György Purebl

Suicide prevention strategies revisited: 10-year systematic review.

BACKGROUND Many countries are developing suicide prevention strategies for which up-to-date, high-quality evidence is required. We present updated evidence for the effectiveness of suicide prevention interventions since 2005. METHODS We searched PubMed and the Cochrane Library using multiple terms related to suicide prevention for studies published between Jan 1, 2005, and Dec 31, 2014. We assessed seven interventions: public and physician education, media strategies, screening, restricting access to suicide means, treatments, and internet or hotline support. Data were extracted on primary outcomes of interest, namely suicidal behaviour (suicide, attempt, or ideation), and intermediate or secondary outcomes (treatment-seeking, identification of at-risk individuals, antidepressant prescription or use rates, or referrals). 18 suicide prevention experts from 13 European countries reviewed all articles and rated the strength of evidence using the Oxford criteria. Because the heterogeneity of populations and methodology did not permit formal meta-analysis, we present a narrative analysis. FINDINGS We identified 1797 studies, including 23 systematic reviews, 12 meta-analyses, 40 randomised controlled trials (RCTs), 67 cohort trials, and 22 ecological or population-based investigations. Evidence for restricting access to lethal means in prevention of suicide has strengthened since 2005, especially with regard to control of analgesics (overall decrease of 43% since 2005) and hot-spots for suicide by jumping (reduction of 86% since 2005, 79% to 91%). School-based awareness programmes have been shown to reduce suicide attempts (odds ratio [OR] 0·45, 95% CI 0·24-0·85; p=0·014) and suicidal ideation (0·5, 0·27-0·92; p=0·025). The anti-suicidal effects of clozapine and lithium have been substantiated, but might be less specific than previously thought. Effective pharmacological and psychological treatments of depression are important in prevention. Insufficient evidence exists to assess the possible benefits for suicide prevention of screening in primary care, in general public education and media guidelines. Other approaches that need further investigation include gatekeeper training, education of physicians, and internet and helpline support. The paucity of RCTs is a major limitation in the evaluation of preventive interventions. INTERPRETATION In the quest for effective suicide prevention initiatives, no single strategy clearly stands above the others. Combinations of evidence-based strategies at the individual level and the population level should be assessed with robust research designs. FUNDING The Expert Platform on Mental Health, Focus on Depression, and the European College of Neuropsychopharmacology.

Measures of stress in epidemiological research

A comprehensive assessment of psychosocial stress often poses significant challenges due to diversity in conceptualization of stress. Consequently, a number of instruments that measure psychosocial stress, its stressors, and its impact at the individual, organizational, and societal levels have been developed. This article aims to provide a brief review of such instruments, focusing on established questionnaire and interview measures in line with the environmentalist and psychological conceptualizations of stress. This includes measures of major life events; work, marital, and social stress; the individuals coping abilities; and psychological and somatic outcomes of stress. We provide a general description of selected instruments and discuss their administration, scoring, and psychometric properties. Appropriate application of these instruments in epidemiological and clinical research, as well as in inpatient care, can aid the detection of psychosocial stress, support thorough assessment and management of the individuals illness, and ensure accurate identification of individuals who would benefit from specific behavioral (psychotherapeutic) interventions.

How to decrease suicide rates in both genders? An effectiveness study of a community-based intervention (EAAD).

Background The suicide rate in Hungary is high in international comparison. The two-year community-based four-level intervention programme of the European Alliance Against Depression (EAAD) is designed to improve the care of depression and to prevent suicidal behaviour. Our aim was to evaluate the effectiveness of a regional community-based four-level suicide prevention programme on suicide rates. Method The EAAD programme was implemented in Szolnok (population 76,311), a town in a region of Hungary with an exceptionally high suicide rate. Effectiveness was assessed by comparing changes in suicide rates in the intervention region after the intervention started with changes in national suicide rates and those in a control region (Szeged) in the corresponding period. Results For the duration of the programme and the follow-up year, suicide rates in Szolnok were significantly lower than the average of the previous three years (p = .0076). The suicide rate thus went down from 30.1 per 100,000 in 2004 to 13.2 in 2005 (−56.1 %), 14.6 in 2006 (−51.4 %) and 12.0 in 2007 (−60.1 %). This decrease of annual suicide rates in Szolnok after the onset of the intervention was significantly stronger than that observed in the whole country (p = .017) and in the control region (p = .0015). Men had the same decrease in suicide rates as women. As secondary outcome, an increase of emergency calls to the hotline service (200%) and outpatient visits at the local psychiatry clinic (76%) was found. Conclusions These results seem to provide further support for the effectiveness of the EAAD concept. Whilst the majority of suicide prevention programs mainly affect female suicidal behaviour, this programme seems to be beneficial for both sexes. The sustainability and the role of the mediating factors (social service and health care utilization, community attitudes about suicide) should be key points in future research.

