Effects of a stigma reduction intervention on help-seeking behaviors in university students: A 2019-2021 randomized controlled trial

INTRODUCTION

Stigma is one of the most frequently identified help-seeking barriers, but there is a lack of research on the effects of stigma reduction interventions on actual mental health help-seeking behaviors during crucial academic years. This research explores the effects of stigma on university students' mental health care help-seeking behaviors before and during the pandemic.

METHODS

A randomized control trial spanned from 2019 to 2021 at the University of Porto, along five evaluation moments, with students into one control group and two intervention groups-the interventions aimed to reduce depression stigma.

RESULTS

Among the 702 participants (mean age 18.87, 59.4 % female), the intervention groups significantly increased help-seeking behaviors. In 2020, the intervention groups, having reduced stigma, continued to demonstrate to be more prompt to seek mental health help. In 2021, 22 months, the effects of the intervention on help-seeking were no longer significant; however, participants in the intervention groups showed less severe symptomatology.

CONCLUSION

Stigma reduction interventions have a pronounced effect on enhancing help-seeking behaviors among university students, even during times of crisis. This study advocates for prioritizing stigma reduction in academic settings, highlighting its value in promoting mental health access during crucial academic and life challenges.

Psychometric properties of the Depression Stigma Scale in the Portuguese population and its association with gender and depressive symptomatology

Background

Stigma is one of the most significant constraints on people living with depression. There is a lack of validated scales in Portugal to measure depression stigma; therefore, the Depression Stigma Scale (DSS) is essential to the depression stigma research in Portugal.

Methods

We developed the adaptation process with the ITC Guidelines for Translation and Adapting Tests taken into consideration. We collected the sample as part of the OSPI program—Optimizing suicide prevention programs and their implementation in Europe, specifically within the application in Portugal, and included 1693 participants. Floor-ceiling effects and response ranges were analyzed, and we calculated Cronbach alphas, and Confirmatory Analysis. Validity evidence was tested with two well-documented hypotheses, using data on gender and depression symptoms.

Results

The sample was well comparable with the general Portuguese population, indicating its representativeness. We identified a three-factor structure in each subscale (personal and perceived stigma): weak-not-sick, discrimination, and dangerous/unpredictable, with good model fit results. The Cronbach's alphas were satisfactory, and validity was confirmed.

Conclusions

This study established the validity and demonstrated good psychometric properties of the DSS in the Portuguese population. The validation of the DSS can be beneficial in exploring stigma predictors and evaluating the effectiveness of stigma reduction interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12955-022-01945-7.

The effects of a video-based randomized controlled trial intervention on depression stigma and help-seeking attitudes in university students

University students are a risk group for developing mental illness, but they do not receive the care they need because of hampered help-seeking induced by stigma. This study evaluates the effects of a video-based stigma reduction intervention and help-seeking attitudes promotion in university students. We randomly distributed a sample of university students among one control group (CG, n = 188) and two intervention groups (IG-1, n = 222 and IG-2, n = 216): IG-1 watched a contact-based video and IG-2 the same video plus a psychoeducational video. The study followed an experimental single-blind randomized control trial design with a pre-test before the intervention (M0), a post-test, and a follow-up test. We evaluated participants using a sociodemographic questionnaire, the Attitudes Toward Seeking Professional Psychological Help Questionnaire, the Depression Stigma Scale, the 9-item Patient Health Questionnaire, and the 7-item Generalized Anxiety Disorder. A total of 626 participants with a mean age of 19.85 (SD=1.48) responded to all evaluation moments. At M0, there were no differences between groups on stigma or help-seeking attitudes. Immediately after the intervention, stigma levels significantly decreased, and help-seeking attitudes significantly improved. These effects persisted for the next five months. Video-based depression stigma reduction intervention can be an essential tool to reduce depression stigma and improve help-seeking attitudes.

The Association Between Changes in the University Educational Setting and Peer Relationships: Effects in Students' Depressive Symptoms During the COVID-19 Pandemic

Objective: Abrupt life changes imposed by the lockdown measures, with a direct impact on teaching methodology and social interactions, as well as sleeping patterns, harmed university students' mental health. This study aimed to analyze the relationship between satisfaction with online teaching, social interaction with depression, anxiety symptomatology, and to analyze the effects of the pandemic and the lockdown in mental care access. Methods: The online survey collected demographic data, satisfaction with online teaching, and social interaction. We evaluated the depression and anxiety symptomatology using the 9-item Patient Health Questionnaire and the 7-item Generalized Anxiety Disorder, respectively. For the PHQ-9, we used the cut-off 15 for moderately severe depressive symptoms, whereas for GAD-7, we recurred to the cut-off 10 for moderately severe anxiety symptoms. This study used three data points: October 2019, June 2020, and March 2021. Findings: The study included n = 366 participants from all university study fields, with a mean age of 21.71 (SD = 1.42) in the last survey, and 71.3% were women. Depressive symptoms increased significantly from October 2019 to June 2020, and the mean scores grew until March 2021. Anxiety symptoms also significantly increased from October 2019 to June 2020; however, from June 2020 to March 2021, there was a non-significant decrease in the proportion. Mean scores for satisfaction with online teaching were 38.23% in June 2020 and 34.25% in March 2021, a non-significant difference. Satisfaction with social interaction significantly decreased from 37.35% in 2020 to 24.41% in 2021. Participants with scores above the cut-off of moderately severe and severe depressive and anxiety symptoms showed significantly lower satisfaction with online teaching than students with lower depression and anxiety scores. Despite the significant increase in clinical symptomatology, help-seeking behaviors did not change accordingly, and more than 50% of the students with mild or severe depressive and anxiety symptomatology did not get treatment during the pandemic. Conclusion: The findings of this study suggest that most students are dissatisfied with online teaching and the type of social interaction they were forced to adopt because of the pandemic. The severity of depressive and anxiety symptomatology significantly increased between October 2019 and March 2021, but help-seeking behaviors did not increase accordingly.

