Suicide is preventable. Nevertheless, each year 800,000 people die of suicide in the world. While there is evidence indicating that suicide rates de‐crease during times of crises, they are expected ...to increase once the immediate crisis has passed. The COVID‐19 pandemic affects risk and pro‐tective factors for suicide at each level of the socio‐ecological model. Economic downturn, augmented barriers to accessing health care, increased access to suicidal means, inappropriate media reporting at the societal level; deprioritization of mental health and preventive activities at the community level; interpersonal conflicts, neglect and violence at the relationship level; unemployment, poverty, loneliness and hopelessness at the individual level: all these variables contribute to an increase of depression, anxiety, post‐traumatic stress disorder, harmful use of alcohol, substance abuse, and ultimately suicide risk. Suicide should be prevented by strengthening universal strategies directed to the entire population, including mitigation of unemployment, poverty and inequalities; prioritization of access to mental health care; responsible media reporting, with information about available support; prevention of increased alcohol intake; and restriction of access to lethal means of suicide. Selective interventions should continue to target known vulnerable groups who are socio‐economically disadvantaged, but also new ones such as first responders and health care staff, and the bereaved by COVID‐19 who have been deprived of the final contact with loved ones and funerals. Indicated preventive strategies targeting individuals who display suicidal behaviour should focus on available pharmacological and psychological treatments of mental disorders, ensuring proper follow‐up and chain of care by increased use of telemedicine and other digital means. The scientific community, health care professionals, politicians and decision‐makers will find in this paper a systematic description of the effects of the pandemic on suicide risk at the society, community, family and individual levels, and an overview of how evidence‐based suicide preventive interventions should be adapted. Research is needed to investigate which adaptations are effective and in which con‐texts.
Using longitudinal and prospective measures, the authors assessed the relationship between childhood trauma and psychotic experiences, addressing the following questions: 1) Does exposure to trauma ...predict incident psychotic experiences? 2) Does cessation of trauma predict cessation of psychotic experiences? 3) What is the direction of the relationship between childhood trauma and psychotic experiences?
This was a nationally representative prospective cohort study of 1,112 school-based adolescents 13-16 years of age, assessed at baseline and at 3-month and 12-month follow-ups for childhood trauma (physical assault and bullying) and psychotic experiences.
A bidirectional relationship was observed between childhood trauma and psychosis, with trauma predicting psychotic experiences over time and vice versa. However, even after accounting for this bidirectional relationship with a number of strict adjustments (only newly incident psychotic experiences occurring over the course of the study following exposure to traumatic experiences were examined), trauma was strongly predictive of psychotic experiences. A dose-response relationship was observed between severity of bullying and risk for psychotic experiences. Moreover, cessation of trauma predicted cessation of psychotic experiences, with the incidence of psychotic experiences decreasing significantly in individuals whose exposure to trauma ceased over the course of the study.
After a series of conservative adjustments, the authors found that exposure to childhood trauma predicted newly incident psychotic experiences. The study also provides the first direct evidence that cessation of traumatic experiences leads to a reduced incidence of psychotic experiences.
Summary Background Suicidal behaviours in adolescents are a major public health problem and evidence-based prevention programmes are greatly needed. We aimed to investigate the efficacy of ...school-based preventive interventions of suicidal behaviours. Methods The Saving and Empowering Young Lives in Europe (SEYLE) study is a multicentre, cluster-randomised controlled trial. The SEYLE sample consisted of 11 110 adolescent pupils, median age 15 years (IQR 14–15), recruited from 168 schools in ten European Union countries. We randomly assigned the schools to one of three interventions or a control group. The interventions were: (1) Question, Persuade, and Refer (QPR), a gatekeeper training module targeting teachers and other school personnel, (2) the Youth Aware of Mental Health Programme (YAM) targeting pupils, and (3) screening by professionals (ProfScreen) with referral of at-risk pupils. Each school was randomly assigned by random number generator to participate in one intervention (or control) group only and was unaware of the interventions undertaken in the other three trial groups. The primary outcome measure was the number of suicide attempt(s) made by 3 month and 12 month follow-up. Analysis included all pupils with data available at each timepoint, excluding those who had ever attempted suicide or who had shown severe suicidal ideation during the 2 weeks before baseline. This study is registered with the German Clinical Trials Registry, number DRKS00000214. Findings Between Nov 1, 2009, and Dec 14, 2010, 168 schools (11 110 pupils) were randomly assigned to interventions (40 schools 2692 pupils to QPR, 45 2721 YAM, 43 2764 ProfScreen, and 40 2933 control). No significant differences between intervention groups and the control group were recorded at the 3 month follow-up. At the 12 month follow-up, YAM was associated with a significant reduction of incident suicide attempts (odds ratios OR 0·45, 95% CI 0·24–0·85; p=0·014) and severe suicidal ideation (0·50, 0·27–0·92; p=0·025), compared with the control group. 14 pupils (0·70%) reported incident suicide attempts at the 12 month follow-up in the YAM versus 34 (1·51%) in the control group, and 15 pupils (0·75%) reported incident severe suicidal ideation in the YAM group versus 31 (1·37%) in the control group. No participants completed suicide during the study period. Interpretation YAM was effective in reducing the number of suicide attempts and severe suicidal ideation in school-based adolescents. These findings underline the benefit of this universal suicide preventive intervention in schools. Funding Coordination Theme 1 (Health) of the European Union Seventh Framework Programme.
