors and suicide attempts Master Class

20. Candidate gene approach • Candidate gene approach studies in suicidal behaviour aimed at identifying associations between specific polymorphisms of genes related with serotonergic transmission and suicidal behaviour Master Class

21. FAMILY, ADOPTION ANDTWIN STUDIES Suicidal behavior aggregates within families: • Schulsinger et al., 1979: • A six-fold higher rate of suicidal behavior in the biological relatives of adoptees who committed suicide • Absence of suicidal behavior among the adoptive relatives of the person who committed suicide versus control adoptees • Roy, Sarchiapone and Segal, 1999: • Increased concordance for suicidal behavior in MZ versus DZ twins (18% versus 0.7%) Master Class

22. THE HEMINGWAY FAMILY Master Class

23. THE HEMINGWAY FAMILY Grace Hall B. 1872 D. 1951 Clarence Edmonds Hemingway B. 1871 D. 1928 Marcelline Hemingway B. 1898 D. 1963 Ursula Hemingway B. 1902 D. 1966 Ernest Miller Hemingway B. 1899 D. 1961 Carol Hemingway B. 1911 D. 2002 Madelaine Hemingway B. 1904 D. 1995 Leicester Clarence Hemingway B. 1911 D. 2002 John Hadley Nicanor Hemingway B. 1923 D. 2000 Patrick Hemingway B. 1928 Gregory Hancock Hemingway B. 1931 D. 2001 Joan Whittlesey Hemingway B. 1950 Margot (Margaux) Hemingway B. 1955 D. 1996 Hadley (Mariel) Hemingway B. 1961 Master Class

24. Familial transmission • Besides the genetic component, familial clustering of suicidal behaviour may be due to transmission through environmental conditions (i.e. poor and inappropriate parenthood, family disruption, child abuse and neglect) • The risk of suicide attempt in adolescents and young adults tends to be associated with familial psychopathology, particularly substance abuse, affective, neurotic and personality disorders (Mittendorfer-Rutz et al., 2008) • The risk of suicide attempt tends to be associated with familial suicidal behaviour, primarily familial suicide attempt (OR 2.3-5.8) (Mittendorfer-Rutz et al., 2008) Master Class

25. Familialtransmission • Association between disrupted family background and the risk for suicide • Positive association of divorce rate with suicide rates in youth • Lone parenthood linked to an increase in suicide mortality and morbidity in offspring • Suicide victims communicate less often and less fully with their parents than control teens (Shaffer et al., 2007) Master Class

26. Psychiatric disorders • More than 90% of adolescents who commit suicide suffered from an associated psychiatric disorder at the time of their death. More than half had suffered from a psychiatric disorder for at least 2 years (Shaffer et al., 2001) • Youth suicide almost always occurs in the context of an active, often treatable, mental illness that has frequently gone unrecognized or untreated (Shaffer et al., 2004; Brent et al., 1999) • The most common forms of psychiatric disorder found in completed suicides are some form of mood disorder and substance and/or alcohol abuse • Comorbidity between different disorders is common Master Class

27. Psychiatric Diagnoses in Child and Adolescent Suicides Shaffer, D., Gould, M., & Hicks, R. (2007). Teen Suicide Fact Sheet. Master Class

28. ALCOHOL ANDsubstance ABUSE • Increasing alcohol use among adolescents is one important risk factor contributing to the rise of suicidal behaviour among young adults (Sher et al., 2006) • Substance use is associated with suicidality (Sher & Zalsman, 2005; Swahn & Bossarte, 2007) and is an important risk factor of attempted and completed suicide (Fleming et al., 2007; Galaif et al., 2007) • Suicide attempters are more likely to have substance abuse/dependence disorders than suicidal ideators, suggesting that substance use may facilitate the transition from ideation to behaviour(Gould et al., 1998) Master Class

29. Psychosocial Stressors • The suicide is often preceded by a stress event (i.e. getting into trouble at school, a ruptured relationship with a boyfriend/girlfriend, or a fight among friends) • Low levels of communication between parents and children may act as a significant risk factor (Gould et al., 1996; Hollis, 1996) • It also appears that a suicide can be precipitated by exposure to news of another person’s suicide • The most frequent problems underlying suicidal behaviour among adolescents are relationship difficulties with parents, problems with friends, and social isolation (Hawton et al., 1996) • Family, school, and peer conflicts play a major role during childhood and early teens, and the effect of major mental illness comes on later Master Class

30. methods • The methods used to commit suicide show great geographic variation and this may reflect availability • Shift to suicide methods with higher lethality for both genders • Boys: • hanging, vehicle exhaust gas, firearms, and jumping • Girls: • self-poisoning, a method which, while it may have high toxicity, tends to have low lethality and a relatively slow rate of action • If women were to adopt more lethal methods, then the female suicide rate may approach or even exceed the male suicide rate (Beautrais et al., 2003) Master Class