Depression and anxiety consequences of the COVID-19 pandemic: A longitudinal cohort study with university students

Introduction

For young people, just as in the general population, COVID-19 caused many changes in their lives. The literature review has shown an increased risk for mental illness symptoms as a consequence of the pandemic.

Objectives

With this study, we aimed to evaluate the impact of COVID-19 pandemic in university students’ anxiety and depression symptoms.

Methods

This study is part of a larger longitudinal research on university students’ mental health with the Portuguese version of The Patient Health Questionnaire (PHQ-9) and the Portuguese version of the Generalised Anxiety Disorder (GAD-7) data with evaluations on January, May and October 2019 and June 2020, as well as socio-demographic information.

Results

341 university students (257 females and 84 males) were included in this study, with a mean age of 19.91 (SD=1.58). In June 2020, the mean for perceived well-being loss was 60.47% (SD=26.56) and 59.54% (SD=28.95) for mental health loss. In the PHQ-9, the proportion of students with scores equal or above 15 ranged between 22.6% and 25.5% in 2019, however, in June 2020, the proportion was significantly higher (37.0%). The proportion of GAD-7 scores above the cut-off 10 ranged between 46.0% and 47.8% in 2019, and, in 2020, 64.5% of the students scored 10 or above. Compared with preceding trends, PHQ-9 scores were 3.11 (CI=2.40-3.83) higher than expected, and GAD-7 scores were 3.56 (CI=2.75-5.37) higher.

Conclusions

COVID-19 had a negative impact on depressive and anxiety symptoms in university students, in line with the literature and confirming the vulnerability of young people in such uncertain times.

Suicide time-series structural change analysis in Portugal (1913-2018): Impact of register bias on suicide trends

BACKGROUND

Suicide is a potentially preventable cause of death. Epidemiology might help to identify death determinants and to monitor prevention strategies. Few studies address secular trends in suicide deaths, and even fewer describe trend-changes in relation to data collection/registration bias. Moreover, suicide is admittedly underreported. It is crucial to validate results in the context of other external causes of death trends, such as unintentional and undetermined intent deaths. We aimed to explore trends in suicide and other external causes of death in Portugal from the inception of registries until 2018, considering breaks in series.

METHODS

We collected data from all available official primary sources. We calculated cause-specific age-standardized death rates (SDR) by sex for ages equal or higher than 15 years with reference to the European Standard Population. We considered suicide (S), undetermined intent deaths (UnD), accidents (Accs), and all causes of death (ttMty). A time-series structural analysis was executed.

RESULTS

Suicide and other external causes of death rates were consistently higher in males than females. A global decline of deaths by suicide, undetermined intention and unintentional is observable. Breakpoints in years 1930, 1954, 1982, 2000-2001 were associated with major changes in deaths registration procedures or methodology.

CONCLUSIONS

The epidemiology of suicide in Portugal has changed over 106 years. However, adjusted data and consideration of bias reduce trends fluctuation. Trend changes are akin to specific changes in methodology of death registry. Suicide surveillance will improve with more reliable and stable procedures.

A systematic review of older adults' request for or attitude toward euthanasia or assisted-suicide

OBJECTIVES

Prevalence rates of death by euthanasia (EUT) and physician-assisted suicide (PAS) have increased among older adults, and public debates on these practices are still taking place. In this context, it seemed important to conduct a systematic review of the predictors (demographic, physical health, psychological, social, quality of life, religious, or existential) associated with attitudes toward, wishes and requests for, as well as death by EUT/PAS among individuals aged 60 years and over.

METHOD

The search for quantitative studies in PsycINFO and MEDLINE databases was conducted three times from February 2016 until April 2018. Articles of probable relevance (n = 327) were assessed for eligibility. Studies that only presented descriptive data (n = 306) were excluded.

RESULTS

This review identified 21 studies with predictive analyses, but in only 4 did older adults face actual end-of-life decisions. Most studies (17) investigated attitudes toward EUT/PAS (9 through hypothetical scenarios). Younger age, lower religiosity, higher education, and higher socio-economic status were the most consistent predictors of endorsement of EUT/PAS. Findings were heterogeneous with regard to physical health, psychological, and social factors. Findings were difficult to compare across studies because of the variety of sample characteristics and outcomes measures.

CONCLUSION

Future studies should adopt common and explicit definitions of EUT/PAS, as well as research designs (e.g. mixed longitudinal) that allow for better consideration of personal, social, and cultural factors, and their interplay, on EUT/PAS decisions.

A Naturalistic, European Multi-Center Clinical Study of Electrodermal Reactivity and Suicide Risk Among Patients With Depression

Background: Electrodermal hyporeactivity has been proposed as a marker of suicidal risk. The EUDOR-A study investigated the prevalence of electrodermal hyporeactivity among patients with depression and its association with attempted and completed suicide. Methods: Between August 2014 and March 2016, 1,573 in- and outpatients with a primary diagnosis of depression (active or remission phase) were recruited at 15 European psychiatric centers. Each patient was followed-up for 1 year. Electrodermal activity was assessed at baseline with the ElectroDermal Orienting Reactivity Test. Data on the sociodemographic characteristics, clinical diagnoses, and treatment of the subjects were also collected. The severity of the depressive symptoms was assessed through the Montgomery-Asberg Depression Rating Scale. Information regarding number, time, and method of suicide attempts was gathered at baseline and at the end of the 1-year follow-up. The same data were collected in case of completed suicide. Results: Hyporeactive patients were shown to be significantly more at risk of suicide attempt compared to reactive patients, both at baseline and follow-up. A sensitivity of 29.86% and a positive predictive value (PPV) of 46.77% were found for attempted suicide at baseline, while a sensitivity of 35.36% and a PPV of 8.92% were found for attempted suicide at follow-up. The sensitivity and PPV for completed suicide were 25.00 and 0.61%, respectively. However, when controlled for suicide attempt at baseline, the association between hyporeactivity and follow-up suicide attempt was no longer significant. The low number of completed suicides did not allow any analysis.

