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basic principles and best practices in prevention of suicides among adolescents. Marco Sarchiapone Department of Health Sciences, University of Molise [email protected] I declare no conflict of interest regarding this presentation. introduction. Suicidal behaviour includes:

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Basic principles and best practices in prevention of suicides among adolescents

basic principles and best practices in prevention of suicides among adolescents

Marco Sarchiapone

Department of Health Sciences, University of Molise

[email protected]

I declare no conflict of interest regarding this presentation

I suicides declareno conflict of interest regarding this presentation

Master Class

introduction suicides

  • Suicidal behaviour includes:

    • suicidal thoughts (suicidal ideation)

    • attempted suicide

    • suicide

  • Suicide can occur at any age

  • Youth suicide is an increasingly important public health issue that impacts many adolescents, their families and communities

  • In order to develop effective prevention programs we need to know on what risk and protective factors we can act

Master Class

Suicidal behaviour is multidetermined
Suicidal Behaviour is Multidetermined suicides

  • Suicidal behaviour, as well as other human behaviours and psychiatric disorders, is a complex phenomenon determined by the action of several bio-psycho-social factors

  • A useful model for describing and studying suicidal behaviors is the Multifactorial Model of diseases

  • This will lead us to define outline a “map” of risk and protective factors of a subject towards suicide

Master Class

Stress diathesis model

  • Predisposing or distal risk factors for suicidal behaviours constitute a basis on which potentiating or proximal risk factors act as a trigger for suicidal behaviours (Mośckici, 1997)










Master Class

Suicidal threshold
Suicidal threshold suicides






Non vulnerable




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Magnitude of the problem
Magnitude of suicides the problem

  • Almost one million people die each year of suicide

  • Annual global mortality rate of about 14.5 per 100,000 or one death about every 40 seconds

  • For every completed suicide, there are estimated 10-20 suicide attempts made

  • The real number of suicides is higher than the statistics show

Master Class

Magnitude of the problem1
Magnitude of suicides the problem

  • According to WHO, suicidal thoughts and behaviours are increasing in Western countries, especially in Europe

Master Class

Magnitude of the problem2
Magnitude of suicides the problem

  • The frequency of suicidal behaviour escalates steeply from childhood through middle to late adolescence and into adulthood, with suicide rates peaking in the 19- to 23-year-old population

  • At least 100,000 adolescents commit suicide every year

  • The act of deliberate self-harm in children and adolescents is frequently impulsive, and in many cases, they do not intend to die

  • Youth frequently explain their actions in terms of wanting to stop unbearable feelings or escape from a painful situation

Master Class

Suicidal ideation
Suicidal ideation suicides

  • Between 3.5% and 52.1% of adolescents report suicidal thoughts (Diekstra et al., 1995)

  • 13.8% of students had seriously considered attempting suicide and about 10.9% had made a plan to attempt suicide, during the 12 months before the survey (Youth Risk Behaviour Survey, 2009)

  • Suicidal ideation is both associated with and predictive of psychopathology, especially mood, anxiety, and substance use disorders, among adolescents as well as older age groups (Reinherz et al., 2006)

  • Adolescent suicidal ideation has been linked to deficits in behavioural and emotional functioning (e.g., low self-esteem, depressive symptoms) in adolescence, extending into young adulthood (Reinherz et al., 2006)

Master Class

Suicidal ideation1
Suicidal suicides ideation

  • Precursors of suicidal ideation (McGee et al., 2001):

  • Boys: hopelessness, dependence, and poor social/emotional adjustment

  • Girls: family discord, early behavioural problems, and poor perception of family roles

  • Substance use or separation anxiety may provoke adolescent ideators of both sexes to attempt suicide

  • Mood and anxiety disorders increase the risk of suicidal ideation: panic attacks are a risk factor for ideation or attempt in females, while aggressiveness increases the risk of suicidal ideation or attempt in males

  • In contrast to other adolescents with suicidal ideas, those who attempt suicide have more severe feelings of hopelessness, isolation, and suicidal ideation and are reluctant to discusstheirsuicidalthoughts(Shaffer et al., 2001)

  • Master Class

    Attempted suicide
    Attempted suicide suicides

    • Non-fatal suicidal behaviour is more prevalent among younger people than among older people

    • The ratio of fatal to non-fatal suicidal behaviour in people under 25 years is usually estimated to be of the order of 1:100–200(McIntire et al., 1981)

