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Depression and Suicide: Depression and Suicide: Tackling the Public Health Tackling the Public Health

ChallengeChallengeJune 13, 2008June 13, 2008

Kelly Posner, Ph.D.Kelly Posner, Ph.D.Columbia UniversityColumbia University

New York State Psychiatric InstituteNew York State Psychiatric Institute

Scope of the Problem: Scope of the Problem: DepressionDepression

World Health Organization predicts that World Health Organization predicts that Depression will be the Depression will be the second second most most burdensome disease by the year 2020 burdensome disease by the year 2020 (Murray & Lopez, 1997).(Murray & Lopez, 1997).Lifetime prevalence in Europe (Alonso et al Lifetime prevalence in Europe (Alonso et al 2004):2004):–– Major Depression 12.8%Major Depression 12.8%

17% of adult women, 9% adult males17% of adult women, 9% adult males

Impact of Depression on SocietyImpact of Depression on Society

Cost of depression in Europe in 2004 est. Cost of depression in Europe in 2004 est. €€118 billion 118 billion –– doubled doubled in last 10 years (Soboki et al 2006)in last 10 years (Soboki et al 2006)MortalityMortality–– Premature death by suicidePremature death by suicide

EconomicEconomic–– Lost productivity Lost productivity –– 25% of work days lost, even more than those 25% of work days lost, even more than those

with heart disease, diabeteswith heart disease, diabetes–– Lost wagesLost wages–– Early retirementEarly retirement

FunctioningFunctioning–– Two thirds of depressed report severe interference with normal Two thirds of depressed report severe interference with normal

functioning, higher than other physical conditionsfunctioning, higher than other physical conditionsSocialSocial–– Impact on relationshipsImpact on relationships–– Family breakdownFamily breakdown–– Increased alcoholism and substance abuseIncreased alcoholism and substance abuse

Scope of the Problem: SuicideScope of the Problem: SuicideSuicide is one of the worldSuicide is one of the world’’s greatest public health s greatest public health epidemicsepidemicsSuicide is a leading cause of death and represents 2.3% Suicide is a leading cause of death and represents 2.3% of burden of disease in Europeof burden of disease in Europe–– 22ndnd -- 33rdrd leading cause of death in children & adolescentsleading cause of death in children & adolescents

More deaths per year than war and homicideMore deaths per year than war and homicideSuicidal ideation and behavior quite prevalent Suicidal ideation and behavior quite prevalent –– Youth: USA/CDC 10% attempted suicide in last year; Youth: USA/CDC 10% attempted suicide in last year;

~40% had suicidal thoughts ~40% had suicidal thoughts –– similar in Europe similar in Europe –– Adults: (ESEMeD; Bernal, 2007) Adults: (ESEMeD; Bernal, 2007)

Suicidal ideation = 7.8%Suicidal ideation = 7.8%Suicide attempts = 1.3%Suicide attempts = 1.3%

Suicide is a preventable public health problemSuicide is a preventable public health problem

Comprehensive Plan: Points of Comprehensive Plan: Points of Intervention to Prevent Intervention to Prevent

Depression & SuicideDepression & Suicide

Population Prevention Population Prevention -- Public Health MeasuresPublic Health Measures

Mass ScreeningMass Screening

Individualized Risk AssessmentIndividualized Risk Assessment

Individual TreatmentIndividual Treatment

The First Challenge: The First Challenge: Need for Consistent TerminologyNeed for Consistent Terminology

““ Research on suicide is plagued by many Research on suicide is plagued by many methodological problemsmethodological problems…… Definitions lack Definitions lack uniformity,uniformity,……reporting of suicide is inaccuratereporting of suicide is inaccurate…”…”Reducing Suicide. Reducing Suicide. Institute of Medicine 2002Institute of Medicine 2002

* Limits confidence in epidemiological findings on rates of suicide attempts and completed suicides/can’t compare rates

* Need comparability across countries

What is needed:

Uniform definitions of suicidal ideation Uniform definitions of suicidal ideation and behavior are required across and behavior are required across organizations and nationsorganizations and nations

This will create a This will create a common languagecommon language for for communication about suicidecommunication about suicide

Comprehensive StrategyComprehensive Strategy

Tackling depression and suicide Tackling depression and suicide requires a comprehensive plan and set requires a comprehensive plan and set of strategies (prevention, treatment, of strategies (prevention, treatment, rehabilitation, promotion of well being, rehabilitation, promotion of well being, destigmatization)destigmatization)However, we must think about where However, we must think about where we can have the biggest impactwe can have the biggest impact

Maximizing ImpactMaximizing Impact

Treatment of the underlying disorderTreatment of the underlying disorder

90% of individuals who commit suicide have 90% of individuals who commit suicide have an untreated mental illness, mostly an untreated mental illness, mostly depressiondepression

Access to prevention and treatment is a Access to prevention and treatment is a challenge for Europechallenge for Europe

WhatWhat’’s Effectives Effective……

Antidepressants are effective in the treatment of Antidepressants are effective in the treatment of depression (Agency for Health Care Policy & depression (Agency for Health Care Policy & Research, 1999) Research, 1999)

Psychotherapies are effective treatments for Psychotherapies are effective treatments for depressive disorders and can be used in depressive disorders and can be used in combination with antidepressantscombination with antidepressants

What do we do andWhat do we do andwhat do we know?what do we know?