Prevention of suicidal behaviour: Results of a controlled community-based intervention study in four European countries

The 'European Alliance Against Depression' community-based intervention approach simultaneously targets depression and suicidal behaviour by a multifaceted community based intervention and has been implemented in more than 115 regions worldwide. The two main aims of the European Union funded project "Optimizing Suicide Prevention Programmes and Their Implementation in Europe" were to optimise this approach and to evaluate its implementation and impact. This paper reports on the primary outcome of the intervention (the number of completed and attempted suicides combined as 'suicidal acts') and on results concerning process evaluation analysis. Interventions were implemented in four European cities in Germany, Hungary, Portugal and Ireland, with matched control sites. The intervention comprised activities with predefined minimal intensity at four levels: training of primary care providers, a public awareness campaign, training of community facilitators, support for patients and their relatives. Changes in frequency of suicidal acts with respect to a one-year baseline in the four intervention regions were compared to those in the four control regions (chi-square tests). The decrease in suicidal acts compared to baseline in the intervention regions (-58 cases, -3.26%) did not differ significantly (χ2 = 0.13; p = 0.72) from the decrease in the control regions (-18 cases, -1.40%). However, intervention effects differed between countries (χ2 = 8.59; p = 0.04), with significant effects on suicidal acts in Portugal (χ2 = 4.82; p = 0.03). The interviews and observations explored local circumstances in each site throughout the study. Hypothesised mechanisms of action for successful implementation were observed and drivers for 'added-value' were identified: local partnership working and 'in-kind' contributions; an approach which valued existing partnership strengths; and synergies operating across intervention levels. It can be assumed that significant events during the implementation phase had a certain impact on the observed outcomes. However, this impact was, of course, not proven.

Effectiveness of General Practitioner training to improve suicide awareness and knowledge and skills towards depression

BACKGROUND

General Practitioners (GPs) are well placed as gatekeepers for managing depression and suicidal ideation but not always well prepared. Capacity building has therefore been recommended as a useful strategy for suicide prevention. This study aimed to examine whether GPs' knowledge and attitudes towards and confidence to deal with depression and suicide improve after following a training program.

METHODS

As part of the OSPI-Europe multilevel intervention, a standardized training on depression and suicide was provided to 208 GPs in three European countries. Core outcomes were assessed using the Depression Attitude Questionnaire, the Attitude towards Suicide Prevention Scale, and the Morriss Confidence Scale. Data were collected before and after training, and at three to six months follow-up.

RESULTS

At baseline, GPs demonstrated various stigmatizing attitudes towards depression and low optimism about the therapeutic treatment of depression. They showed moderately positive attitudes towards suicide prevention but felt little confident in dealing with depression and suicide in daily practice. The training resulted in improved knowledge, attitudes and confidence regarding depression and suicide and their prevention and treatment. At follow-up, only the increase in confidence to deal with depression and suicide was sustained.

LIMITATIONS

The Depression Attitude Questionnaire has rather weak psychometric properties. Other external factors may have contributed to the observed training effects as the study included no control group.

CONCLUSIONS

The OSPI-Europe training program was able to improve the GPs' attitudes towards suicide prevention, several attitudes towards depression and its treatment as well as the GPs' confidence to deal with depression and suicide in everyday practice. At follow, only the GPs' confidence to deal with depression and suicide was preserved.

A multi-centre, randomised, double-blind, placebo-controlled clinical trial of methylphenidate in the initial treatment of acute mania (MEMAP study)

Based on many clinical and preclinical findings the 'vigilance regulation model of mania' postulates that an unstable regulation of wakefulness is a pathogenetic factor in both mania and Attention Deficit Hyperactivity Disorder (ADHD) and induces hyperactivity and sensation seeking as an autoregulatory attempt to stabilize wakefulness. Accordingly, stimulant medications with their vigilance stabilizing properties could have rapid antimanic effects similar to their beneficial effects in ADHD. The MEMAP study - a multi-center, double-blind, placebo-controlled and randomized clinical trial (RCT) - assessed the antimanic efficacy and safety of a 2.5-day treatment with methylphenidate (20-40mg/day). Of 157 screened patients with acute mania, 42 were randomly assigned to receive 20-40mg per day of methylphenidate in one or two applications, or placebo. The primary outcome was the change in Young Mania Rating Scale (YMRS) sum scores from baseline to day 2.5 in the methylphenidate group compared to the placebo group. A group sequential design was chosen to justify early RCT termination based on efficacy or futility at an interim analysis after inclusion of 40 patients. In the interim analysis, the change from baseline in the YMRS total score at day 2.5 was not significantly different between both groups (F(1,37)=0.23; p=0.64). Thus, futility was declared for methylphenidate and the RCT was stopped. In summary, although methylphenidate was well tolerated and safe in the full analysis set, it failed to show efficacy in the treatment of acute mania.

TRIAL REGISTRATION

clinicaltrials.gov (URL: http://www.clinicaltrials.gov; registration number: NCT01541605).

Exploring synergistic interactions and catalysts in complex interventions: longitudinal, mixed methods case studies of an optimised multi-level suicide prevention intervention in four european countries (Ospi-Europe)

BACKGROUND

The Medical Research Council (MRC) Framework for complex interventions highlights the need to explore interactions between components of complex interventions, but this has not yet been fully explored within complex, non-pharmacological interventions. This paper draws on the process evaluation data of a suicide prevention programme implemented in four European countries to illustrate the synergistic interactions between intervention levels in a complex programme, and to present our method for exploring these.

METHODS

A realist evaluation approach informed the process evaluation, which drew on mixed methods, longitudinal case studies. Data collection consisted of 47 semi-structured interviews, 12 focus groups, one workshop, fieldnoted observations of six programme meetings and 20 questionnaires (delivered at six month intervals to each of the four intervention sites). Analysis drew on the framework approach, facilitated by the use of QSR NVivo (v10). Our qualitative approach to exploring synergistic interactions (QuaSIC) also developed a matrix of hypothesised synergies that were explored within one workshop and two waves of data collection.

