School-based interventions to prevent suicidal behavior andrisk behaviors among adolescents in Germany:

Results from the European Research Consortium SEYLE

R. Brunner, M. Kaess, P. Parzer, G. Fischer, J. Haffner, F. Resch and the SEYLE Consortium

Section Disorders of Personality DevelopmentClinic of Child and Adolescent Psychiatry

Center for Psychosocial Medicine

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

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

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

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

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

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

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)

Definition and prevalence of occasional and repetitive forms of NSSI

Suicidality

Suicidal ideationBoys Girls

Never 90% 80%1-3 times 8% 14%4 and more times 2% 6%

Suicide attemptBoys Girls

Never 95% 89% One time 4% 8%2 times and more 1% 3%

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

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

Prevalence of diagnostic criteria of borderline personality disorder (BPD)

Total (%) BPD (%)

1. Feelings of abandonment - -2. Instable relationships 3.9 34.03. Identity disturbances 3.1 36.24. Impulsivity 17.5 81.95. Self-injurious/suicidal behav. 6.1 85.1 6. Affective instability 17.0 88.37. Feelings of emptiness 9.0 80.98. Loss of anger control 7.5 59.69. Dissociative symptoms 18.6 59.6

Dimensional assessment by items of the Youth self-report, n=5832, mean age 15.2 y

54.39

24.66

11.45

5.252.64

1.01 0.38 0.15 0.07

020

4060

per

cent

0 1 2 3 4 5 6 7 8

Numbers of fullfilled diagnostic criteria

BPD-Symptomatology

n=5832, mean age 15.2 y

95.0

89.1

3.88.0

0.6 2.1 0.5 0.9

020

4060

8010

0P

er c

ent

none oncel 2-3 timesl >3 times

Report of the students

male female

99.598.6

0.3 1.1 0.1 0.2 0.1 0.2

020

4060

8010

0P

er c

ent

none once 2-3 times >3 times

Report of the parents

male female

Suicide attempts

Only 10-12% of the students with suicidal

behavior received professional help!

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

Participating centers: 10 European countries and Israel

Coordination: Karolinska Institute,Stockholm, Sweden

Supervision: Columbia University, New York, USA

Saving and EmpoweringYoung Lives in Europe (SEYLE)

Four Interventions

Gatekeeper-Training (n= 250)

Awareness-Training (n= 250)

Professional Screening (n= 250)

Control condition (n= 250)

t0

(baseline)

t1

(three months)

t2

(12 months after t0 )

Intervention

Recruitment and Procedure

11.000 adolescents aged between 14 and 16 years (n=1.000 per country)

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

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)

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)

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

Prevalence and gender differences of internet use

pathological usemaladaptive useadaptive use

Boys

11,8%

83,4%

4,8%

pathological use

maladaptive use

adaptive use

Girls

78,3

4,8%

16,9%

Young‘s Diagnostic Questionnaire (YDQ) asks symptoms according to the DSM-IV diagnostic criteria of „pathological gambling“

Suicidal behavior and internet use

Suicidal behavior and excessive internet usePaykel Suicide Scale

Baseline in 8 European countries (I)

Country Suicide attempts

last 2 weeks life time

Total

n % n % n %

Estonia 5 0.5 28 2.7 1,023 100

Germany 13 0.9 82 5.7 1,438 100

Hungary 0 0.0 24 2.4 1,007 100

Ireland 7 0.7 32 2.9 1,093 100

Israel 33 2.7 84 7.0 1,200 100

Italy 1 0.1 26 2.2 1,192 100

Romania 6 0.5 15 1.6 934 100

Spain 5 0.5 27 2.6 1,025 100

Total 70 0.8 318 3.6 8,912 100

Baseline in 8 European countries (II)

Country NSSI (more than 5 times)

NSSI (1-4 times) Total

n % n % n %

Estonia 79 7.7 261 25.3 1,033 100

Germany 149 10.4 354 24.8 1,430 100

Hungary 35 3.5 136 13.6 1,000 100

Ireland 47 4.4 173 16.2 1,071 100

Israel 101 8.5 284 23.9 1,191 100

Italy 40 3.4 209 17.5 1,193 100

Romania 21 1.9 210 18.7 1,126 100

Spain 66 6.4 232 22.6 1,025 100

Total 538 5.9 1,859 20.5 9,069 100

Baseline in 8 European countries (III)

Country Anxiety

(SAS)

Depression

(BDI)

Psychopathology

(SDQ)

Mean SD Mean SD Mean SD

Estonia 31.1 6.3 7.7 6.8 10.5 4.9

Germany 33.1 7.3 8.7 8.0 11.5 5.2

Hungary 35.1 4.7 6.9 6.3 9.6 4.6

Ireland 31.6 7.1 6.8 7.3 9.3 5.5

Israel 33.2 7.9 8.9 9.5 12.7 5.9

Italy 32.9 6.6 8.0 6.5 10.9 4.6

Romania 31.9 7.3 7.0 7.0 9.9 4.9

Spain 31.9 6.7 7.6 7.2 11.4 4.7

Difference of prevalence rates of NSSI and depressive symptoms

Evaluation of the referrals

Referral

Interview

ScreeningDrop-out

Drop-out

< Cut-off

> Cut-off

< Cut-off

> Cut-off

Professional Screening

- Baseline questionnaire

- Defined cut-offs

- Structured clinical interview by (trained psychologist and psychiatrists)

Professional Screening designed by Kaess, Parzer & Brunner 2009

Results of the screening (stage I)

• Eating behaviour 4.2 %• Substance abuse 47.0 %• Excessive use of media 15.8 %• Sensation seeking

& delinquent behaviour 11.1 %• School attendance 2.6 %• Peer victimization 8.3 %• Social relationships 6.4 %• Anxiety 8.4 %• Depression 20.6 %• NSSI 21.7 %• Suicidal behaviour 19.1 %

In total, 68.5 % of the sample was screened as being at-risk by the questionnaire!

Students took part in the interview: 95

Risk cases defined by questionnaire: 293 (out of 423)

Students contacted:259

Results of the interview (stage II)

Students could not be

contacted: 34

Students refused to take

part in the interview: 164

At-risk students

referred: 31

Students not at-risk (false positives): 64

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

Another predictor for attending the interview: Distance to professional institutions

Gender and response of intervention

Specific types of intervention programs as

– Awareness Program– Professional Screening

showed significant better response in female

students

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

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