Merike Sisask

Adolescent subthreshold-depression and anxiety: psychopathology, functional impairment and increased suicide risk

BACKGROUND  Subthreshold-depression and anxiety have been associated with significant impairments in adults. This study investigates the characteristics of adolescent subthreshold-depression and anxiety with a focus on suicidality, using both categorical and dimensional diagnostic models. METHODS  Data were drawn from the Saving and Empowering Young Lives in Europe (SEYLE) study, comprising 12,395 adolescents from 11 countries. Based on self-report, including Beck Depression Inventory-II (BDI-II), Zung Self-Rating Anxiety Scale (SAS), Strengths and Difficulties Questionnaire (SDQ) and Paykel Suicide Scale (PSS) were administered to students. Based on BDI-II, adolescents were divided into three groups: nondepressed, subthreshold-depressed and depressed; based on the SAS, they were divided into nonanxiety, subthreshold-anxiety and anxiety groups. Analyses of Covariance were conducted on SDQ scores to explore psychopathology of the defined groups. Logistic regression analyses were conducted to explore the relationships between functional impairments, suicidality and subthreshold and full syndromes. RESULTS  Thirty-two percent of the adolescents were subthreshold-anxious and 5.8% anxious, 29.2% subthreshold-depressed and 10.5% depressed, with high comorbidity. Mean scores of SDQ of subthreshold-depressed/anxious were significantly higher than the mean scores of the nondepressed/nonanxious groups and significantly lower than those of the depressed/anxious groups. Both subthreshold and threshold-anxiety and depression were related to functional impairment and suicidality. CONCLUSIONS Subthreshold-depression and subthreshold-anxiety are associated with an increased burden of disease and suicide risk. These results highlight the importance of early identification of adolescent subthreshold-depression and anxiety to minimize suicide. Incorporating these subthreshold disorders into a diagnosis could provide a bridge between categorical and dimensional diagnostic models.

Media Roles in Suicide Prevention: A Systematic Review

The aim of the current systematic review was to monitor and provide an overview of the research performed about the roles of media in suicide prevention in order to find out possible effects media reporting on suicidal behaviours might have on actual suicidality (completed suicides, attempted suicides, suicidal ideation). The systematic review was performed following the principles of the PRISMA statement and includes 56 articles. Most of the studies support the idea that media reporting and suicidality are associated. However, there is a risk of reporting bias. More research is available about how irresponsible media reports can provoke suicidal behaviours (the ‘Werther effect’) and less about protective effect media can have (the ‘Papageno effect’). Strong modelling effect of media coverage on suicide is based on age and gender. Media reports are not representative of official suicide data and tend to exaggerate sensational suicides, for example dramatic and highly lethal suicide methods, which are rare in real life. Future studies have to encounter the challenges the global medium Internet will offer in terms of research methods, as it is difficult to define the circulation of news in the Internet either spatially or in time. However, online media can provide valuable innovative qualitative research material.

Characteristics of attempted suicides seen in emergency-care settings of general hospitals in eight low- and middle-income countries

BACKGROUND The objective was to describe patients presenting themselves at emergency-care settings following a suicide attempt in eight culturally different sites [Campinas (Brazil), Chennai (India), Colombo (Sri Lanka), Durban (South Africa), Hanoi (Viet Nam), Karaj (Iran), Tallinn (Estonia), and Yuncheng, (China)]. METHOD Subjects seen for suicide attempts, as identified by the medical staff in the emergency units of 18 collaborating hospitals were asked to participate in a 45-minute structured interview administered by trained health personnel after the patient was medically stable. RESULTS Self-poisoning was the main method of attempting suicide in all eight sites. Self-poisoning by pesticides played a particularly important role in Yuncheng (71.6% females, 61.5% males), in Colombo (43.2% males, 19.6% females), and in Chennai (33.8% males, 23.8% females). The suicide attempt resulted in danger to life in the majority of patients in Yuncheng and in Chennai (over 65%). In four of the eight sites less than one-third of subjects received any type of referral for follow-up evaluation or care. CONCLUSIONS Action for the prevention of suicide attempts can be started immediately in the sites investigated by addressing the one most important method of attempted suicide, namely self-poisoning. Regulations for the access to drugs, medicaments, pesticides, and other toxic substances need to be improved and revised regulations must be implemented by integrating the efforts of different sectors, such as health, agriculture, education, and justice. The care of patients who attempt suicide needs to include routine psychiatric and psychosocial assessment and systematic referral to professional services after discharge.