RESULTS

All four implementation countries provided examples of synergistic interactions that added value beyond the sum of individual intervention levels or components in isolation. For instance, the launch ceremony of the public health campaign (a level 3 intervention) in Ireland had an impact on the community-based professional training, increasing uptake and visibility of training for journalists in particular. In turn, this led to increased media reporting of OSPI activities (monitored as part of the public health campaign) and also led to wider dissemination of editorial guidelines for responsible reporting of suicidal acts. Analysis of the total process evaluation dataset also revealed the new phenomenon of the OSPI programme acting as a catalyst for externally generated (and funded) activity that shared the goals of suicide prevention.

CONCLUSIONS

The QuaSIC approach enabled us to develop and refine our definition of synergistic interactions and add the innovative concept of catalytic effects. This represents a novel approach to the evaluation of complex interventions. By exploring synergies and catalytic interactions related to a complex intervention or programme, we reveal the added value to planned activities and how they might be maximised.

Changes in prescribing patterns of benzodiazepines after training of general practitioners

Introduction

Benzodiazepines are the most utilized anxiolytic and hypnotic drugs. The high consumption of benzodiazepines has been a concern due to reported side effects of long-term use and dependence. Portugal has the highest benzodiazepine utilization in Europe.

Objectives

To analyze the change in general practitioners’ (GPs) benzodiazepine prescription pattern after an intervention period.

Methods

An educational session was delivered to a group of intervened GPs. The benzodiazepine prescription pattern of intervened group was compared to the pattern of a non-intervened matched group from the same region, and of another non-intervened matched group from a different region. The research time frame was 12 months before and after intervention. The analysis of the prescription trends used the defined daily dose (DDD) and defined daily dose per 1000 patients per day (DHD) methodology. The statistical methods consisted of segmented regression analysis.

Results

There was a decrease in benzodiazepine prescription pattern of intervened GPs after intervention (P = 0.005). There was also a decrease in benzodiazepine prescription pattern for the non-intervened group from the same region (P = 0.037) and for the non-intervened group from a different region (P = 0.010). Concerning an analysis by gender, female gender prescribed a higher amount of benzodiazepines. The intervened female gender prescribers presented the highest decrease in prescription trend after intervention (P = 0.008).

Conclusions

Intervention was effective in reducing benzodiazepine prescription after intervention. It demonstrates that a single intervention has a positive impact on improving prescription trends. The replication of this intervention might be an opportunity for changing the worrying benzodiazepine utilization in Portugal.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Community-based 4-level approach: Background, implementation and evidence for efficacy

The community-based 4-level-intervention concept developed within the “European Alliance against Depression” (http://www.eaad.net/) combines two important aims: to improve the care and treatment of patients with depression and to prevent suicidal behavior. It has been shown to be effective concerning the prevention of suicidal behavior [1–4] and is worldwide the most broadly implemented community-based intervention targeting depression and suicidal behavior. The 4-level intervention concept comprises training and support of primary care providers (level 1), a professional public relation campaign (level 2), training of community facilitators (teacher, priests, geriatric caregivers, pharmacists, journalists) (level 3), and support for self-help of patients with depression and for their relatives (level 4). In order to deepen the understanding of factors influencing the effectiveness of the intervention, a systematic implementation research and process analysis was performed within the EU-funded study “Optimizing Suicide Prevention Programs and Their Implementation in Europe” (http://www.ospi-europe.com/; 7th Framework Programme) [5]. These analyses were based on data from four intervention and four control regions from four European countries. In addition to intervention effects on suicidal behaviour, a variety of intermediate outcomes (e.g. changes in attitude or knowledge in different populations) were considered. Strong synergistic as well as catalytic effects were identified as a result of being active simultaneously at four different levels. Predictable and unpredictable obstacles to a successful implementation of such community-based programs will be discussed. Via the EAAD, the intervention concept and materials (available in eight different languages) are offered to interested region in and outside of Europe.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Depression Awareness and Self-Management Through the Internet: Protocol for an Internationally Standardized Approach

Background

Depression incurs significant morbidity and confers increased risk of suicide. Many individuals experiencing depression remain untreated due to systemic and personal barriers to care. Guided Internet-based psychotherapeutic programs represent a promising means of overcoming such barriers and increasing the capacity for self-management of depression. However, existing programs tend to be available only in English and can be expensive to access. Furthermore, despite evidence of the effectiveness of a number of Internet-based programs, there is limited evidence regarding both the acceptability of such programs and feasibility of their use, for users and health care professionals.

Objective

This paper will present the protocol for the development, implementation, and evaluation of the iFightDepression tool, an Internet-based self-management tool. This is a cost-free, multilingual, guided, self-management program for mild to moderate depression cases.

Methods

The Preventing Depression and Improving Awareness through Networking in the European Union consortium undertook a comprehensive systematic review of the available evidence regarding computerized cognitive behavior therapy in addition to a consensus process involving mental health experts and service users to inform the development of the iFightDepression tool. The tool was implemented and evaluated for acceptability and feasibility of its use in a pilot phase in 5 European regions, with recruitment of users occurring through general practitioners and health care professionals who participated in a standardized training program.

Results

Targeting mild to moderate depression, the iFightDepression tool is based on cognitive behavioral therapy and addresses behavioral activation (monitoring and planning daily activities), cognitive restructuring (identifying and challenging unhelpful thoughts), sleep regulation, mood monitoring, and healthy lifestyle habits. There is also a tailored version of the tool for young people, incorporating less formal language and additional age-appropriate modules on relationships and social anxiety. The tool is accompanied by a 3-hour training intervention for health care professionals.