Electrodermal activity (EDA) and other peripheral autonomic electrical parameters have been used as indicators of emotional states, including depressive states and suicidal state. We aimed to review ...EDA research systematically, focusing on EDA's usefulness as a biomarker for depression and suicidal behaviour.
We searched MEDLINE, Scopus, Cochrane Library, and Web of Science databases, following PRISMA guidelines. The initial screening of articles was based on titles and abstracts; then the full text was reviewed. A preliminary synthesis of findings was developed using tables, thematic analysis and quality ratings.
1287 articles were screened and 77 relevant studies were identified and included in the systematic review. The studies were fairly consistent in maintaining that hypoactive electrodermal response is an established feature of patients affected by depression. There is also preliminary evidence that monitoring EDA may help to differentiate the phases of mood disorders. A few studies provided evidence that EDA can be used to differentiate acutely suicidal subjects from depressed patients who are not severely suicidal. Although EDA has been shown to be a valid, sensitive marker of suicidal ideation, suicide attempts and violent suicidal behaviour, it also seems to be influenced to some extent by antidepressant treatment.
Most of the studies summarised in this review are quite outdated and employed a variety of designs and methods to evaluate EDA. This limits the generalisability of the results and makes it difficult to draw clear conclusions about the role of EDA in real-world settings. Electrodermal hypoactivity seems to be a reliable feature of depression and a valid marker of suicidal risk. Nevertheless, the potential utility of EDA in diagnosis, prevention, and treatment planning for depression and suicidal behaviour, should be thoroughly studied.
To investigate behavioral sleep habits, self-perceived quality of sleep, and chronotype, and to examine their association with clinically relevant levels of depression in Swedish adolescents. ...Questionnaire data were obtained from a representative sample of Swedish adolescents (n = 8449; 50.8% girls; aged 12-16). Depression was defined as >13 BDI-II scores. Logistic regression modelling estimated the effects of sleep duration, sleep quality, and chronotype on depression, adjusted for socio-demographic factors. On weekdays, approximately 46% of adolescents slept less than the recommended length of eight hours per night (depressed: 68%, non-depressed: 40%). On weekends, however, only 17% slept shorter than recommended. Short weekday sleep duration was more common among girls than boys (53% vs. 38%) and girls reported worse sleep quality. The regression model showed that depression was predicted by weekday sleep duration (OR = 0.773, p < .0001), sleep quality (OR = 0.327, p < .0001), and late chronotype (OR = 1.126, p = .0017), but not by weekend sleep duration. A 30-minute increase in weekday sleep duration was associated with about 10% lower odds of depression. A substantial proportion of Swedish adolescents do not seem to meet the sleep recommendations of eight hours per night. Short sleep duration on weekdays, poor sleep quality, and late chronotype were associated with increased risk of depression. Interventions promoting longer weekday sleep duration (e.g., later school start times) seem relevant in this context, but further research is needed to investigate the directionality and underlying mechanisms of these associations.
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.
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.
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.
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.
The Expert Platform on Mental Health, Focus on Depression, and the European College of Neuropsychopharmacology.