Hours of sleep in adolescents and its association with anxiety, emotional concerns, and suicidal ideation

OBJECTIVES Anxiety and concerns in daily life may result in sleep problems and consistent evidence suggests that inadequate sleep has several negative consequences on cognitive performance, physical activity, and health. The aim of our study was to evaluate the association between mean hours of sleep per night, psychologic distress, and behavioral concerns. METHODS A cross-sectional analysis of the correlation between the number of hours of sleep per night and the Zung Self-rating Anxiety Scale (Z-SAS), the Paykel Suicidal Scale (PSS), and the Strengths and Difficulties Questionnaire (SDQ), was performed on 11,788 pupils (mean age±standard deviation [SD], 14.9±0.9; 55.8% girls) from 11 different European countries enrolled in the SEYLE (Saving and Empowering Young Lives in Europe) project. RESULTS The mean number of reported hours of sleep per night during school days was 7.7 (SD, ±1.3), with moderate differences across countries (r=0.06; P<.001). A reduced number of sleeping hours (less than the average) was more common in girls (β=0.10 controlling for age) and older pupils (β=0.10 controlling for sex). Reduced sleep was found to be associated with increased scores on SDQ subscales of emotional (β=-0.13) and peer-related problems (β=-0.06), conduct (β=-0.07), total SDQ score (β=-0.07), anxiety (Z-SAS scores, β=-10), and suicidal ideation (PSS, β=-0.16). In a multivariate model including all significant variables, older age, emotional and peer-related problems, and suicidal ideation were the variables most strongly associated with reduced sleep hours, though female gender, conduct problems measured by the SDQ, and anxiety only showed modest effects (β=0.03-0.04). CONCLUSIONS Our study supports evidence that reduced hours of sleep are associated with potentially severe mental health problems in adolescents. Because sleep problems are common among adolescents partly due to maturational processes and changes in sleep patterns, parents, other adults, and adolescents should pay more attention to their sleep patterns and implement interventions, if needed.

Is Religiosity a Protective Factor Against Attempted Suicide: A Cross-Cultural Case-Control Study

This cross-cultural study investigates whether religiosity assessed in three dimensions has a protective effect against attempted suicide. Community controls (n = 5484) were more likely than suicide attempters (n = 2819) to report religious denomination in Estonia (OR = 0.5) and subjective religiosity in four countries: Brazil (OR = 0.2), Estonia (OR = 0.5), Islamic Republic of Iran (OR = 0.6), and Sri Lanka (OR = 0.4). In South Africa, the effect was exceptional both for religious denomination (OR = 5.9) and subjective religiosity (OR = 2.7). No effects were found in India and Vietnam. Organizational religiosity gave controversial results. In particular, subjective religiosity (considering him/herself as religious person) may serve as a protective factor against non-fatal suicidal behavior in some cultures.

Pathological Internet use among European adolescents: psychopathology and self-destructive behaviours

Rising global rates of pathological Internet use (PIU) and related psychological impairments have gained considerable attention in recent years. In an effort to acquire evidence-based knowledge of this relationship, the main objective of this study was to investigate the association between PIU, psychopathology and self-destructive behaviours among school-based adolescents in eleven European countries. This cross-sectional study was implemented within the framework of the European Union project: Saving and Empowering Young Lives in Europe. A representative sample of 11,356 school-based adolescents (M/F: 4,856/6,500; mean age: 14.9) was included in the analyses. PIU was assessed using the Young’s Diagnostic Questionnaire. Psychopathology was measured using the Beck Depression Inventory-II, Zung Self-Rating Anxiety Scale and Strengths and Difficulties Questionnaire. Self-destructive behaviours were evaluated by the Deliberate Self-Harm Inventory and Paykel Suicide Scale. Results showed that suicidal behaviours (suicidal ideation and suicide attempts), depression, anxiety, conduct problems and hyperactivity/inattention were significant and independent predictors of PIU. The correlation between PIU, conduct problems and hyperactivity/inattention was stronger among females, while the link between PIU and symptoms of depression, anxiety and peer relationship problems was stronger among males. The association between PIU, psychopathology and self-destructive behaviours was stronger in countries with a higher prevalence of PIU and suicide rates. These findings ascertain that psychopathology and suicidal behaviours are strongly related to PIU. This association is significantly influenced by gender and country suggesting socio-cultural influences. At the clinical and public health levels, targeting PIU among adolescents in the early stages could potentially lead to improvements of psychological well-being and a reduction of suicidal behaviours.