    • 6.3% of students had attempted suicide one or more times and 1.9%reported a suicide attempt that required medical care, during the 12 months before the survey (YRBS, 2009)

    • More than half of those attempting suicide made more than one attempt

    • Over 10% of teenagers have made repeated suicide attempts within the first year after an attempt and the repetition rate increases to 20% over 7 years (Hultén et al., 2002)

    Master Class

    Attempted suicide1
    Attempted suicide suicides

    • A previous suicide attempt is in itself the strongest predictor of future suicide

    • Previous suicidal experience sensitizes suicide-related thoughts and behaviours, such that these later become more accessible and active

    • Attempts by unusual methods and medically serious attempts are predictive of further suicide attempt behaviour and seem to be predictive of completed suicide (Beck et al., 1974)

    • Local rates of attempted suicide and regional and national suicide rates in young people are strongly correlated (Hawton et al., 1998)

    • There is an association between repeated suicide attempts and completed suicide, particularly in males and when a violent method has been used (Hawton, 1993)

    Master Class

    suicide suicides

    • Suicide ranks as the second cause of death after traffic accidents and other injuries in the ages 15-19

    • In Europe each year, approximately 13,500 young men and women aged 15-24 years die by suicide

    • Several birth cohort analyses have reported an increase in risk for later birth cohorts, particularly among young males

    • Suicide in adolescence is estimated to be under-reported by around 30% or more

    Master Class

    Trends in suicide rates in adolescents
    trends in suicide suicides rates in adolescents

    Shaffer, D., Gould, M., & Hicks, R. (2007). Teen Suicide Fact Sheet.

    Master Class

    Sociodemographic characteristics
    Sociodemographic characteristics suicides

    Adolescent suicide attempters who are at greater risk for suicide are:

    • Older (16 to 19 years old)

    • Male

    • Adolescents (of either sex, regardless of age) with a current mental disorder

    • Especially when complicated by comorbid substance abuse, irritability, agitation, or psychosis

    • Those who have made previous suicide attempts and persist in wanting to die

      (Shaffer, 2001)

    Master Class

    Gender differences
    Gender differences suicides

    • Suicide is much more common in adolescent and young adult males than females (5.5:1 in 15- to 24-yearolds)

    • Suicide attempts are more common in girls than boys (1.6:1)

    • Completed suicide is more common in the male population in the United States, western Europe, Australia, and New Zealand, but suicide rates are equal between the sexes in some countries in Asia and more common in the female population in China and India (Gould et al., 2003; IASP, 1999)

    • Sex differences between completed suicides and suicide attempts can be explained by sex differences in methods (Beautrais, 2003)

    • There may be gender-specific patterns of early risk factors and/or developmental pathways associated with suicidal ideation and behaviour in adolescence and young adulthood

    Master Class

    Risk factors for suicide in adolescents
    Risk factors suicides for suicide in Adolescents





    • Neurobiological risk factors

    • Family history of suicide

    • Psychiatric disorders

    • Substance use/abuse

    • Impulsive/aggressive behaviours

    • Childhood trauma

    • Stressful life events

    • Availability of means

    • Physical illness

    • Grief

    • Acute phases of psychiatric disorders

    • Risk taking behaviours

    Master Class

    Impulsivity and serotoninergic system

    Asberg et al., 1976

    5-HIAA in the cerebrospinal fluid. A biochemical suicide predictor?

    Arch Gen Psychiatry 33(10):1193-7

    Linnoila & Virkkunen, 1992

    Aggression, suicidality, and serotonin

    J Clin Psychiatry


    Virkkunen et al., 1995

    Low Brain Serotonin Turnover Rate (Low CSF 5-HIAA) and Impulsive Violence

    J Psychiatry Neurosci 20(4): 271-5

    Low brain serotonin turnover, as indicated by low cerebrospinal fluid (CSF) 5-hydroxyindoleacetic acid (5-HLAA), is associated with increased impulsiveness, impaired control of aggressive behaviors and suicide attempts

    Master Class

    Candidate gene approach
    Candidate gene approach suicides

    • Candidate gene approach studies in suicidal behaviour aimed at identifying associations between specific polymorphisms of genes related with serotonergic transmission and suicidal behaviour

    Master Class

    Family adoption and twin studies

    Suicidal behavior aggregates within families:

    • Schulsinger et al., 1979:

      • A six-fold higher rate of suicidal behavior in the biological relatives of adoptees who committed suicide