Conclusions

It is intended that the iFightDepression tool and associated training for health care professionals will represent a valuable resource for the management of depression that will complement existing resources for health care professionals. It is also intended that the iFightDepression tool and training will represent an additional resource within a multifaceted approach to improving the care of depression and preventing suicidal behavior in Europe.

What Are Reasons for the Large Gender Differences in the Lethality of Suicidal Acts? An Epidemiological Analysis in Four European Countries

Background

In Europe, men have lower rates of attempted suicide compared to women and at the same time a higher rate of completed suicides, indicating major gender differences in lethality of suicidal behaviour. The aim of this study was to analyse the extent to which these gender differences in lethality can be explained by factors such as choice of more lethal methods or lethality differences within the same suicide method or age. In addition, we explored gender differences in the intentionality of suicide attempts.

Methods and Findings

Methods. Design: Epidemiological study using a combination of self-report and official data. Setting: Mental health care services in four European countries: Germany, Hungary, Ireland, and Portugal. Data basis: Completed suicides derived from official statistics for each country (767 acts, 74.4% male) and assessed suicide attempts excluding habitual intentional self-harm (8,175 acts, 43.2% male).

Main Outcome Measures and Data Analysis. We collected data on suicidal acts in eight regions of four European countries participating in the EU-funded “OSPI-Europe”-project (www.ospi-europe.com). We calculated method-specific lethality using the number of completed suicides per method * 100 / (number of completed suicides per method + number of attempted suicides per method). We tested gender differences in the distribution of suicidal acts for significance by using the χ²-test for two-by-two tables. We assessed the effect sizes with phi coefficients (φ). We identified predictors of lethality with a binary logistic regression analysis. Poisson regression analysis examined the contribution of choice of methods and method-specific lethality to gender differences in the lethality of suicidal acts.

Findings Main Results

Suicidal acts (fatal and non-fatal) were 3.4 times more lethal in men than in women (lethality 13.91% (regarding 4106 suicidal acts) versus 4.05% (regarding 4836 suicidal acts)), the difference being significant for the methods hanging, jumping, moving objects, sharp objects and poisoning by substances other than drugs. Median age at time of suicidal behaviour (35–44 years) did not differ between males and females. The overall gender difference in lethality of suicidal behaviour was explained by males choosing more lethal suicide methods (odds ratio (OR) = 2.03; 95% CI = 1.65 to 2.50; p < 0.000001) and additionally, but to a lesser degree, by a higher lethality of suicidal acts for males even within the same method (OR = 1.64; 95% CI = 1.32 to 2.02; p = 0.000005). Results of a regression analysis revealed neither age nor country differences were significant predictors for gender differences in the lethality of suicidal acts. The proportion of serious suicide attempts among all non-fatal suicidal acts with known intentionality (NFSAi) was significantly higher in men (57.1%; 1,207 of 2,115 NFSAi) than in women (48.6%; 1,508 of 3,100 NFSAi) (χ² = 35.74; p < 0.000001).

Main limitations of the study

Due to restrictive data security regulations to ensure anonymity in Ireland, specific ages could not be provided because of the relatively low absolute numbers of suicide in the Irish intervention and control region. Therefore, analyses of the interaction between gender and age could only be conducted for three of the four countries. Attempted suicides were assessed for patients presenting to emergency departments or treated in hospitals. An unknown rate of attempted suicides remained undetected. This may have caused an overestimation of the lethality of certain methods. Moreover, the detection of attempted suicides and the registration of completed suicides might have differed across the four countries. Some suicides might be hidden and misclassified as undetermined deaths.

Conclusions

Men more often used highly lethal methods in suicidal behaviour, but there was also a higher method-specific lethality which together explained the large gender differences in the lethality of suicidal acts. Gender differences in the lethality of suicidal acts were fairly consistent across all four European countries examined. Males and females did not differ in age at time of suicidal behaviour. Suicide attempts by males were rated as being more serious independent of the method used, with the exceptions of attempted hanging, suggesting gender differences in intentionality associated with suicidal behaviour. These findings contribute to understanding of the spectrum of reasons for gender differences in the lethality of suicidal behaviour and should inform the development of gender specific strategies for suicide prevention.

Effectiveness of community facilitator training in improving knowledge, attitudes, and confidence in relation to depression and suicidal behavior: results of the OSPI-Europe intervention in four European countries

BACKGROUND

Community facilitators (CFs), such as teachers, nurses and social workers, are well placed as gatekeepers for depression and suicidal behavior, but not properly prepared to provide preventive and supportive services. The current study aimed: (1) to improve CFs' attitudes toward depression, knowledge on suicide, and confidence to detect suicidal behavior in four European countries and (2) to identify specific training needs across regions and CF groups.

METHODS

A standardized training program was provided to 1276 CFs in Germany, Hungary, Ireland, and Portugal. Attitudes toward depression, knowledge about suicide, and confidence in identifying suicidal persons were assessed before training, after training, and at three to six months follow-up. Additionally, several participants' characteristics were registered.

RESULTS

At baseline, CFs showed relatively favorable attitudes toward depression, but limited knowledge on suicide, and little confidence to identify suicidal behavior. Basic skills strongly differed across CF groups and countries. For example, in Germany, carers for the elderly, nurses, teachers, and managers were most in need of training, while in Portugal pharmacists and the clergy appeared to be important target groups. Most importantly, the training program improved the competencies of CF groups across countries and these improvements were sustained after three to six months. CFs with low basic skills benefited most of the training.

LIMITATIONS

The observed training effects could be influenced by other external factors as our results are based upon a pre-post comparison with no control group.

CONCLUSIONS

Gatekeeper trainings in community settings are successful in improving knowledge, reshaping attitudes, and boosting the confidence of gatekeepers. The most effective strategy to achieve the preferred objectives is to target those CF groups that are most in need of training and to tailor the content of the training program to the individual needs of the target group.