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.

Massive increase in injury deaths of undetermined intent in ex-USSR Baltic and Slavic countries: hidden suicides?

Aims: Observed changes in subcategories of injury death were used to test the hypothesis that a sizeable proportion of ‘‘injury deaths of undetermined intent’’ (Y10—Y34 in ICD 10) in the Baltic and Slavic countries after the USSR dissolved in 1991 were hidden suicides. Methods: Using male age-adjusted suicide rates for two distinctly different periods, 1981—90 and 1992—2005, changes, ratios and correlations were calculated. The data were compared with the EU average. Results: After the USSR broke up, the obligation to make a definitive diagnosis became less strict. A massive increase in ‘‘injury deaths of undetermined intent’’ resulted. The mean rate for the second period reached 52.8 per 100,000 males in Russia (the highest rate) and 12.9 in Lithuania (the lowest), against 3.2 in EU-15. The rise from the first to the second period was highest in Belarus (56%) and Russia (44%). The number of injury deaths of undetermined intent was almost equal to that of suicides in Russia in 2005 (ratio 1.0) and Ukraine in 2002 (1.1). In all the countries, especially the Slavic ones, prevalence trends of injury-death subcategories were uniform, i.e. strongly correlated over time. No direct substitution of one diagnosis for another was evident. Conclusions: There is no evidence that the category of ‘‘injury deaths of undetermined intent’’ in the Baltic and Slavic countries hides suicides alone. Aggregate level analysis indicates that accidents and homicides could sometimes be diagnosed as undetermined.

Repetition of suicide attempts

BACKGROUND Attempted suicide is a strong risk factor for subsequent suicidal behaviors. Innovative strategies to deal with people who have attempted suicide are needed, particularly in resource-poor settings. AIMS To evaluate a brief educational intervention and periodic follow-up contacts (BIC) for suicide attempters in five culturally different sites (Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic Republic of Iran; and Yuncheng, Peoples Republic of China) as part of the WHO Multisite Intervention Study on Suicidal Behaviors (SUPRE-MISS). METHODS Among the 1,867 suicide attempters enrolled in the emergency departments of the participating sites, 922 (49.4%) were randomly assigned to a brief intervention and contact (BIC) group and 945 (50.6%) to a treatment as usual (TAU) group. Repeated suicide attempts over the 18 months following the index attempt - the secondary outcome measure presented in this paper - were identified by follow-up calls or visits. Subsequent completed suicide - the primary outcome measure - has been reported in a previous paper. RESULTS Overall, the proportion of subjects with repeated suicide attempts was similar in the BIC and TAU groups (7.6% vs. 7.5%, chi(2) = 0.013; p = .909), but there were differences in rates across the five sites. CONCLUSIONS This study from five low- and middle-income countries does not confirm the effectiveness of brief educational intervention and follow-up contacts for suicide attempters in reducing subsequent repetition of suicide attempts up to 18 months after discharge from emergency departments.

Subjective psychological well-being (WHO-5) in assessment of the severity of suicide attempt

An objective way to measure the severity of suicide attempt is to use different psychometric scales. Aspects of suicide risk like suicidal intent, depression, hopelessness and well-being can be assessed and different practical scales are in use to facilitate the risk assessment procedure. The aims of current study were: 1) to analyse the association between the severity of suicide attempt measured by suicidal intent scale and characteristics of emotional status of suicide attempters measured by depression, hopelessness and well-being scales in different gender and age groups; 2) to test the applicability of well-being measured by the World Health Organisation well-being index (WHO-5) in suicide risk assessment. The data on suicide attempters (n=469) was obtained in Estonia (Tallinn) by the WHO Suicide Prevention—Multisite Intervention Study on Suicidal Behaviours (SUPRE-MISS) methodology. Different psychometric scales were used to measure suicidal intent (Pierce Suicidal Intent Scale) and emotional status (Beck Depression Inventory for depression, Beck Hopelessness Scale for hopelessness, WHO-5 for well-being). All psychometric scales correlated well with each other (P<0.05). Low level of well-being associated with high level of suicidal intent, depression and hopelessness. Suicidal intent correlated the most strongly with well-being. Analysis by gender and age groups revealed also significant correlations with two exceptions only: correlation between suicidal intent and hopelessness did not reach the significant level in males and in older adults (40+). The WHO-5 well-being scale, which is a short and emotionally positively loaded instrument measuring protective factors, can be used in settings without psychological/psychiatric expertise in preliminary suicide risk assessment.