31. Risk taking behaviours • Risk-taking behaviours may be considered as suicidal equivalents • In the United States, 74% of all deaths among youth aged 10–24 years result from four causes: motor-vehicle crashes (30%), other unintentional injuries (16%), homicide (16%), and suicide (12%) (Eaton et al., 2010) • Recent research showed a link between unhealthy behaviours and suicidal behaviour(Wasserman, 2001) • Teens engaging in risk behaviours are at increased odds of depression, suicidal ideation, and suicide attempts (Hallfors et al. 2004) • Early alcohol onset, having had sex before age 13, injection drug use, smoking, fighting and being forced to have sex are all critical behaviours associated with suicidality (Epstein & Spirito, 2010) Master Class

32. RISK TAKING behaviours • HIV related risky sexual behaviours (being forced to have sex, having sex with more than 4 people in the past 12 months, use of alcohol before sex and no regular use of condom) are strong predictors of suicidal ideation and attempt (Epstein & Spirito, 2009) • Suicide ideation and suicide attempts have been associated with both occasional, regular smoking and nicotine dependence (Bronisch et al., 2008) • Suicidal behaviours are associated with extreme and less extreme weight control behaviours (Crow et al., 2008) • Frequent exposure to victimization or bullying others are related to high risk of depression, ideation and suicide attempts (Klomek et al., 2009) Master Class

33. Risk taking behaviours • Risk behaviors are significantly correlated with one another and often appear in clusters (Winters et al., 2009; Flisher et al., 2000) • Mazur et al. (2004) described a “risk behaviour syndrome” involving psychoactive substances abuse, early sexual initiation and frequent contact with violence While a close relation exists between unhealthy behaviours and suicide it is possible tohypothesize that preventive interventions designed to identify and refer subjects with suicidal risk could have an impact on a wider range of unhealthy behaviours Master Class

34. High-Risk Factors for Suicide in Adolescents • Suicidal behaviour rarely occurs in isolation and is often associate to: • Mental health problems • Risk taking behaviours • Immediate risk predicted by agitation and major depressive disorder • Among males: • Previous suicide attempts • Age 16 or older • Associated mood disorder • Associated substance abuse • Among females: • Mood disorders • Previous suicide attempts (Shaffer et al., 2007) Master Class

35. Presence of Suicide Risk Factors Among Subjects Under 25 Years of Age Who Did or Did Not Make a Serious Suicide Attempt Beautrais, A. L. (2003). Suicide and serious suicide attempts in youth: a multiple-group comparison study. The American Journal of Psychiatry, 160(6), 1093-1099 Master Class

36. Protective factors COGNITIVE STYLE AND PERSONALITY FAMILY PATTERNS ENVIRONMENTAL FACTORS • A sense of personal value • Confidence in oneself and one’s own situation and achievements • Seeking help when difficulties arise • Seeking advise when important choices must be made • Openess to other people’s experiences and solutions • Openess to learning • Good family relationships • Support from family • Devoted and consistant parenting • Good diet and sleep • Sunlight • Physical excercise • Non-drug, non-smoking environment Master Class

37. Protective factors • Religious beliefs might have a protective effect on suicidality and depression (Miller & Gur, 2000) • Borowsky et al. 2001: • Perceived parent and family connectedness was protective against suicide attempts for girls and boys (OR = 0.06-0.32) • Boys: high grade point average • Girls: emotional well-being • The presence of 3 protective factors reduced the risk of a suicide attempt by 70% to 85% for each of the gender, including those with and without identified risk factors • Promotion of protective factors may offer an effective approach to primary as well as secondary prevention of adolescent suicidal behavior Master Class

38. What can be done to prevent suicidal behaviour among youngsters? • Schools are one of the most important settings for health promotion and preventive interventions for young people (WHO, 2004) • Several promising empirically based school prevention strategies have been identified • The treatment and prevention actions targeting adolescents who display risk behaviours or attempt suicide in the EU are not sufficiently based on scientific evidence • Acute need of exhaustive research data and clear evaluation criteria of what kind of health interventions are evidence-based and cost-effective Master Class

39. Strategies inSuicide Prevention • Health Care Perspective • Pharmacotherapy • Psychotherapy • Follow-up care after suicide attempts • Public Health Perspective • Awareness and Education • MEDIA reporting • Means restriction • Screening Master Class

40. Strategies inSuicide Prevention UNIVERSAL • everyone in a defined population SELECTIVE • subgroups at particular risk for suicide INDICATED • specific individuals at high risk Master Class

