Suicide prevention strategies. A systematic review Mann JJ et al., JAMA 2005, 294: 2064-2074. Asbtract Conclusions: „Physician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates. Other interventions need more evidence of efficacy”.
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Suicide prevention strategies.A systematic review
Mann JJ et al., JAMA 2005, 294: 2064-2074.
AsbtractConclusions: „Physician education in
depression recognition and treatment andrestricting access to lethal methodsreduce suicide rates. Other interventions need more evidence of efficacy”.
Medical contact before suicide (%)
GPs Psychiatrists
• 3 months 47-73 -----
• 4 weeks 34-66 18-21
• 1 week 18-40 9-11
- Medical contact: Females > males- Suicide victims: 65-80 % are males
Pirkis and Burgess, Brit J Psychiat 1998, 173:462-474. Andersen et al, Acta Psychiat Scand 2000, 102:126-134.
Suicide prevention strategies –Competence of healthcare (1)
I. Patient-oriented prespective (targetinghigh-risk groups)
Antidepressants, benzodiazepines and suicide risk in schizophrenia
• 2.588 Finish patients with schizophrenia• 4 year follow-up• 35 patients completed suicides (1.35%)• Among patients who used also
antidepressants the suicide risk was 85%lower
• Benzodiazepine use was associated with marked increase of suicidality (283%, protocol violation, withdraval syndrome, confunding by indication)
Tiihonen et al, Arch Gen Psychiat, 2012; 69: 476-483.
Mostly temazepam, diazepam and oxaepam but no suicide on alprazolam, nitrazepamand chloridazepoxide ! Comorbid substance-use disorders were not detected !
AD vs AD+BZD in short-term treatment of major depression
• Meta-analysis of 9 RCTs (1979-1998,n=679, in-and outpatients with MDD)
• In the AD+BZD group (vs AD+PLAC group):fewer drop-outs (- 37%)more early responders at (+ 41-63%)
• Comparing with AD + PL group responders in the AD+BZD group:
week 1 + 63%week 2 + 41%week 4 + 38%week 6-8 + 6%
Furukawa et al. J. Affect. Disord.2001,65:173-7.
Fluoxetine vs fluoxetine + clonazepam in short-term treatment of major
---------------------------------------------------------------Smith et al. J. Affect. Dis. 2002,70: 251-259.
Insomnia, major depression and suicide
• In patients with MDE insomnia is a powerful suicide risk factor
• In patients with MDE hypersomnia is a suicide protective factor
Fawcett et al, Amer J Psychiat, 1990; 147: 1189-1194.Taylor et al, Behav Sleep Med, 2003; 1: 227-247.McGirr et al, J Affect Disord, 2007; 97: 203-209.
McGirr et al, J Affect Disord, 2007; 97: 203-209.
Evaluation of the HAM-D17 following eszopiclone treatment in patients with
insomnia co-morbid with major depressive disorder or GAD (n=545)
• Conclusions: „Treatment of insomnia with eszopiclone co-therapy was associated with significant improvement in HAM-D17 scores relative to fluoxetine or escitalopram monotherapy in patients with insomnia comorbid with MDD or GAD, even after removal of insomnia items from the scale”
Montgomery et al, Int. J. Psychopharmacol, 2008; 11: S1, p.306.
• Fluoxetine + eszopiclone therapy in major depression resulted in significantly higher response/remission rates than fluoxetine monotherapy. This beneficial effect was more than the simple reflexion of improved sleep.
Fava et al, Biol Psychiat, 2006; 59: 1052-1060.
Fava et al, Biol Psychiat, 2006; 59: 1052-1060.
Zarate et al, Biol Psychiat, 2012; 71: 939-946.
___________________
Psychotherapy for depression, suicidality and hopelessness
and hopelessness• Suicidality (and hopelessness) in
depressed patients can not be significantly reduced with psychotherapy for depression
Cuijpers et al, J Affect Disord, 2013; 144: 183-190.
Antidepressants, psychotherapy and suicidality in pediatric depression (FDA RCTs)
Rate of suicide attempt and ideation (there were no completed suicides in these trials)
*Whittington et al., Lancet, 2004, 363, 1341-1345**Bridge et al., Amer J Psychiat, 2005, 162, 2173-2175
%
Antidepressants* (n=1208)
Placebo* (n=1054)
Psychotherapy** (n=88)
15
10
54.7%
2.4%
12.5%
The role of GPs in suicide prevention
• The majority of depressives areseen/diagnosed /treated by GPs
• GP contact is very common (40-60%) 4 weeks before the suicide
• The rate of recognized/treated depression in primary care is quite low (20-50%)
Luoma et al, Amer J Psychiat, 2002; 159: 909-916.Berardi et al, Psychother Psychosom, 2005; 74: 225-230.