How to adjust media recommendations on reporting suicidal behavior to new media developments

This study examines the inclusion of preventive factors and new media developments in media recommendations on suicide reporting. Of the 193 member states of the United Nations screened for media recommendations, information was available for 74 countries. Similarities and differences in their contents were analyzed by cluster analysis. Results indicate that of these 74 countries, 38% have national suicide prevention programs, 38% have media recommendations, and 25% have press codes including suicide reporting. Less than 25% of the media recommendations advise against mentioning online forums, suicide notes, pacts, clusters, hotspots, details of the person, and positive consequences. No more than 15% refer to self-help groups, fictional and online reporting. We conclude that media recommendations need to be revised by adding these preventive factors and by including sections on new media reporting.

Antidepressant Utilization and Suicide in Europe: An Ecological Multi-National Study

BACKGROUND

Research concerning the association between use of antidepressants and incidence of suicide has yielded inconsistent results and is the subject of considerable controversy. The first aim is to describe trends in the use of antidepressants and rates of suicide in Europe, adjusted for gross domestic product, alcohol consumption, unemployment, and divorce. The second aim is to explore if any observed reduction in the rate of suicide in different European countries preceded the trend for increased use of antidepressants.

METHODS

Data were obtained for 29 European countries between 1980 and 2009. Pearson correlations were used to explore the direction and magnitude of associations. Generalized linear mixed models and Poisson regression distribution were used to clarify the effects of antidepressants on suicide rates, while an autoregressive adjusted model was used to test the interaction between antidepressant utilization and suicide over two time periods: 1980-1994 and 1995-2009.

FINDINGS

An inverse correlation was observed in all countries between recorded Standardised Death Rate (SDR) for suicide and antidepressant Defined Daily Dosage (DDD), with the exception of Portugal. Variability was marked in the association between suicide and alcohol, unemployment and divorce, with countries depicting either a positive or a negative correlation with the SDR for suicide. Every unit increase in DDD of an antidepressant per 1000 people per day, adjusted for these confounding factors, reduces the SDR by 0.088. The correlation between DDD and suicide related SDR was negative in both time periods considered, albeit more pronounced between 1980 and 1994.

CONCLUSIONS

Suicide rates have tended to decrease more in European countries where there has been a greater increase in the use of antidepressants. These findings underline the importance of the appropriate use of antidepressants as part of routine care for people diagnosed with depression, therefore reducing the risk of suicide.

Methylphenidate in mania project (MEMAP): study protocol of an international randomised double-blind placebo-controlled study on the initial treatment of acute mania with methylphenidate

BACKGROUND

Treatment of patients with acute mania remains a considerable medical challenge since onset of action of antimanic medication is delayed for several days. Psychostimulants could have an earlier onset of action. This assumption is based on the 'vigilance regulation model of mania' which postulates that vigilance is unstable in manic patients. Accordingly, vigilance-stabilising psychostimulants could be more useful than conventional treatment in acute mania. We present here the study protocol of a trial intended to study the efficacy and safety of methylphenidate in the initial treatment of acute mania.

METHODS/DESIGN

A multi-centre, randomised, double-blind, placebo-controlled clinical trial will be conducted in 88 bipolar inpatients with acute mania. Male and female patients older than 18 years will be randomised to treatment with either methylphenidate (20 to 40 mg/day) or placebo for 2.5 days, given once or twice daily. The main outcome measure is the reduction in the Young Mania Rating Scale (YMRS) after 2.5 days of treatment. Other outcome measures include the Positive and Negative Syndrome Scale-Excited Component (PANSS-EC) the Clinical Global Impression-Bipolar Scale (CGI-BP), the Screen for Cognitive Impairment in Psychiatry (SCIP), actigraphy and the EEG-'Vigilance Algorithm Leipzig' (VIGALL).

DISCUSSION

A positive study outcome of the proposed study could substantially impact our understanding of the etiopathogenesis of mania and open new treatment perspectives.

Developing social capital in implementing a complex intervention: a process evaluation of the early implementation of a suicide prevention intervention in four European countries

BACKGROUND

Variation in the implementation of complex multilevel interventions can impact on their delivery and outcomes. Few suicide prevention interventions, especially multilevel interventions, have included evaluation of both the process of implementation as well as outcomes. Such evaluation is essential for the replication of interventions, for interpreting and understanding outcomes, and for improving implementation science. This paper reports on a process evaluation of the early implementation stage of an optimised suicide prevention programme (OSPI-Europe) implemented in four European countries.

METHODS

The process analysis was conducted within the framework of a realist evaluation methodology, and involved case studies of the process of implementation in four European countries. Datasets include: repeated questionnaires to track progress of implementation including delivery of individual activities and their intensity; serial interviews and focus groups with stakeholder groups; and detailed observations at OSPI implementation team meetings.

RESULTS

Analysis of local contexts in each of the four countries revealed that the advisory group was a key mechanism that had a substantial impact on the ease of implementation of OSPI interventions, particularly on their ability to recruit to training interventions. However, simply recruiting representatives of key organisations into an advisory group is not sufficient to achieve impact on the delivery of interventions. In order to maximise the potential of high level 'gatekeepers', it is necessary to first transform them into OSPI stakeholders. Motivations for OSPI participation as a stakeholder included: personal affinity with the shared goals and target groups within OSPI; the complementary and participatory nature of OSPI that adds value to pre-existing suicide prevention initiatives; and reciprocal reward for participants through access to the extended network capacity that organisations could accrue for themselves and their organisations from participation in OSPI.

CONCLUSIONS

Exploring the role of advisory groups and the meaning of participation for these participants revealed some key areas for best practice in implementation: careful planning of the composition of the advisory group to access target groups; the importance of establishing common goals; the importance of acknowledging and complementing existing experience and activity; and facilitating an equivalence of benefit from network participation.