Comorbidity of pain problems and depressive symptoms in young women: results from a cross-sectional survey among women aged 15–24 in Hungary

Frequent headaches and musculoskeletal pain problems were assessed as part of a cross‐sectional health survey in a representative sample of 3615 young Hungarian women, aged 15–24 (mean age: 19.0 years). The representative sample was obtained by a multilevel stratified sampling procedure based on national statistical data, the refusal rate was 6%. Depressive symptomatology was assessed as well using the shortened form of the Beck Depression Inventory. The overall prevalence of frequent headaches was 43.8% in the sample, 25.8% of the investigated population reported chronic musculoskeletal pain problems. The co‐prevalence rate of depression was significantly higher in the group of interviewees reporting pain problems, 11.2% in the group indicating frequent headaches (χ2=53.1, p<0.001), 10.3% in the group reporting musculoskeletal pain problems (χ2=12.4, p<0.001). In contrast, the prevalence of depressive symptomatology was 4.6% and 6.6% in the subgroups denying frequent headaches and musculoskeletal pain, respectively. The prevalence of chronic pain problems decreased with higher age, increased with the smaller size of residence and was lower in the non‐student employment group, however, these differences across sociodemographic variables did not remain significant if tested by a multivariate logistic regression analysis.

Morningness-eveningness interferes with perceived health, physical activity, diet and stress levels in working women: A cross-sectional study

Sleep and health are closely interrelated and sleep quality is a well-known contributor to perceived health. However, effects of sleep-timing preference i.e. morningness–eveningness on health has yet to be revealed. In this study, we explored the relationship between morningness–eveningness and perceived health in a sample of female working professionals (N = 202). Sleep-timing preference was measured using the Composite Scale of Morningness. Perceived health was characterized by Center for Epidemiologic Studies Depression Scale, WHO Well-Being Scale-5 and Patient Health Questionnaire-15 scores. We also investigated possible mechanisms, including stress and health-impairing behaviours. In accordance with previous data, we found more depressive mood, lower well-being and poorer perceived health among evening types. To assess health-impairing behaviours we collected data on smoking habits, alcohol consumption, physical activity and diet. Among the possible mechanism variables, greater stress, less frequent physical activity and less healthy diet were associated with eveningness. Furthermore, stress diminished the strength of the association between morningness–eveningness and depressed mood. Physical activity attenuated the strength of the association between morningness–eveningness and well-being. No effects of alcohol consumption could be identified. Our data show that evening preference behaves as a health risk in terms of associating with poor perceived health. Our findings also suggest that this effect might be mediated by health behaviours and stress.

The Relationship of Biological and Psychological Risk Factors of Cardiovascular Disorders in a Large-scale National Representative Community Survey

A large-scale national representative community survey of 11,122 persons aged more than 35 years included the investigation of the coincidence of depressive symptoms, vital exhaustion, cardiovascular disorders, stroke, and myocardial infarction. A total of 20.3% of the survey participants reported having experienced a cardiovascular disorder (CVD). Of the subjects reporting a CVD, 52.1% exhibited depressive symptoms (22.0% subthreshold depressive symptoms, 30.1% clinical depression), and 69.7% exhibited vital exhaustion. The authors investigated 3 cardiovascular subgroups: (1) subjects having experienced a myocardial infarction (MI), (2) subjects having experienced stroke, and (3) subjects with a CVD but no experience of either an MI or a stroke. The frequency and severity of depressive symptoms did not differ significantly in the 3 subgroups. CVD subjects with no MI or stroke had almost as high frequencies of depressive symptoms and vital exhaustion as patients who experienced stroke or MI. The strength of relationships between these psychological variables and CVDs do not differ significantly from the relationships between hypertension or diabetes and CVDs. Depressive symptoms and increased vital exhaustion have exceptionally high comorbidity with CVDs. The authors detected the same high comorbidity among patients with a milder CVD and without stroke or MI. The assessment and management of depressive symptoms and vital exhaustion should be routine procedure in clinical cardiology.