      • Absence of suicidal behavior among the adoptive relatives of the person who committed suicide versus control adoptees

    • Roy, Sarchiapone and Segal, 1999:

      • Increased concordance for suicidal behavior in MZ versus DZ twins (18% versus 0.7%)

    Master Class

    The hemingway family

    Master Class

    The hemingway family1

    Grace Hall

    B. 1872

    D. 1951

    Clarence Edmonds Hemingway

    B. 1871

    D. 1928

    Marcelline Hemingway

    B. 1898

    D. 1963



    B. 1902

    D. 1966

    Ernest Miller


    B. 1899

    D. 1961



    B. 1911

    D. 2002



    B. 1904

    D. 1995

    Leicester Clarence


    B. 1911

    D. 2002

    John Hadley

    Nicanor Hemingway

    B. 1923

    D. 2000



    B. 1928

    Gregory Hancock


    B. 1931

    D. 2001




    B. 1950

    Margot (Margaux)


    B. 1955

    D. 1996




    B. 1961

    Master Class

    Familial transmission
    Familial transmission suicides

    • Besides the genetic component, familial clustering of suicidal behaviour may be due to transmission through environmental conditions (i.e. poor and inappropriate parenthood, family disruption, child abuse and neglect)

    • The risk of suicide attempt in adolescents and young adults tends to be associated with familial psychopathology, particularly substance abuse, affective, neurotic and personality disorders (Mittendorfer-Rutz et al., 2008)

    • The risk of suicide attempt tends to be associated with familial suicidal behaviour, primarily familial suicide attempt (OR 2.3-5.8) (Mittendorfer-Rutz et al., 2008)

    Master Class

    Familial transmission1
    Familial suicides transmission

    • Association between disrupted family background and the risk for suicide

    • Positive association of divorce rate with suicide rates in youth

    • Lone parenthood linked to an increase in suicide mortality and morbidity in offspring

    • Suicide victims communicate less often and less fully with their parents than control teens (Shaffer et al., 2007)

    Master Class

    Psychiatric disorders
    Psychiatric disorders suicides

    • More than 90% of adolescents who commit suicide suffered from an associated psychiatric disorder at the time of their death. More than half had suffered from a psychiatric disorder for at least 2 years (Shaffer et al., 2001)

    • Youth suicide almost always occurs in the context of an active, often treatable, mental illness that has frequently gone unrecognized or untreated (Shaffer et al., 2004; Brent et al., 1999)

    • The most common forms of psychiatric disorder found in completed suicides are some form of mood disorder and substance and/or alcohol abuse

    • Comorbidity between different disorders is common

    Master Class

    Psychiatric diagnoses in child and adolescent suicides
    Psychiatric Diagnoses in Child and Adolescent Suicides suicides

    Shaffer, D., Gould, M., & Hicks, R. (2007). Teen Suicide Fact Sheet.

    Master Class

    Alcohol and substance abuse
    ALCOHOL AND suicides substance ABUSE

    • Increasing alcohol use among adolescents is one important risk factor contributing to the rise of suicidal behaviour among young adults (Sher et al., 2006)

    • Substance use is associated with suicidality (Sher & Zalsman, 2005; Swahn & Bossarte, 2007) and is an important risk factor of attempted and completed suicide (Fleming et al., 2007; Galaif et al., 2007)

    • Suicide attempters are more likely to have substance abuse/dependence disorders than suicidal ideators, suggesting that substance use may facilitate the transition from ideation to behaviour(Gould et al., 1998)

    Master Class

    Psychosocial stressors
    Psychosocial Stressors suicides

    • The suicide is often preceded by a stress event (i.e. getting into trouble at school, a ruptured relationship with a boyfriend/girlfriend, or a fight among friends)

    • Low levels of communication between parents and children may act as a significant risk factor (Gould et al., 1996; Hollis, 1996)

    • It also appears that a suicide can be precipitated by exposure to news of another person’s suicide

      • The most frequent problems underlying suicidal behaviour among adolescents are relationship difficulties with parents, problems with friends, and social isolation (Hawton et al., 1996)

      • Family, school, and peer conflicts play a major role during childhood and early teens, and the effect of major mental illness comes on later

    Master Class

    methods suicides

    • The methods used to commit suicide show great geographic variation and this may reflect availability

    • Shift to suicide methods with higher lethality for both genders

    • Boys:

      • hanging, vehicle exhaust gas, firearms, and jumping

      • Girls:

      • self-poisoning, a method which, while it may have high toxicity, tends to have low lethality and a relatively slow rate of action

      • If women were to adopt more lethal methods, then the female suicide rate may approach or even exceed the male suicide rate (Beautrais et al., 2003)

    Master Class

    Risk taking behaviours
    Risk taking behaviours suicides

    • Risk-taking behaviours may be considered as suicidal equivalents

    • In the United States, 74% of all deaths among youth aged 10–24 years result from four causes: motor-vehicle crashes (30%), other unintentional injuries (16%), homicide (16%), and suicide (12%) (Eaton et al., 2010)

    • Recent research showed a link between unhealthy behaviours and suicidal behaviour(Wasserman, 2001)

    • Teens engaging in risk behaviours are at increased odds of depression, suicidal ideation, and suicide attempts (Hallfors et al. 2004)

    • Early alcohol onset, having had sex before age 13, injection drug use, smoking, fighting and being forced to have sex are all critical behaviours associated with suicidality (Epstein & Spirito, 2010)

    Master Class

    Risk taking behaviours1
    RISK TAKING behaviours suicides

    • HIV related risky sexual behaviours (being forced to have sex, having sex with more than 4 people in the past 12 months, use of alcohol before sex and no regular use of condom) are strong predictors of suicidal ideation and attempt (Epstein & Spirito, 2009)

    • Suicide ideation and suicide attempts have been associated with both occasional, regular smoking and nicotine dependence (Bronisch et al., 2008)

    • Suicidal behaviours are associated with extreme and less extreme weight control behaviours (Crow et al., 2008)

    • Frequent exposure to victimization or bullying others are related to high risk of depression, ideation and suicide attempts (Klomek et al., 2009)

    Master Class

    Risk taking behaviours2
    Risk taking behaviours suicides

    • Risk behaviors are significantly correlated with one another and often appear in clusters (Winters et al., 2009; Flisher et al., 2000)

    • Mazur et al. (2004) described a “risk behaviour syndrome” involving psychoactive substances abuse, early sexual initiation and frequent contact with violence

    While a close relation exists between unhealthy behaviours and suicide it is possible tohypothesize that preventive interventions designed to identify and refer subjects with suicidal risk could have an impact on a wider range of unhealthy behaviours

    Master Class

    High risk factors for suicide in adolescents
    High-Risk Factors for Suicide in Adolescents suicides

    • Suicidal behaviour rarely occurs in isolation and is often associate to:

      • Mental health problems

      • Risk taking behaviours

      • Immediate risk predicted by agitation and major depressive disorder

    • Among males:

      • Previous suicide attempts

      • Age 16 or older

      • Associated mood disorder

      • Associated substance abuse

    • Among females:

      • Mood disorders

      • Previous suicide attempts

        (Shaffer et al., 2007)

    Master Class

    Presence of Suicide Risk Factors Among Subjects Under 25 Years of Age Who Did or Did Not Make a Serious Suicide Attempt

    Beautrais, A. L. (2003). Suicide and serious suicide attempts in youth: a multiple-group comparison study. The American Journal of Psychiatry, 160(6), 1093-1099

    Master Class

    Protective factors
    Protective factors Years of Age Who Did or Did Not Make a Serious Suicide Attempt




    • A sense of personal value

    • Confidence in oneself and one’s own situation and achievements

    • Seeking help when difficulties arise

    • Seeking advise when important choices must be made

    • Openess to other people’s experiences and solutions

    • Openess to learning

    • Good family relationships

    • Support from family

    • Devoted and consistant parenting

    • Good diet and sleep

    • Sunlight

    • Physical excercise

    • Non-drug, non-smoking environment

    Master Class

    Protective factors1
    Protective factors Years of Age Who Did or Did Not Make a Serious Suicide Attempt

    • Religious beliefs might have a protective effect on suicidality and depression (Miller & Gur, 2000)

    • Borowsky et al. 2001:

      • Perceived parent and family connectedness was protective against suicide attempts for girls and boys (OR = 0.06-0.32)

      • Boys: high grade point average

      • Girls: emotional well-being

      • The presence of 3 protective factors reduced the risk of a suicide attempt by 70% to 85% for each of the gender, including those with and without identified risk factors

    • Promotion of protective factors may offer an effective approach to primary as well as secondary prevention of adolescent suicidal behavior

    Master Class

    What can be done to prevent suicidal behaviour among youngsters
    What can be done to prevent suicidal behaviour among youngsters?

