Claire Coffey

Antidepressant utilization and suicide in Europe: an ecological multi-national study

Background Research concerning the association between use of antidepressants and incidence of suicide has yielded inconsistent results and is the subject of considerable controversy. The first aim is to describe trends in the use of antidepressants and rates of suicide in Europe, adjusted for gross domestic product, alcohol consumption, unemployment, and divorce. The second aim is to explore if any observed reduction in the rate of suicide in different European countries preceded the trend for increased use of antidepressants. Methods Data were obtained for 29 European countries between 1980 and 2009. Pearson correlations were used to explore the direction and magnitude of associations. Generalized linear mixed models and Poisson regression distribution were used to clarify the effects of antidepressants on suicide rates, while an autoregressive adjusted model was used to test the interaction between antidepressant utilization and suicide over two time periods: 1980–1994 and 1995–2009. Findings An inverse correlation was observed in all countries between recorded Standardised Death Rate (SDR) for suicide and antidepressant Defined Daily Dosage (DDD), with the exception of Portugal. Variability was marked in the association between suicide and alcohol, unemployment and divorce, with countries depicting either a positive or a negative correlation with the SDR for suicide. Every unit increase in DDD of an antidepressant per 1000 people per day, adjusted for these confounding factors, reduces the SDR by 0.088. The correlation between DDD and suicide related SDR was negative in both time periods considered, albeit more pronounced between 1980 and 1994. Conclusions Suicide rates have tended to decrease more in European countries where there has been a greater increase in the use of antidepressants. These findings underline the importance of the appropriate use of antidepressants as part of routine care for people diagnosed with depression, therefore reducing the risk of suicide.

Public attitudes toward depression and help-seeking in four European countries baseline survey prior to the OSPI-Europe intervention

BACKGROUND Stigmatizing attitudes toward depression and toward help-seeking are important barriers for people with mental health problems to obtain adequate professional help. This study aimed to examine: (1) population attitudes toward depression and toward seeking professional help in four European countries; (2) the relation between depression stigma and attitudes toward help-seeking; (3) the relation between both attitudes and socio-demographic characteristics; and (4) differences in attitudes across countries. METHODS A representative general population survey (n=4011) was conducted in Germany, Hungary, Ireland, and Portugal, assessing attitudes toward depression and toward help-seeking, and a number of socio-demographic variables. RESULTS Respondents showed a moderate degree of personal stigma toward depression and a strikingly higher degree of perceived stigma. Although a substantial majority showed openness to seek professional help, only half of the people perceived professional help as valuable. More negative attitudes were found in Hungary and were associated with male gender, older age, lower educational level and living alone. Also, personal stigma was related to less openness to and less perceived value of professional treatment. LIMITATIONS The survey was cross-sectional, so no causal inferences could be drawn. CONCLUSIONS Personal and perceived stigma toward depression deserves public health attention, since they impact upon the intention of people with depression to seek professional help. Public media campaigns should focus on the credibility of the mental health care sector, and target males, older people, and those with a lower educational level and living alone. The content of each campaign should be adapted to the cultural norms of the country for which it is intended.

What Are Reasons for the Large Gender Differences in the Lethality of Suicidal Acts? An Epidemiological Analysis in Four European Countries