Rihmer, Curr Opin Psychiat, 2007; 20: 17-22.
The Gotland Study
13
11 11
54
10
13
10
1312
9
56
109
0
2
4
6
8
10
12
14
1981 82 83 84 85 86 87 88 89 90 91 92 93 94 95
Number of suicide victims on Gotland between 1981-1995
Mean number of victims between 1969–1980: 14.5 (8–20)
Rutz et al., IJCP, 1997; 1: 39–46
GPeducation GP
education
ADs: 1981= 5.8 � 1996 = 28.9 DDD/1000/year (5 x)
620
183
0
100
200
300
400
500
600
700
2000 2000
500
182
2001
-19,4%
-0,01%
2001
471
196
2002
Chi² (one-tailed):2000 versus 2001; p< 0,052000 versus 2002; p< 0,012000 versus 2003; p< 0,01
-24,0%
+7,7%
2002 2003
173
-5,5%
2003
420-32,2%
The Nuremberg StudySuicidal acts, Nuremberg - Wuerzburg
Sui
cida
lact
s
Nuremberg (intervention) Würzburg (cotrol)
Baseline, intervention and follow up
Hegerl et al, Psychol Med, 2006; 36: 1225-1234.
The Jamtland Study
Jamtland Sweden• Mean suicide rate’
1970 - 1994 27.7 25.01995 - 2002 17.3 17.6
change - 36% - 30%• Antidepressants’’
1995 21.6 27.52002 56.4 57.2
change + 161% +108%
Henriksson and Isacsson, Acta Psychiat Scand, 2006, 114: 159-167.
‘ per 100.000/year, ‘’ DDD/1000 persons/day
N
50
40
30
’96 ’97 ’98 ’99 ’00 ’01 ’02 ’03 ’04 ‘05
36
50
41
51
4243
34
42
37
30
N
50
40
30
’96 ’97 ’98 ’99 ’00 ’01 ’02 ’03 ’04 ‘05
36
50
41
51
4243
34
42
37
30
The Hungarian GP-based suicideprevention study
Before GP trainingmean 44,0 / year
After GP trainingmean 37,2 / year
Before GP trainingmean 44,0 / year
After GP trainingmean 37,2 / year
- 15 %
x
x
x
x
x
x
x
Szántó et al,AGP, 2007:64. 914-920.
(+ 34 lifes)
10.6
30.4
N
50
40
30
’96 ’97 ’98 ’99 ’00 ’01 ’02 ’03 ’04 ‘05
36
50
41
51
4243
34
42
37
30
Yearly number of suicides and ADs in Kiskunhalas region (1996 – 2000 vs 2001 –
2005)
Before GP training mean 44,0 / year
After GP training mean 37,2 / year
- 15 %
10.6x
30.4x
x
x
x
x
x
(+34 lifes)
Szántó et al,AGP, 2007:64: 914-920.
ADs(DDD/1000/day)
The role of psycho-social interventions in suicide prevention
Standard psychotherapy plus intensive care for suicide attempters - RCT
ATTEMPTERS CONTR
(N=258) (N=258)
• Suicide attempt rate 7,7 13,9x
at month 12, (%)
• Suicide rate 3,1 3,6
at month 12, (%)
• Suicide or suicide attempt 10,7 17,4xx
rate at month 12, (%)
x p = 0,07 xx p = 0,056van Heeringen et al: Psychol.Med. 25:963-970, 1995
January 2008Danuta Wasserman 35
WHO Brief intervention and contact study -
18-month follow-up• RCT multi-center based intervention study SUPRE-MISS (2002-
2005)
• BIC = An 1 hour consultation in combination with discharge after a suicide attempt and afterwards nine further follow-up contacts – 1,2,4 7,11 weeks, and 4,6,12 och 18 months after a suicide attempt - with a doctor, psychologist or nurse
1867 suicide attemptpatients after randomisation
TAU = 945Treatment as usual
BIC = 922(Brief intervention and contact) +TAU
Fleischmann et al, Bulletin of the WHO, 2008; 86: 703-709.
Suicide:N = 18,2.2 %
Suicide:N = 2,0.2 %
Suicide prevention strategies –Competence of healthcare (2)
II. Public-oriented prespective (targetinggeneral population/specific subpopulations)
• Community suicide prevention programs -Gatekeeper training (GPs, teachers, priests,social workers, civil organizations..)