    • Schools are one of the most important settings for health promotion and preventive interventions for young people (WHO, 2004)

    • Several promising empirically based school prevention strategies have been identified

    • The treatment and prevention actions targeting adolescents who display risk behaviours or attempt suicide in the EU are not sufficiently based on scientific evidence

    • Acute need of exhaustive research data and clear evaluation criteria of what kind of health interventions are evidence-based and cost-effective

    Master Class

    Strategies in suicide prevention
    Strategies in youngsters?Suicide Prevention

    • Health Care Perspective

      • Pharmacotherapy

      • Psychotherapy

      • Follow-up care after suicide attempts

    • Public Health Perspective

      • Awareness and Education

      • MEDIA reporting

      • Means restriction

      • Screening

    Master Class

    Strategies in suicide prevention1
    Strategies in youngsters?Suicide Prevention


    • everyone in a defined population


    • subgroups at particular risk for suicide


    • specific individuals at high risk

    Master Class

    School based suicide prevention strategies
    School- youngsters?based suicide preventionstrategies


    Education and awareness programs


    Screening for individuals at risk

    Master Class

    Skills training example 1
    SKILLS youngsters?TRAININGexample 1

    • Good Behavior Game (GBG) (Barrish et al., 1969; Wilcox et al., 2008)

      • To socialize children of elementary schools into the role of student and to teach them to regulate their own and their classmates’ behaviour through a process of interdependent team behaviour–contingent reinforcement

      • To reduce early aggressive, disruptive behaviour at the classroom level and at the individual level, a frequently reported antecedent of later problem outcomes

    • By young adulthood significant impact was found among males, particularly those in first grade who were more aggressive, disruptive, in reduced drug and alcohol abuse/dependence disorders, regular smoking, and antisocial personality disorder

    • GBGhad an impact on suicide ideation and suicide attempts among both genders

    Master Class

    Skills training example 2
    SKILLS youngsters?TRAININGexample 2

    • Sources of Strength Suicide Prevention Program (Wyman et al., 2010)

      • To build socioecological protective influences across a full student population

      • Youth opinion leaders are trained to change the norms and behaviours of their peers by conducting well-defined messaging activities with adult mentoring

    • Training improved the peer leaders’ adaptive norms regarding suicide, their connectedness to adults, and their school engagement, with the largest gains for those entering with the least adaptive norms

    • Trained peer leaders were 4 times as likely as were untrained peer leaders to refer a suicidal friend to an adult

    • The intervention increased perceptions of adult support for suicidal youths and the acceptability of seeking help

    Master Class

    Case finding example 1
    CASE youngsters?FINDINGexample 1

    • Columbia Suicide Screen (CSS) (Shaffer et al., 2004; Scott et al., 2009)

      • 11-item self-report questionnaire embedded within a health survey, measures suicidal ideation in the preceding 3 months, history of suicide attempts and problems associated with feeling unhappy or sad, irritable, anxious, or socially withdrawn and with using alcohol or drugs in the preceding 3 months

    • School-based screening improves identification of students at the highest risk for suicide, and it also improves identification of students with lesser mental health problems (suicidal ideation, previous suicidal behavior, internalizing disorders)

    • In the absence of screening, a large proportion of students with serious mental health problems would go undetected by school staff and mental health providers as well

    Master Class

    Case finding example 2
    CASE youngsters?FINDINGexample 2

    • Gatekeeper Training (Wyman et al., 2008)

      • Question, Persuade, Refer (QPR) training thatinclude information onrates of youth suicide, warning signs and risk factors for suicide and procedures for asking a student about suicide, persuading to get help and referring a student for help

    • The largest impact from training was to raise school staff members’ appraisals of their preparation and efficacy to perform a gatekeeper role and of their access to services for suicidal students

    • Appraisals increased most for staff with lowest baseline appraisals and suicide identification behaviours

    • With respect to knowledge, training had a medium-size effect on increasing participants’ accuracy to identify warning signs and risk factors for youth suicide and recommended QPR intervention behaviours

    • Training increased the number of staff queries of students about suicide but only for the 14% of staff already communicating with students about suicide before training

    Master Class

    Combined programs example 1
    Combined youngsters?programsexample 1

    • Lifelines(Kalafat et al. 2003)

      • It includes gatekeeper training, such as teachers, school staff and parents, as well as curriculum for students: teaching students to seek adult help for troubled peers, and also increasing the likelihood that these gatekeepers identify, engage and obtain help for at-risk youth