Treatment save lives, not Treatment save lives, not treating depression is treating depression is

responsible for many deathsresponsible for many deaths

However, Under Treatment of However, Under Treatment of Mental Illness is PervasiveMental Illness is Pervasive

In a Europe, one third of people with In a Europe, one third of people with mental illness receive any treatmentmental illness receive any treatmentOf those receiving treatment, the Of those receiving treatment, the majority receive inadequate treatmentmajority receive inadequate treatmentThis indicates need for expansion and This indicates need for expansion and targeting of resources and training of targeting of resources and training of professionals (Alonso et al 2007; professionals (Alonso et al 2007; Wang et al 2007)Wang et al 2007)

Antidepressants May Prevent Antidepressants May Prevent SuicideSuicide

Studies show suicide rate has fallen steadily since the introducStudies show suicide rate has fallen steadily since the introduction of tion of SSRI antidepressantsSSRI antidepressants–– Across age groupsAcross age groups–– In many countries (Rihmer et al 2005) In many countries (Rihmer et al 2005)

Denmark (Erlangsen et al 2008)Denmark (Erlangsen et al 2008)Hungary (Rihmer et al 2000)Hungary (Rihmer et al 2000)Sweden (Carlsten et al 2001)Sweden (Carlsten et al 2001)Italy (Barbui et al 1999)Italy (Barbui et al 1999)Japan (Nakagawa et al 2007)Japan (Nakagawa et al 2007)USA (Olfson et al 2003; Gibbons et al 2005)USA (Olfson et al 2003; Gibbons et al 2005)Australia (Hall et al 2003)Australia (Hall et al 2003)

Even after controlling for unemployment & alcoholism Even after controlling for unemployment & alcoholism (Grunebaum et al 2004)(Grunebaum et al 2004)Antidepressants associated with reduction in suicide Antidepressants associated with reduction in suicide attempts (Gibbons et al 2007)attempts (Gibbons et al 2007)

Evidence Suggests That it is Evidence Suggests That it is Untreated Depression That KillsUntreated Depression That Kills

Autopsy/toxicology studies show suicide Autopsy/toxicology studies show suicide associated with no treatment or nonassociated with no treatment or non--compliance (Gray et al, 2003; Leon et al 2006)compliance (Gray et al, 2003; Leon et al 2006)

MisunderstandingsMisunderstandings……

Concern over safety of antidepressants Concern over safety of antidepressants have resulted in regulatory actionhave resulted in regulatory actionMuch misunderstanding and media Much misunderstanding and media distortion around this issuedistortion around this issue

Unintended ConsequencesUnintended Consequences……

Impact on Prescribing Impact on Prescribing --Suicide Epidemic?Suicide Epidemic?

Significant reductions in prescribing antidepressants across the world following regulatory action and warnings

Increased suicide ratesIncreased suicide ratesNetherlands: 22% drop in prescriptions and 49% Netherlands: 22% drop in prescriptions and 49% increase in youth suicide (Gibbons et al 2007)increase in youth suicide (Gibbons et al 2007)USA: USA: Single largest increase in suicide within this age Single largest increase in suicide within this age group since first documenting of suicide began in group since first documenting of suicide began in 19791979Canada: Suicide rates among children and Canada: Suicide rates among children and adolescents increased significantly after the Health adolescents increased significantly after the Health Canada issued a warningCanada issued a warning

More consequencesMore consequences……

Impact on depression identificationImpact on depression identification

Diagnosis of depression in youth and Diagnosis of depression in youth and young adults dropped to levels not young adults dropped to levels not seen in 10 years in the US (Libby et al seen in 10 years in the US (Libby et al 2007)2007)

Other Prevention StrategiesOther Prevention Strategies

AlcoholAlcohol–– Alcohol use prior to suicide is common (Bilban et al 2005; Alcohol use prior to suicide is common (Bilban et al 2005;

Cherpital et al 2004)Cherpital et al 2004)–– Restriction of alcohol consumption has led to reduction in Restriction of alcohol consumption has led to reduction in

suicide in some countriessuicide in some countries

AftercareAftercare–– Suicide attempters are 30Suicide attempters are 30--40 times more likely to 40 times more likely to

complete suicide compared with those who have never complete suicide compared with those who have never attempted (Harris & Barraclough, 1997)attempted (Harris & Barraclough, 1997)