Background In Europe, men have lower rates of attempted suicide compared to women and at the same time a higher rate of completed suicides, indicating major gender differences in lethality of suicidal behaviour. The aim of this study was to analyse the extent to which these gender differences in lethality can be explained by factors such as choice of more lethal methods or lethality differences within the same suicide method or age. In addition, we explored gender differences in the intentionality of suicide attempts. Methods and Findings Methods. Design: Epidemiological study using a combination of self-report and official data. Setting: Mental health care services in four European countries: Germany, Hungary, Ireland, and Portugal. Data basis: Completed suicides derived from official statistics for each country (767 acts, 74.4% male) and assessed suicide attempts excluding habitual intentional self-harm (8,175 acts, 43.2% male). Main Outcome Measures and Data Analysis. We collected data on suicidal acts in eight regions of four European countries participating in the EU-funded “OSPI-Europe”-project (www.ospi-europe.com). We calculated method-specific lethality using the number of completed suicides per method * 100 / (number of completed suicides per method + number of attempted suicides per method). We tested gender differences in the distribution of suicidal acts for significance by using the χ2-test for two-by-two tables. We assessed the effect sizes with phi coefficients (φ). We identified predictors of lethality with a binary logistic regression analysis. Poisson regression analysis examined the contribution of choice of methods and method-specific lethality to gender differences in the lethality of suicidal acts. Findings Main Results Suicidal acts (fatal and non-fatal) were 3.4 times more lethal in men than in women (lethality 13.91% (regarding 4106 suicidal acts) versus 4.05% (regarding 4836 suicidal acts)), the difference being significant for the methods hanging, jumping, moving objects, sharp objects and poisoning by substances other than drugs. Median age at time of suicidal behaviour (35–44 years) did not differ between males and females. The overall gender difference in lethality of suicidal behaviour was explained by males choosing more lethal suicide methods (odds ratio (OR) = 2.03; 95% CI = 1.65 to 2.50; p < 0.000001) and additionally, but to a lesser degree, by a higher lethality of suicidal acts for males even within the same method (OR = 1.64; 95% CI = 1.32 to 2.02; p = 0.000005). Results of a regression analysis revealed neither age nor country differences were significant predictors for gender differences in the lethality of suicidal acts. The proportion of serious suicide attempts among all non-fatal suicidal acts with known intentionality (NFSAi) was significantly higher in men (57.1%; 1,207 of 2,115 NFSAi) than in women (48.6%; 1,508 of 3,100 NFSAi) (χ2 = 35.74; p < 0.000001). Main limitations of the study Due to restrictive data security regulations to ensure anonymity in Ireland, specific ages could not be provided because of the relatively low absolute numbers of suicide in the Irish intervention and control region. Therefore, analyses of the interaction between gender and age could only be conducted for three of the four countries. Attempted suicides were assessed for patients presenting to emergency departments or treated in hospitals. An unknown rate of attempted suicides remained undetected. This may have caused an overestimation of the lethality of certain methods. Moreover, the detection of attempted suicides and the registration of completed suicides might have differed across the four countries. Some suicides might be hidden and misclassified as undetermined deaths. Conclusions Men more often used highly lethal methods in suicidal behaviour, but there was also a higher method-specific lethality which together explained the large gender differences in the lethality of suicidal acts. Gender differences in the lethality of suicidal acts were fairly consistent across all four European countries examined. Males and females did not differ in age at time of suicidal behaviour. Suicide attempts by males were rated as being more serious independent of the method used, with the exceptions of attempted hanging, suggesting gender differences in intentionality associated with suicidal behaviour. These findings contribute to understanding of the spectrum of reasons for gender differences in the lethality of suicidal behaviour and should inform the development of gender specific strategies for suicide prevention.

Developing social capital in implementing a complex intervention: a process evaluation of the early implementation of a suicide prevention intervention in four European countries

BackgroundVariation in the implementation of complex multilevel interventions can impact on their delivery and outcomes. Few suicide prevention interventions, especially multilevel interventions, have included evaluation of both the process of implementation as well as outcomes. Such evaluation is essential for the replication of interventions, for interpreting and understanding outcomes, and for improving implementation science. This paper reports on a process evaluation of the early implementation stage of an optimised suicide prevention programme (OSPI-Europe) implemented in four European countries.MethodsThe process analysis was conducted within the framework of a realist evaluation methodology, and involved case studies of the process of implementation in four European countries. Datasets include: repeated questionnaires to track progress of implementation including delivery of individual activities and their intensity; serial interviews and focus groups with stakeholder groups; and detailed observations at OSPI implementation team meetings.ResultsAnalysis of local contexts in each of the four countries revealed that the advisory group was a key mechanism that had a substantial impact on the ease of implementation of OSPI interventions, particularly on their ability to recruit to training interventions. However, simply recruiting representatives of key organisations into an advisory group is not sufficient to achieve impact on the delivery of interventions. In order to maximise the potential of high level ‘gatekeepers’, it is necessary to first transform them into OSPI stakeholders. Motivations for OSPI participation as a stakeholder included: personal affinity with the shared goals and target groups within OSPI; the complementary and participatory nature of OSPI that adds value to pre-existing suicide prevention initiatives; and reciprocal reward for participants through access to the extended network capacity that organisations could accrue for themselves and their organisations from participation in OSPI.ConclusionsExploring the role of advisory groups and the meaning of participation for these participants revealed some key areas for best practice in implementation: careful planning of the composition of the advisory group to access target groups; the importance of establishing common goals; the importance of acknowledging and complementing existing experience and activity; and facilitating an equivalence of benefit from network participation.