Abstract Purpose To examine risk and protective factors moderating the associations between three types of bullying victimization (physical, verbal, and relational bullying) with suicide ...ideation/attempts in a large representative sample of European adolescents. Methods We analyzed cross-sectional data on 11,110 students (mean age = 14.9, standard deviation = .89) recruited from 168 schools in 10 European Union countries involved in the Saving and Empowering Young Lives in Europe study. A self-report questionnaire was used to measure victimization types, depression, anxiety, parental and peer support, and suicide ideation and attempts. For each outcome, we applied hierarchical nonlinear models controlling for sociodemographics. Results Prevalence of victimization was 9.4% physical, 36.1% verbal, and 33.0% relational. Boys were more likely to be physically and verbally victimized, whereas girls were more prone to relational victimization. Physical victimization was associated with suicide ideation, and relational victimization was associated with suicide attempts. Other associations between victimization and suicidality (ideation/attempts) were identified through analysis of interactions with additional risk and protective factors. Specifically, verbal victimization was associated with suicide ideation among adolescents with depression who perceived low parental support. Similarly, low peer support increased the associations between verbal victimization and suicide ideation. Verbal victimization was associated with suicide attempts among adolescents with anxiety who perceived low parental support. Conclusions Findings support the development of prevention strategies for adolescent victims of bullying who may be at elevated risk for suicide ideation/behavior, by taking into account gender, the type of bullying, symptomatology, and availability of interpersonal support.
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.
Objectives
To investigate the prevalence and associated psychosocial factors of occasional and repetitive direct self‐injurious behavior (D‐SIB), such as self‐cutting, ‐burning, ‐biting, ‐hitting, ...and skin damage by other methods, in representative adolescent samples from 11 European countries.
Methods
Cross‐sectional assessment of adolescents was performed within the European Union funded project, Saving and Empowering Young Lives in Europe (SEYLE), which was conducted in 11 European countries. The representative sample comprised 12,068 adolescents (F/M: 6,717/5,351; mean age: 14.9 ± 0.89) recruited from randomly selected schools. Frequency of D‐SIB was assessed by a modified 6‐item questionnaire based on previously used versions of the Deliberate Self‐Harm Inventory (DSHI). In addition, a broad range of demographic, social, and psychological factors was assessed.
Results
Overall lifetime prevalence of D‐SIB was 27.6%; 19.7% reported occasional D‐SIB and 7.8% repetitive D‐SIB. Lifetime prevalence ranged from 17.1% to 38.6% across countries. Estonia, France, Germany, and Israel had the highest lifetime rates of D‐SIB, while students from Hungary, Ireland, and Italy reported low rates. Suicidality as well as anxiety and depressive symptoms had the highest odds ratios for both occasional and repetitive D‐SIB. There was a strong association of D‐SIB with both psychopathology and risk‐behaviors, including family related neglect and peer‐related rejection/victimization. Associations between psychosocial variables and D‐SIB were strongly influenced by both gender and country. Only a minor proportion of the adolescents who reported D‐SIB ever received medical treatment.
Conclusion
These results suggest high lifetime prevalence of D‐SIB in European adolescents. Prevalence as well as psychosocial correlates seems to be significantly influenced by both gender and country. These results support the need for a multidimensional approach to better understand the development of SIB and facilitate culturally adapted prevention/intervention.
Background
The association between bullying victimization and depression, suicide ideation and suicide attempts has been studied mainly in cross‐sectional studies. This study aims to test the ...bidirectional effect and the chronicity versus sporadic effect of physical, verbal, and relational bullying victimization on suicidal ideation/attempts and depression.
Methods
Longitudinal assessments with an interval of 3‐ and 12‐months were performed within a sample of 2,933 adolescents (56.1% females; mean age 14.78, SD = .89) from 10 European countries, participating in the Saving and Empowering Young Lives in Europe (SEYLE) school‐based multicenter control sample. Multilevel Structural Equation Models were used, controlling for sociodemographic variables. Victimization was considered chronic when a student was victimized in the first two time points and sporadic when it was reported only at one point but not in another.
Results
Bidirectional prospective association between all types of victimization and depression were found. Among participants, who reported victimization once (but not twice), physical victimization, but not verbal and relational, was associated with later suicidal ideation and attempts. Chronic victimization of any type increased likelihood for later depression compared with sporadic and no‐victimization. Chronic relational victimization increased the likelihood of later suicidal ideation, and chronic physical victimization increased the likelihood for suicidal attempts.
Conclusions
The results support the bidirectional effect of victimization and depression and indicate that there are complex longitudinal associations between victimization and suicidal ideation/attempts. Physical victimization may especially carry effect on suicidal risk over time. Interventions should focus on victimization as a cause of distress but also aim to prevent vulnerable adolescents from becoming targets of victimization.
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