–– Compliance with treatment after a suicide attempt is often Compliance with treatment after a suicide attempt is often poor (Mann et al 2005)poor (Mann et al 2005)

–– ““ChainChain--ofof--carecare”” programs have been shown to be useful programs have been shown to be useful (Dieserud et al 2000)(Dieserud et al 2000)

Treatment GuidelinesTreatment Guidelines

Treatment guidelines foster evidenceTreatment guidelines foster evidence--based based practices for depression and suicide prevention practices for depression and suicide prevention and are available to direct clinicians in their and are available to direct clinicians in their treatment decisions treatment decisions Improve quality of care, combined with training Improve quality of care, combined with training Examples of sources of practice guidelines Examples of sources of practice guidelines include:include:–– The World Health OrganizationThe World Health Organization–– National Institute for Health and Clinical ExcellenceNational Institute for Health and Clinical Excellence–– The American Psychiatric AssociationThe American Psychiatric Association–– The American Academy of Child and Adolescent The American Academy of Child and Adolescent

PsychiatryPsychiatry

Identification & ScreeningIdentification & Screening

Detect atDetect at--risk individuals (suicidal ideation or behavior risk individuals (suicidal ideation or behavior or disorders such as depression, alcohol abuse) and or disorders such as depression, alcohol abuse) and direct them to treatmentdirect them to treatmentAsking about suicide does not cause harm! (Gould et Asking about suicide does not cause harm! (Gould et al 2005 JAMA) al 2005 JAMA) –– ““Dare to AskDare to Ask””Can be completed by physicians, Can be completed by physicians, ‘‘gatekeepersgatekeepers’’ such as such as clergy, care givers or implemented in an organization clergy, care givers or implemented in an organization e.g., schools, prison, military (Mann et al 2005 JAMA)e.g., schools, prison, military (Mann et al 2005 JAMA)Can be promoted as a national initiative e.g. Can be promoted as a national initiative e.g. National National Depression Screening Day (First Thursday of October) Depression Screening Day (First Thursday of October) in the USAin the USAScreening programs are successful!Screening programs are successful!–– Doubling in detection of atDoubling in detection of at--risk youth in schools (Scott et al risk youth in schools (Scott et al

2004)2004)–– Adults primary care 10Adults primary care 10--47% increase in rates of detection and 47% increase in rates of detection and

diagnosis of depressiondiagnosis of depression

Primary Care:Primary Care:Opportunity for PreventionOpportunity for PreventionMajority of suicides see their doctor prior to their Majority of suicides see their doctor prior to their deathdeath–– 45% in the month prior to their death (Luoma et al 45% in the month prior to their death (Luoma et al

2002)2002)–– 80% in the year prior to death 80% in the year prior to death

Excellent opportunity for prevention! Excellent opportunity for prevention! Physician education has improved detection and Physician education has improved detection and treatment of depression (Pignone et al 2002, treatment of depression (Pignone et al 2002, Szanto et al 2007Szanto et al 2007) and problematic alcohol use ) and problematic alcohol use (Miller et al 2006)(Miller et al 2006)

How do we do it?How do we do it?Screening tool: For example, the ColumbiaScreening tool: For example, the Columbia--Suicide Suicide Severity Rating Scale (CSeverity Rating Scale (C--SSRS) SSRS) -- Brief measure of Brief measure of suicidal ideation and behavior, used across primary suicidal ideation and behavior, used across primary care, hospitals, clinics etc and available in 90 care, hospitals, clinics etc and available in 90 languageslanguagesInternational dissemination: Australia roll out to 5 International dissemination: Australia roll out to 5 million people across all settings (e.g. primary care, million people across all settings (e.g. primary care, mental health, police)mental health, police)Brief depression screening toolsBrief depression screening toolsPotential promising area: eHealth Potential promising area: eHealth –– improving access improving access of young people who donof young people who don’’t attend servicest attend services

Example of Prevention Through Example of Prevention Through Education: Caring for PhysiciansEducation: Caring for Physicians

Physicians have high rates of suicide, Physicians have high rates of suicide, particularly females (Shernhammer et al particularly females (Shernhammer et al 2004) 2004) Wide distribution of educational materials Wide distribution of educational materials developed by the American Foundation for developed by the American Foundation for Suicide Prevention Suicide Prevention to encourage treatment of to encourage treatment of depression and suicide prevention in depression and suicide prevention in physicians by changing professional attitudes physicians by changing professional attitudes and policyand policy

This paper was produced for a meeting organized by Health & Consumer Protection DG and represents the views of its author on thesubject. These views have not been adopted or in any way approved by the Commission and should not be relied upon as a statement of the Commission's or Health & Consumer Protection DG's views. The European Commission does not guarantee the accuracy of the dataincluded in this paper, nor does it accept responsibility for any use made thereof.