Exploring synergistic interactions and catalysts in complex interventions: longitudinal, mixed methods case studies of an optimised multi-level suicide prevention intervention in four european countries (Ospi-Europe)

BackgroundThe Medical Research Council (MRC) Framework for complex interventions highlights the need to explore interactions between components of complex interventions, but this has not yet been fully explored within complex, non-pharmacological interventions. This paper draws on the process evaluation data of a suicide prevention programme implemented in four European countries to illustrate the synergistic interactions between intervention levels in a complex programme, and to present our method for exploring these.MethodsA realist evaluation approach informed the process evaluation, which drew on mixed methods, longitudinal case studies. Data collection consisted of 47 semi-structured interviews, 12 focus groups, one workshop, fieldnoted observations of six programme meetings and 20 questionnaires (delivered at six month intervals to each of the four intervention sites). Analysis drew on the framework approach, facilitated by the use of QSR NVivo (v10). Our qualitative approach to exploring synergistic interactions (QuaSIC) also developed a matrix of hypothesised synergies that were explored within one workshop and two waves of data collection.ResultsAll four implementation countries provided examples of synergistic interactions that added value beyond the sum of individual intervention levels or components in isolation. For instance, the launch ceremony of the public health campaign (a level 3 intervention) in Ireland had an impact on the community-based professional training, increasing uptake and visibility of training for journalists in particular. In turn, this led to increased media reporting of OSPI activities (monitored as part of the public health campaign) and also led to wider dissemination of editorial guidelines for responsible reporting of suicidal acts. Analysis of the total process evaluation dataset also revealed the new phenomenon of the OSPI programme acting as a catalyst for externally generated (and funded) activity that shared the goals of suicide prevention.ConclusionsThe QuaSIC approach enabled us to develop and refine our definition of synergistic interactions and add the innovative concept of catalytic effects. This represents a novel approach to the evaluation of complex interventions. By exploring synergies and catalytic interactions related to a complex intervention or programme, we reveal the added value to planned activities and how they might be maximised.

Depression Awareness and Self-Management Through the Internet: Protocol for an Internationally Standardized Approach

Background Depression incurs significant morbidity and confers increased risk of suicide. Many individuals experiencing depression remain untreated due to systemic and personal barriers to care. Guided Internet-based psychotherapeutic programs represent a promising means of overcoming such barriers and increasing the capacity for self-management of depression. However, existing programs tend to be available only in English and can be expensive to access. Furthermore, despite evidence of the effectiveness of a number of Internet-based programs, there is limited evidence regarding both the acceptability of such programs and feasibility of their use, for users and health care professionals. Objective This paper will present the protocol for the development, implementation, and evaluation of the iFightDepression tool, an Internet-based self-management tool. This is a cost-free, multilingual, guided, self-management program for mild to moderate depression cases. Methods The Preventing Depression and Improving Awareness through Networking in the European Union consortium undertook a comprehensive systematic review of the available evidence regarding computerized cognitive behavior therapy in addition to a consensus process involving mental health experts and service users to inform the development of the iFightDepression tool. The tool was implemented and evaluated for acceptability and feasibility of its use in a pilot phase in 5 European regions, with recruitment of users occurring through general practitioners and health care professionals who participated in a standardized training program. Results Targeting mild to moderate depression, the iFightDepression tool is based on cognitive behavioral therapy and addresses behavioral activation (monitoring and planning daily activities), cognitive restructuring (identifying and challenging unhelpful thoughts), sleep regulation, mood monitoring, and healthy lifestyle habits. There is also a tailored version of the tool for young people, incorporating less formal language and additional age-appropriate modules on relationships and social anxiety. The tool is accompanied by a 3-hour training intervention for health care professionals. Conclusions It is intended that the iFightDepression tool and associated training for health care professionals will represent a valuable resource for the management of depression that will complement existing resources for health care professionals. It is also intended that the iFightDepression tool and training will represent an additional resource within a multifaceted approach to improving the care of depression and preventing suicidal behavior in Europe.

How to Adjust Media Recommendations on Reporting Suicidal Behavior to New Media Developments

This study examines the inclusion of preventive factors and new media developments in media recommendations on suicide reporting. Of the 193 member states of the United Nations screened for media recommendations, information was available for 74 countries. Similarities and differences in their contents were analyzed by cluster analysis. Results indicate that of these 74 countries, 38% have national suicide prevention programs, 38% have media recommendations, and 25% have press codes including suicide reporting. Less than 25% of the media recommendations advise against mentioning online forums, suicide notes, pacts, clusters, hotspots, details of the person, and positive consequences. No more than 15% refer to self-help groups, fictional and online reporting. We conclude that media recommendations need to be revised by adding these preventive factors and by including sections on new media reporting.

Effectiveness of Depression-Suicidal Behaviour Gatekeeper Training among police officers in three European regions: Outcomes of the Optimising Suicide Prevention Programmes and Their Implementation in Europe (OSPI-Europe) study.