41. School-based suicide preventionstrategies SKILLS TRAINING Education and awareness programs CASE FINDING Screening for individuals at risk Master Class

42. SKILLS TRAININGexample 1 • Good Behavior Game (GBG) (Barrish et al., 1969; Wilcox et al., 2008) • To socialize children of elementary schools into the role of student and to teach them to regulate their own and their classmates’ behaviour through a process of interdependent team behaviour–contingent reinforcement • To reduce early aggressive, disruptive behaviour at the classroom level and at the individual level, a frequently reported antecedent of later problem outcomes • By young adulthood significant impact was found among males, particularly those in first grade who were more aggressive, disruptive, in reduced drug and alcohol abuse/dependence disorders, regular smoking, and antisocial personality disorder • GBGhad an impact on suicide ideation and suicide attempts among both genders Master Class

43. SKILLS TRAININGexample 2 • Sources of Strength Suicide Prevention Program (Wyman et al., 2010) • To build socioecological protective influences across a full student population • Youth opinion leaders are trained to change the norms and behaviours of their peers by conducting well-defined messaging activities with adult mentoring • Training improved the peer leaders’ adaptive norms regarding suicide, their connectedness to adults, and their school engagement, with the largest gains for those entering with the least adaptive norms • Trained peer leaders were 4 times as likely as were untrained peer leaders to refer a suicidal friend to an adult • The intervention increased perceptions of adult support for suicidal youths and the acceptability of seeking help Master Class

44. CASE FINDINGexample 1 • Columbia Suicide Screen (CSS) (Shaffer et al., 2004; Scott et al., 2009) • 11-item self-report questionnaire embedded within a health survey, measures suicidal ideation in the preceding 3 months, history of suicide attempts and problems associated with feeling unhappy or sad, irritable, anxious, or socially withdrawn and with using alcohol or drugs in the preceding 3 months • School-based screening improves identification of students at the highest risk for suicide, and it also improves identification of students with lesser mental health problems (suicidal ideation, previous suicidal behavior, internalizing disorders) • In the absence of screening, a large proportion of students with serious mental health problems would go undetected by school staff and mental health providers as well Master Class

45. CASE FINDINGexample 2 • Gatekeeper Training (Wyman et al., 2008) • Question, Persuade, Refer (QPR) training thatinclude information onrates of youth suicide, warning signs and risk factors for suicide and procedures for asking a student about suicide, persuading to get help and referring a student for help • The largest impact from training was to raise school staff members’ appraisals of their preparation and efficacy to perform a gatekeeper role and of their access to services for suicidal students • Appraisals increased most for staff with lowest baseline appraisals and suicide identification behaviours • With respect to knowledge, training had a medium-size effect on increasing participants’ accuracy to identify warning signs and risk factors for youth suicide and recommended QPR intervention behaviours • Training increased the number of staff queries of students about suicide but only for the 14% of staff already communicating with students about suicide before training Master Class

46. Combinedprogramsexample 1 • Lifelines(Kalafat et al. 2003) • It includes gatekeeper training, such as teachers, school staff and parents, as well as curriculum for students: teaching students to seek adult help for troubled peers, and also increasing the likelihood that these gatekeepers identify, engage and obtain help for at-risk youth • Lifelines may increase students’ expressed intent to tell an adult about an at-risk peer Master Class

47. Combinedprogramsexample2 • Signs of Suicide (SOS) (Aseltine and DeMartino, 2004) • A2-day schoolbased intervention which includes: • An educational curriculum (via video and group discussion) in which the students learn the acronym ACT: Acknowledging the signs of suicide that others display; letting the other know you Care and want to help; and Telling a responsible adult • Abrief anonymous self-screening for depression and other risk factors associated with suicide. The students evaluate their own level of risk and depending on their score on the screen the students are provided instructions about seeking treatment • High satisfaction by school personnel and a short-term decrease in students’ suicide attempts; although neither help-seeking behaviour nor suicide ideation were affected Master Class

48. School-based suicide prevention strategies: examples from Italy and other EU countries SEYLE Saving and Empowering Young Lives in Europe WE-STAY Working in Europe to Stop Truancy Among Youth SUPREME Suicide Prevention by Internet and Media based Mental Health Promotion Master Class

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50. SAVING AND EMPOWERING YOUNG LIVES IN EUROPE (SEYLE) • Randomized controlled trial of Mental Health promotion and suicide preventive interventions that is performed in the real world of European High Schools • Project Reference: 223091 • Duration: January 2009 – December 2011 • Project cost: € 5 Million • Co-funded by the EU, 7th Framework Programme (€ 3 Million) • Intervention in 11 countries • Sample: 12,395 pupils in the ages 14-15 Master Class