• Decresig negative attitudes regarding mental disorders and suicide and showing that mental illnesses can be successfully treated and suicide is preventable
To implement the 4 level approach, you need a local/regional network
Association ofmedical doctors
PsychiatricHospital
Psychotherapists
GeneralPractitioners
Health insurancefunds
Schools
Churches andsocial services
Police/Military Forces Local health
authorities
Crisisintervention
centres
Self-helf groups
Geriatric care
Hegerl, 2010
Non-pharmacological health-care interventions for reducing suicide risk
• Crisis intervention• Intensive aftercare of suicidal patients• Problem-solving psychotherapy• TeleHelp-TeleCheck services• Decreasing access to means• Appropriate media policy
King et al, Brit J Psychiat, 2001; 178: 531-536.Motto and Bostrom, Psychiat Serv, 2001; 52: 828-833.Van Heeringen et al, Psychol Med, 1995; 25: 963-970.Linehan et al, Arch Gen Psychiat, 1993; 50: 971-974.DeLeo et al, Brit J psychiat, 2002; 226-229.
Rates of Suicide Attempts During 4 Weeks After Initial Antidepressant Prescriptiona
aBars indicate 95% confidence intervals.
Simon et al., Amer J Psychiat 2006, 163:41-47
Suicide attempts 4 weeks after starting ADs
Rates of Suicide Attempts During the 4 Weeks Before and 4 Weeks After Initial Antidepressant Prescriptiona
aBars indicate 95% confidence intervals.
Suicide attempts 4 weeks before and after starting ADs
Simon et al, Amer J Psychiat, 2006; 163: 41-47.
Why suicidal behaviour in depressed patients receiving ADs is still high in the
first few days/weeks of the AD treatment ?
• Lack of action of ADs (no change or spontaneous worsening of depression)- Resolution: close observation, removing lethal means, crisis intervention, anxiolysis, sedation (sleep !, BZPs), lithium, 2GAPs
• Worsening of depression due to AD in (potentially) bipolar depressives via inducing and/or aggravating depressive mixed states/agitation- Resolution: co-therapy: MSs, BZDs, 2GAPs
(quetiapine, olanzapine, MSs alone or in combination)
Why is suicide mortality still so high in the population?
• Low proportion of depressed/psychiatric patients are treated
• High rate of nonadherence• Lacking psychoeducation/psychotherapy• Low access to healthcare in some countries or
subpopulations• Increasing negative public attitude regarding
psychiatry, depression, and antidepressants• Internet propagation of suicide (!)• Increasing alcohol consumption• Negative psycho-social factors (unemployment) show
increasing tendency• Media coverage of mental disorders/suicide is not
optimal
Suicide rates and antidepressants in Italy and Hungary
6 x
- 51%
- 25%3 x
Gusmao et al, PLoSOne, 2013
Antidepresants and suicidal behaviour
Antidepressants and suicidality in adult population – RC drug trials
In the cases of unrecognized/covert bipolarity, antidepressant monotherapy (unprotected by mood-stabilizers or atypical antipsychotics) in „unipolar” depression can result in:
Hantouche et al. J Affect Disord, 2005, 84: 243-249.
Antidepressants and suicidal behaviour in RCTs on unipolar
depression
EXCLUDED:Acutely suicidal, very severe, comorbid,noncompliant, and officially (DSM-IV orICD-10) diagnosed Bipolar I and II pts
INCLUDED:Subsyndromal bipolar, and bipolar spectrum disorder patients, and agitated depressives resulting in about 30 % covert bipolarity in these „unipolar” patients
x therefore no detectable anti-suicidal effect is expected
x
%30
20
10
3%1.5%
Suicidality (attempts + suicides) and AD treatment in UP MDE
RCTsExcl. suic. pts
+100%
Before/without ADs
On ADs
%30
20
10
30%
3%1.5%
6%
Real life studiesIncl. suic. pts
RCTsExcl. suic. pts
-80%
+100%
Before/without ADs
On ADs
Suicidality (attempts + suicides) and AD treatment in UP MDD
Conclusions
• Untreated major mood disorders (schizophrenia and substance-use disorders) markedly increases the risk of suicidal behaviour particularly in severe bipolar (mixed) depresion
• As the majority of mood disorder patients never complete suicide, other (personality and psychosocial) factors play also a role
• Suicide risk factors are additive in their nature• Suicide risk is predictable with good chance• Effective acute and long-term treatment of psychiatric patients
(Li, MS, ADs, APs, ANXLs) significantly reduces the risk of suicidal behaviour
• MS is the key component in the acute and long-term treatment of bipolar disorders
• AD monotherapy in bipolar depression (incl. subthreshold forms) can worsen depression and resulting in suicidal behaviour
• Supportive psychotherapy is allways needed and supplementary specific psychosocial interventions further improve the results