Physical and sexual abuse: risk factors for substance use among young Hungarian women.

Abstract The authors used a multistage stratified sampling method to conduct a cross-sectional survey of a nationally representative sample of 3,615 Hungarian women aged 15 to 24 years to acquire epidemiologic data on physical and sexual abuse and analyze the relationship between abuse and health-risk behaviors. Just over 30% of the young women reported having experienced some type of abuse in their lifetimes. All maladaptive coping strategies, especially sedative use, were more prevalent among those who had experienced physical abuse. The prevalence of smoking, drinking alcohol, and experimenting with drugs was closely related to both physical and sexual abuse. Having experienced abuse is an important factor in young womens development of risky health behaviors. Clinicians should screen for abuse in this age group to prevent behaviors that lead to long-term health problems.

The Role of Health Anxiety and Depressive Symptoms in Dry Eye Disease

ABSTRACT Purpose: To investigate the associations between health anxiety, depressive and anxiety symptoms, and the severity of the subjective and objective symptoms of dry eye disease (DED). Methods: Participants completed the following psychological questionnaires: Shortened Health Anxiety Inventory, Shortened Beck Depression Inventory, and Beck Anxiety Inventory. Dry eye symptoms were evaluated using the ocular surface disease index (OSDI). Bilateral tear osmolarity measurement, tear film break-up time (TBUT), ocular surface staining, Schirmer 1 test, and meibomian gland dysfunction assessment were performed. Results: Based on the OSDI score, 56 of the 84 participants enrolled were symptomatic and 28 asymptomatic. According to the objective parameters, 48/56 (85.7%) in the symptomatic group and 23/28 (82.1%) in the asymptomatic group were diagnosed with DED. In terms of the objective parameters, except for TBUT, there were no statistically significant differences between the symptomatic and asymptomatic group (p > 0.108), or between the subgroups with objectively proven dry eye (p > 0.233). The results of the psychological questionnaires were significantly worse in the symptomatic group (p < 0.01) and the symptomatic subgroup with objective dry eye (p < 0.05), than in the asymptomatic groups. In the overall study population the scores of the psychological questionnaires demonstrated significant positive correlations with the OSDI scores (r > 0.306, p < 0.01). Conclusions: These results support the role of health anxiety and of depressive and anxiety symptoms in DED, and may serve as an explanation for the lack of correlation between subjective symptoms and objective signs of the disease.

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.

Gender Differences in Deliberate Self-Poisoning in Hungary

BACKGROUND The suicide rate in Hungary is one of the highest in the European Union, with a male-female ratio of 3.55:1. Suicide rates correlate positively with suicide attempts, for which depression is the most frequent underlying disorder. AIMS The aim of this qualitative study was to examine gender differences in suicide attempts, with a focus on the effect of precipitating factors on depression. METHOD Semistructured interviews were conducted among 150 suicide attempters. Data on circumstances, reason, and method of attempt were recorded. Patients completed the Shortened Beck Depression Inventory, the Beck Hopelessness Scale, the Sense of Coherence Scale, and the Social Support Questionnaire. RESULTS Interpersonal conflict was found to be the most frequent precipitating factor. There were significant gender differences in depressive symptoms among patients with interpersonal conflicts. We found differences in depressive symptoms according to presence or absence of interpersonal conflicts among men, but not among women. Male suicide attempters who indicated interpersonal conflicts had lower levels of depression. CONCLUSION Depressive symptoms are frequent among suicide attempters. However, a subgroup of male attempters reporting interpersonal conflicts are characterized by a lower level of depression. This subgroup of attempters would probably not be detected with depression screening programs and may have an unmet need for other forms of screening and prevention.