    • Lifelines may increase students’ expressed intent to tell an adult about an at-risk peer

    Master Class

    Combined programs example 2
    Combined youngsters?programsexample2

    • Signs of Suicide (SOS) (Aseltine and DeMartino, 2004)

      • A2-day schoolbased intervention which includes:

      • An educational curriculum (via video and group discussion) in which the students learn the acronym ACT: Acknowledging the signs of suicide that others display; letting the other know you Care and want to help; and Telling a responsible adult

      • Abrief anonymous self-screening for depression and other risk factors associated with suicide. The students evaluate their own level of risk and depending on their score on the screen the students are provided instructions about seeking treatment

    • High satisfaction by school personnel and a short-term decrease in students’ suicide attempts; although neither help-seeking behaviour nor suicide ideation were affected

    Master Class

    School based suicide prevention strategies examples from italy and other eu countries
    School-based suicide prevention youngsters?strategies: examples from Italy and other EU countries


    Saving and Empowering Young Lives in Europe


    Working in Europe to Stop Truancy Among Youth


    Suicide Prevention by Internet and Media based Mental Health Promotion

    Master Class

    Master Class youngsters?

    Saving and empowering young lives in europe seyle

    • Randomized controlled trial of Mental Health promotion and suicide preventive interventions that is performed in the real world of European High Schools

    • Project Reference: 223091

    • Duration: January 2009 – December 2011

    • Project cost: € 5 Million

    • Co-funded by the EU, 7th Framework Programme (€ 3 Million)

    • Intervention in 11 countries

    • Sample: 12,395 pupils in the ages 14-15

    Master Class

    Seyle objectives
    SEYLE youngsters?Objectives

    Master Class

    Seyle study design
    SEYLE youngsters?Study design

    Master Class

    Baseline evaluation
    Baseline Evaluation youngsters?

    • A comprehensive evaluation questionnaire aimed at evaluating students’ lifestyles, coping styles, at-risk truancy, mental health, self-harm behaviours and suicidality

    • It include:

      • WHO Well-being Scale (WHO-5)

      • Beck Depression Inventory (BDI)

      • Paykel Suicide Scale (PSS)

      • Strengths and Difficulties Questionnaire (SDQ)

      • Global School-Based Pupil Health Survey (GSHS)

      • Deliberate Self-Harm Inventory (DSHI)

      • Young's Diagnostic Questionnaire (YDQ) for Internet Addiction

      • Questions from the European Values Study (EVS)

      • Specific items developed for the SEYLE study

    Master Class

    Arm 1 question persuade and refer
    Arm youngsters? 1 – question persuade and refer

    • Gatekeepers training and referral: training for teachers and school staff aimed at recognize adolescents at risk and teaching how to refer pupils exhibiting suicide warning signs and mental health problems to treatment

    • QPR Institute:

    • One single session training of two hours, administered to groups of 10-20 gatekeepers at every centre, in the 2 weeks prior to the start of the intervention

    • The first 45 minutes dedicated to a formal lecture using the QPR slides; the remaining time dedicated to role-play; discussion of feelings and emotions of the participants to the role-play session and the audience

    Master Class

    Arm 1 question persuade and refer1
    Arm 1 – question persuade and refer youngsters?

    • QPR booklet and business card with referral information handed out to teachers during the training session

    • QPR booklet themes:

      • QPR for Suicide Prevention

      • Who Needs to Know QPR?

      • Overcoming our Emotional Reactions to Suicide

      • Understanding Suicide

      • Clues to Suicide and When to Apply QPR

      • How to Ask the “S” Question

      • How to Persuade Someone to Get Help

      • How to Refer Someone to Help

      • Tips for Effective QPR

    Master Class

    Arm 2 awareness
    Arm youngsters? 2 - awareness

    • Awareness program with self referral: general health promotion program targeting students’ awareness on healthy/unhealthy behaviours

    • Intervention on groups of 25 pupils each (one class if possible)

    • Three sessions in 3 consecutive weeks, the first two of two school hours and the last of one school hour:

      • Week 1: Opening-Lecture and Role-play I session

      • Week 2: Role-Play II and III

      • Week 3: Closing-Lecture

    Master Class

    Arm 2 awareness1
    Arm youngsters? 2 - awareness

    • Standardised PowerPoint presentation includes the same content which is represented in the 6 posters hanged on the wall in each classroom and an awareness booklet “Affect and improve the way you feel” handed out to pupils:

      • Awareness of Mental health

      • Self-help advice

      • Stress and crisis

      • Depression and suicidal thoughts

      • Helping a troubled friend

      • Getting advice: who to contact

      • Role-play Themes:

      • Awareness about choices

      • Awareness about feelings and how to manage stress and crises situations

      • Awareness about depression and suicidal thoughts

    Master Class

    Arm 3 profscreen
    Arm youngsters? 3 - profscreen

    • Professional screening with referral: detection of unhealthy behaviours and mental health problems by utilizing the baseline questionnaire. Pupils who screen at or above the cut-off point were sent for professional clinical assessment, conducted by psychiatrists or clinical psychologist

    • To identify positive students, specified cut-offs were used about: depression, anxiety, suicidal tendency, non-suicidal self-injury, eating behaviour, sensation seeking & delinquent behaviours, substance abuse, tobacco, alcohol, illegal drugs, exposure to media, social relationships, bullying, school attendance

    • The recommendation for pupils to see a mental health professional or to participate to an healthy lifestyle group was made when one of the threshold values had been reached

    • Parents and youths who were referred to the healthcare services were contacted by the SEYLE facilitator in order to find out whether the appointment with the professional took place. If not, the necessary support to contact the healthcare service was provided

    Master Class

    Arm 3 control
    Arm youngsters? 3 - control

    • Control group with minimal intervention

    • 6 posters hanged on the wall in the classroom comprising the main points used in the awareness booklet and small business cards comprising the same contact information distributed to pupils

    • Pupils didn’t receive any additional education or programme

    • Pupils who, through these posters, self-recognize the need for help had the opportunity to contact a healthcare provider or a healthy lifestyle group

    Master Class

    Emergency cases
    Emergency youngsters?cases

    • Pupils were considered emergency cases if they responded:

      • “sometimes”, “often”, “very often” or “always” to the question “during the past two weeks, have you reached the point where you seriously considered taking your life or perhaps made plans how you would go about doing it?

      • and/or “Yes, during the past 2 weeks” to the question “Have you ever tried to take your own life?”

    • Pupils identified as emergency cases were immediately referred to the same clinical evaluation performed in Arm 3 (ProfScreen), regardless of the randomization procedure, and directed to health care services if necessary

    • These pupils anyway continued to participate in the intervention

    Master Class

    Second intervention and referral
    Second youngsters?interventionand referral

    • Facilitators served as contact points for adolescents in need of help, they didn’t perform any diagnostic or treatment activities, but their primary task was only to facilitate the referral process, encouraging the pupil to follow the referral program without forcing this process if refused

    • Facilitators regularly contacted pupils individuated as at risk in order to verify the referral process

    • Telephone calls every week in the first four weeks after referral, every two weeks in the following eight weeks and subsequently every month up to six months

    Master Class

    Preliminary data
    preliminary DATA youngsters?


      • Particularly high rates of alcohol related behaviours in Austria, Slovenia, Hungary and Germany

      • High rates of cigarettes smoking in Israel and Estonia

      • Use of drugs do not significantly differs across countries, though we can see highest rates in Slovenia and France

      • All risky behaviours are more frequent in males than females, with the exception of cigarettes smoking and rare-never use of condom


      • Germany, France and Israel seem to present higher level of suicidal ideation

      • Germany, France and Israel seem to have also higher rate of suicide attempts

      • Suicidal ideation as well suicidal attempts are more frequent in females than males

    Master Class

    Preliminary data1
    preliminary DATA youngsters?

    • Preliminary results of the 3-months and 12 months follow up after interventions show positive effects, in the total material on emotions (anxiety, depression and suicidal behaviours) but not on lifestyles

    • This could be partially explained by the fact that it is easier to influence emotions as those can probably be more controlled by the individuals, instead lifestyles are probably more influenced by the environment and peers and more difficult to change, when students are older

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    Master Class youngsters?