Best practice elements of multilevel suicide prevention strategies: a review of systematic reviews

Background: Evidence-based best practices for incorporation into an optimal multilevel intervention for suicide prevention should be identifiable in the literature. Aims: To identify effective interventions for the prevention of suicidal behavior. Methods: Review of systematic reviews found in the Pubmed, Cochrane, and DARE databases. Steps include risk-of-bias assessment, data extraction, summarization of best practices, and identification of synergistic potentials of such practices in multilevel approaches. Results: Six relevant systematic reviews were found. Best practices identified as effective were as follows: training general practitioners (GPs) to recognize and treat depression and suicidality, improving accessibility of care for at-risk people, and restricting access to means of suicide. Although no outcomes were reported for multilevel interventions or for synergistic effects of multiple interventions applied together, indirect support was found for possible synergies in particular combinations of interventions within multilevel strategies. Conclusions: A number of evidence-based best practices for the prevention of suicide and suicide attempts were identified. Research is needed on the nature and extent of potential synergistic effects of various preventive activities within multilevel interventions.

Drug suicide: a sex-equal cause of death in 16 European countries

Background

There is a lack of international research on suicide by drug overdose as a preventable suicide method. Sex- and age-specific rates of suicide by drug self-poisoning (ICD-10, X60-64) and the distribution of drug types used in 16 European countries were studied, and compared with other self-poisoning methods (X65-69) and intentional self-injury (X70-84).

Methods

Data for 2000-04/05 were collected from national statistical offices. Age-adjusted suicide rates, and age and sex distributions, were calculated.

Results

No pronounced sex differences in drug self-poisoning rates were found, either in the aggregate data (males 1.6 and females 1.5 per 100,000) or within individual countries. Among the 16 countries, the range (from some 0.3 in Portugal to 5.0 in Finland) was wide. 'Other and unspecified drugs' (X64) were recorded most frequently, with a range of 0.2-1.9, and accounted for more than 70% of deaths by drug overdose in France, Luxembourg, Portugal and Spain. Psychotropic drugs (X61) ranked second. The X63 category ('other drugs acting on the autonomic nervous system') was least frequently used. Finland showed low X64 and high X61 figures, Scotland had high levels of X62 ('narcotics and hallucinogens, not elsewhere classified') for both sexes, while England exceeded other countries in category X60. Risk was highest among the middle-aged everywhere except in Switzerland, where the elderly were most at risk.

Conclusions

Suicide by drug overdose is preventable. Intentional self-poisoning with drugs kills as many males as females. The considerable differences in patterns of self-poisoning found in the various European countries are relevant to national efforts to improve diagnostics of suicide and appropriate specific prevention. The fact that vast majority of drug-overdose suicides came under the category X64 refers to the need of more detailed ICD coding system for overdose suicides is needed to permit better design of suicide-prevention strategies at national level.

Munchausen syndrome mimicking psychiatric disease with concomitant genuine physical illness

Munchausen syndrome is a disorder in which patients intentionally produce symptoms mimicking physical or psychiatric illnesses with the aim to assume the sick role and to gain medical attention. Once a patient receives a Munchausen syndrome diagnosis every complaint made thence tends to be regarded with scepticism by clinical staff. However, it is possible that a bona fide illness, which might be disregarded, may coexist in these patients. We report a case of MS mimicking psychiatric disease with concomitant genuine acute physical illness. Despite the initial doubts about the veracity of the latter, due to its prompt recognition, treatment was successful.

Optimizing suicide prevention programs and their implementation in Europe (OSPI Europe): an evidence-based multi-level approach

BACKGROUND

Suicide and non-fatal suicidal behaviour are significant public health issues in Europe requiring effective preventive interventions. However, the evidence for effective preventive strategies is scarce. The protocol of a European research project to develop an optimized evidence based program for suicide prevention is presented.

METHOD

The groundwork for this research has been established by a regional community based intervention for suicide prevention that focuses on improving awareness and care for depression performed within the European Alliance Against Depression (EAAD). The EAAD intervention consists of (1) training sessions and practice support for primary care physicians,(2) public relations activities and mass media campaigns, (3) training sessions for community facilitators who serve as gatekeepers for depressed and suicidal persons in the community and treatment and (4) outreach and support for high risk and self-help groups (e.g. helplines). The intervention has been shown to be effective in reducing suicidal behaviour in an earlier study, the Nuremberg Alliance Against Depression. In the context of the current research project described in this paper (OSPI-Europe) the EAAD model is enhanced by other evidence based interventions and implemented simultaneously and in standardised way in four regions in Ireland, Portugal, Hungary and Germany. The enhanced intervention will be evaluated using a prospective controlled design with the primary outcomes being composite suicidal acts (fatal and non-fatal), and with intermediate outcomes being the effect of training programs, changes in public attitudes, guideline-consistent media reporting. In addition an analysis of the economic costs and consequences will be undertaken, while a process evaluation will monitor implementation of the interventions within the different regions with varying organisational and healthcare contexts.

DISCUSSION

This multi-centre research seeks to overcome major challenges of field research in suicide prevention. It pools data from four European regions, considerably increasing the study sample, which will be close to one million. In addition, the study will gather important information concerning the potential to transfer this multilevel program to other health care systems. The results of this research will provide a basis for developing an evidence-based, efficient concept for suicide prevention for EU-member states.

Gender issues in suicide rates, trends and methods among youths aged 15-24 in 15 European countries

BACKGROUND

No recent cross-country examinations for youth suicide trends and methods for Europe were found.

AIM

The aim of the study is to specify differences in suicide rates, trends and methods used among 15-24 years olds by gender across 15 European countries.

METHOD

Data for 14,738 suicide cases in the age group 15-24 in 2000-2004/5 were obtained and analysed.

RESULTS

Suicide rates ranged 5.5-35.1 for males and 1.3-8.5 for females. Statistically significant decline since 2000 was observed in Germany, Scotland, Spain, and England for males and in Ireland for females. Hanging was most frequently used for both genders, followed by jumping and use of a moving object for males and jumping and poisoning by drugs for females. Male suicides had a higher risk than females of using firearms and hanging and lower risk of poisoning by drugs and jumping. There were large differences between single countries.