Background: Gatekeeper training for community facilitators, to identify and respond to those at risk of suicide, forms an important part of multi-level community-based suicide prevention programmes. Aims: This study examined the effects of gatekeeper training on attitudes, knowledge and confidence of police officers in dealing with persons at risk of suicide. Methods: A total of 828 police officers across three European regions participated in a 4-hour training programme which addressed the epidemiology of depression and suicidal behaviour, symptoms of depression, warning signs and risk factors associated with suicidal behaviour, motivating help-seeking behaviour, dealing with acute suicidal crisis and informing bereaved relatives. Participants completed internationally validated questionnaires assessing stigmatising attitudes, knowledge about depression and confidence in dealing with suicidal persons pre- and post-training. Results: There were significant differences among countries in terms of previous exposure to suicidal persons and extent of previous training. Post-training evaluation demonstrated significant improvements in stigmatising attitudes, knowledge and confidence in all three countries. Conclusion: The consistently positive effects of gatekeeper training of police officers across different regions support inclusion of this type of training as a fundamental part of multi-level community-based suicide prevention programmes and roll-out, nationally and internationally.

Media recommendations on reporting suicidal behaviour and suggestions for optimisation

Portrayal of suicidal behaviour in the media carries the risk of imitation (suicide contagion, copycat suicide, Werther effect; 1–3). Considerate reporting, in contrast, might decrease suicide and suicide attempt rates (4). Recommendations for media professionals have been introduced in many countries to promote responsible reporting of suicidal behaviour, and to balance the public’s ‘right to know’ against the risk of causing harm. These recommendations, prepared by the World Health Organization (WHO; 5) and (non-) governmental suicide prevention organisations, give detailed proposals on the portrayal of suicidal behaviour. Press codes of ethics, developed by media councils, aim to generally ensure ethical reporting and to hold editors and journalists accountable for their actions. Responsible reporting of suicide events might be among the mentioned criteria for professional journalistic behaviour. To our knowledge, systematic analyses of the existence of media recommendations (also in the context of national suicide prevention programmes), of press codes including a paragraph on portraying suicide, and the included aspects of reporting are not yet available. A survey to systematically assess the contents of media recommendations and press codes of ethics was conducted within the optimizing suicide prevention programmes and their implementation in Europe (OSPI-Europe) project, which aims to establish a best practice and evidence-based approach to reduce suicidal behaviour by community-based multilevel interventions (6, 7). For 74 (38%) of the 193 member states of the United Nations (UN), information on the existence or non-existence of national suicide prevention programmes was found via online search engines and/or a survey among the representatives of the International Association for Suicide Prevention. Of these 74 countries, only 38% have national suicide prevention programmes, 38% media recommendations and 25% press codes of ethics mentioning suicide reporting. A combination of national suicide prevention programmes, media recommendations in the national language, and a section on reporting suicide in the press codes is found in 11% of 74 countries only. All 34 media recommendations advise against describing suicide methods in detail. Most of them (>75%) warn against simplistic explanations and glorification of suicide, and recommend to refer to help in general, to report nonsensationally, and not to use photos. More than half of the recommendations suggest to list warning signs, to link suicide to mental illness and to refer to help agencies. A systematic assessment of media recommendations and press codes of ethics revealed some deficiencies in format, content, up-to-dateness, accessibility and availability, and thus a need for optimisation.

Suicide registration procedures and practices in Europe

Suicide is an important primary outcome measure for evaluating the effectiveness of intervention programmes. The aim of the current study was to describe and compare suicide-registration procedures in eight European countries, pinpoint potential deficiencies and provide recommendations on how best to improve the quality of suicide registration in the EU. Qualitative data on suicide registration were collected within the OSPI-Europe project from country experts using a structured questionnaire. Suicide registration was based on the medico-legal system in six countries and the coronial system in two. Differences not only between, but also within these two systems emerged. In every country, the process starts after the fact of death has been ascertained by a physician and any suspicion of injury death has arisen. It ends with registration of the death in the national mortality statistics. Between these stages, several elements that are crucial to the consistency of suicide registration were identified: the professional background and co-operation among the authorities involved, performance of the legal inquiry and forensic autopsy, certification and final decision-making, and the coding and registry system. A model for recording suicides with maximum accuracy should include: (1) a comprehensive, accurate and time-limited legal inquiry; (2) obligatory forensic autopsy in all cases of injury death; (3) reciprocal and accurate communication among the authorities involved; (4) electronic data transmission; (5) final decision-makers access to comprehensive information and (6) specially trained coders entitled to obtain additional information from the legal authorities and the certifiers.