    Working in europe to stop truancy among youth we stay

    • Aim: to reduce truancy among European adolescents

    • Project Reference: 241542

    • Duration: May 2010 – June 2013

    • Project cost: € 4 Million

    • Co-funded by the EU, 7th Framework Programme (€ 3 Million)

    • Intervention in Estonia, Israel, Italy, Germany, Romania, Spain

    • Sample: 1,600 pupils in the ages 14-18 per country

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    Working in europe to stop truancy among youth we stay1

    • Truancy is a serious public health problem that affects adolescents from all countries around the world

    • Little is known on the short- and long-term outcomes of psychological variables associated to this phenomenon

    • Some researches indicate that the adolescents who truant often have behavioural problems and show signs of impulsivity, failure in schoolwork, low reading level and poor grades, related to a negative self-imagine and a low self-esteem (Mc Care, 2004; Lotz and Lee, 1999; Watkins and Watkins, 1994)

    • Some authors report a high correlation with somatic disorders, anxiety, depression, delinquent behaviour and substance abuse (Steinhausen et al.,2008)

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    We stay objectives
    We-stay youngsters?objectives

    Gather information on truancy on European adolescents

    Perform 3 intervention school-based programmes for adolescents with objectives to reduce truancy rates and improve mental health of students and compare the results with a control intervention

    Evaluate outcomes of all interventions, in comparison with a control group, from a multidisciplinary perspective including social, psychological and economical aspects

    Recommend effective, culturally adjusted models for preventing truancy and promoting mental health of adolescents in different European countries





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    We stay study design
    WE youngsters?-STAY STUDY DESIGN

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    We stay interventions
    We-stay youngsters?interventions

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    Suicide prevention by internet and media based mental health promotion supreme
    Suicide Prevention by internet and Media based mental health promotion (SUPREME)

    • Aim: the prevention of risk behaviors and mental health promotion through the use of mass media and internet

    • Project Reference: 101159-2009

    • Duration: September 2010 – 2013

    • Co-funded by the EU, DG SANCO (€ 780.000,00)








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    Suicide prevention by internet and media based mental health promotion supreme1
    Suicide Prevention by internet and Media based mental health promotion (SUPREME)

    • Some web-sites on young unease, managed by mental health professionals, produced encouraging results about their use in prevention of risk behaviours (Calear et al., 2009; Gilat & Sahar, 2009)

    • The use of some social network, with no specific objectives regarding mental health, have been shown to increase well-being, especially in youth with low self-esteem and low life-satisfaction (Ellison et al. 2009)

    • A lot of adolescents, who suffer from social isolation, use internet to face their loneliness and social exclusion; youth at-risk of suicide spend a lot of time using internet to seek peer-to-peer communications and anonymous professional support platforms (Harris et al., 2009)

    • Internet and media can be used how efficient instruments to spread information among adolescents and to promote programs aimed to improve their mental health and well-being

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    Supreme objectives
    SUPREME promotion (SUPREME)objectives

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    Supreme interventions
    Supreme promotion (SUPREME)interventions

    • Creation of a highly interactive web-site targeted at adolescents and young adults in the age group 14-24

    • Adolescents will take an active part in the construction of the web-site and in the evaluation process of its usability, usefulness and attractiveness, they will be asked to participate in forum, create discussions and assess whether, due to the existence and use of a web-site, they feel less frightened about their emotions and feelings

    • Two schools will be selected and assigned to these two different intervention conditions:



    • The presentation of the web-site, the management of its sections and the interventions to promote mental health will be conducted directly by students with the supervision of teachers and the mental health professionals

    • The presentation of the web-site, the management of its sections and mental health promotion interventions will be conducted directly by mental health professionals

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    Conclusions some limitations
    CONCLUSIONS: promotion (SUPREME)Some limitations

    • Most of what we know about suicide prevention comes from a limited sample of world cultures, wealthy countries with relatively extensive mental health services

    • Most research has focused on the role of health professionals in identifying and managing risk, but little attention has been given to the role of significant others during a suicidal crisis

    • Most studies show results on participants who accept and observe the interventions, but little is known about people who do not seek, use and comply with treatment

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    Conclusions strategies for an effective plan

    • To promote better life opportunities in order to support the groups that are most at need;

    • To minimize alcohol consumption in target and high-risk groups;

    • To reduce the availability of means to commit suicide;

    • To educate gatekeepers about effective management of persons with suicide risk;

    • To support medical, psychological and psychosocial services in preventing suicide;

    • To disseminate knowledge about evidence-based methods for reducing suicide;

    • To raise the competence of health care personnel;

    • To systematically analyse all suicides which occur;

    • To support voluntary organizations

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    Basic principles and best practices in prevention of suicides among adolescents1

    basic principles and best practices in prevention of suicides among adolescents

    Marco Sarchiapone

    Department of Health Sciences, University of Molise

    [email protected]

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    Master Class suicides among adolescents