LIMITATIONS

The limitations of the study are the small numbers of specific suicide methods in some countries as well as the re-categorisation of ICD-9 codes into ICD-10 in England, Ireland and Portugal. Further, the use of suicides (X60-X84) without events of undetermined deaths (Y10-Y34) continues to be problematic considering the possibility of "hidden suicides".

CONCLUSIONS

The present study shows that suicide rates among young males are decreasing since 2000 in several European countries. Analysis of suicide methods confirms that there is a very high proportion of hanging in youths, which is extremely difficult to restrict. However, besides hanging there are also high rates of preventable suicide methods and reducing the availability of means should be one of the goals of suicide prevention.

is Feigned Psychosis a Pathway to Schizophrenia?

Factitious disorders (FD) are characterized by intentional production of either physical, psychological or mixed symptoms that mimic various clinical syndromes, with no apparent advantage for the individual concerned other than allowing him to assume the sick role. Large body of work has been accumulated on FD, but the majority of published data deal with the physical variant of the disease, with comparable few reports on psychiatric FD. Although there are many different presentations for psychiatric FD, the factitious psychosis subset justifies particular attention. Factitious psychosis may be prodromic of a genuine chronic psychosis, usually in the context of a personality disorder. Published data shows Munchausen psychosis, a severe subset of FD psychosis, with a prevalence of 0.25% of all inpatient admissions and global FD psychosis attaining 4.1% of all diagnosed psychoses, generally with a poor prognosis.

The scantiness of studies on the subject of psychiatric FD and factitious psychosis in particular, despite its significant prevalence, coupled with the fact that its recognition embarks on a radically different approach compared with the physical variant, stresses the need for case reporting.

We present four clinical cases with discussion of the underlying pathology and outcome, and a systematic review of the literature of FD psychosis case reports. This is followed by further discussion addressing the recognition of factitious psychosis, its etiological contributing factors, management, effects on staff and diagnostic criteria.

Depressive Disorders in Portugal: EAAD and the Depanx Project Regional Baseline Data and the WMH Survey National Data

Firstly, recent data on depressive disorders and suicidality burden in Portugal is presented and treatment gap is stressed as well as the insufficient information until recent years (1).

At the national level, the first epidemiological study on psychiatric disorders embedded within the World Mental Initiative Survey is ongoing and prevalence and needs for care data will be presented.

Implementation process of the EAAD 4-level intervention in Portugal is ongoing along with restructuring of both liaison and specialized mental health care on a regional sector of 350.000 inhabitants with a mental health specialised care department and four large primary care health centres, where liaison between 4 mental health teams and 200 GP was taking place accordingly with varying models (substitute care in most) and different clinical criteria for admission and follow-up.

The restructuring of mental health teams and their missions implied that while a set of sub-teams stood responsible for severe mental disorders, another subgroup was deemed to comply exclusively with common mental disorders and primary care liaison aided by standardisation of clinical criteria for referrals evaluation and reply, specialised therapeutic interventions, as well as collaborative stepped care.

Baseline and some outcome data on suicide and depression will be presented such as rates, psychopharmacological prescriptions, general population knowledge and beliefs, media reporting, and pre and post training evaluation of primary care professionals.

Co-infection with HTLV-1 is associated with a shorter survival time for HIV-1-infected patients in Bahia, Brazil

Co-infection with HTLV-1 reaches 20% among patients infected by HIV-1 in Bahia, Brazil. To evaluate its impact on survival, we conducted a retrospective, case-control study involving 198 patients (63 cases). Co-infection was associated with parenteral exposure (P = 0.0001) and female sex (P = 0.02). Co-infected patients had a shorter mean survival (1849 days) than controls (2430 days, P = 0.001), regardless of sex or baseline CD4 cell count. In Bahia, Brazil, co-infection with HIV-1 and HTLV-1 is associated with a shorter survival time.

Overview of malaria control in the Americas

The malaria endemic countries of the Americas have adopted in 1992 the WHO Global Malaria Control Strategy whose difficulties of implementation have been compounded to a major reform in the health sector, as the countries adjust to conform to financial scarcity and new economic policies. Most countries of the Region have reoriented its control program from eradication of malaria to the elimination of malaria mortality and morbidity. The Region has advanced towards these objectives having already reduced its mortality by 60% and is now in the final stages of applying new tools to control transmission and rapidly advance to reduce the incidence of malaria in the Americas.

Evora district as a new focus for canine leishmaniasis in Portugal

On the basis of information acquired from local health authorities in Evora district of Portugal on cases of visceral leishmaniasis (VL), an epidemiology survey study was conducted. To determine the prevalence of anti-Leishmania antibodies in the local human and canine populations residing in Evora town and 14 adjacent villages, blood samples collected from 885 children and 3,614 dogs were tested in a direct agglutination test (DAT). Seropositivity for Leishmania parasite obtained by DAT in both endemic populations was further confirmed by an enzyme-linked immunosorbent assay (ELISA) and immunofluorescence test (IFAT). For identification of the responsible sandfly vector, 79 biotopes within the study areas were surveyed. In the infantile population assessed, none of the children screened showed an antibody level indicative (titer, > = 1:3200) of visceral leishmaniasis in the DAT. However, agglutinating antibody rates ranging from 0.7% to 6.9% were obtained in dogs residing in Evora and 11 adjacent villages. Concordant seropositivity of 94.04% was obtained by ELISA and IFAT in the same canine population (141) identified by DAT. Of the 159 sandflies captured, 67 were identified as Phlebotomus sergenti; 15, as P. ariasi; 58, as P. perniciosus; and 19, as Sergentomyia minuta. Unlike the results previously reported in Alto-Douro and Algarve districts of Portugal, as compared with the other three species, P. sergenti appears to be more abundant in Evora district.(ABSTRACT TRUNCATED AT 250 WORDS)