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.

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).

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.

Contribution to the validation of the Kutcher Adolescent Depression Scale (KADS-6) in a Portuguese population / Contribuição para a validação da Kutcher Adolescent Depression Scale (KADS-6) para a população Portuguesa

The KADS-6 is a self-report assessment instrument known for its ease application in assessing depression in young people. This study aimed to contribute to the validation of the Portuguese version of this tool and analyze its psychometric characteristics in comparison with other self-report instruments for depression in adolescents, in Portugal. Two samples were collected, a non-clinical group of in school youth (n=773; 52.4% male) and a clinical sample (n=134 youth; 44% male). Comparisons also used the Beck Depression Inventory (BDI-II) and the Children's Depression Inventory (CDI). Results: The factor analysis revealed the unidimensionality of the measure. The KADS-6 demonstrated good internal consistency (Cronbach's alpha) in both clinical (.74) and school (.80) samples. Its convergent validity with the BDI-II and CDI was r=.44; r=.61, respectively in the clinical sample and r=.60; r=.57 in the school sample. The KADS-6, a short and time efficient instrument, showed good psychometric characteristics in terms of internal consistency and convergent validity in comparison with the BDI-II and the CDI. Given its ease of use and scoring, the KADS-6 could be considered for use in both school and clinical settings when addressing adolescent depression. (AU)

A Kutcher Adolescent Depression Scale (KADS-6) é uma medida de autorrelato, conhecida pela sua facilidade de aplicação na avaliação da depressão em jovens. Este estudo teve como objetivos contribuir para a validação da versão portuguesa desta ferramenta e analisar as suas características psicométricas em comparação com outros instrumentos de autorrelato para a avaliação da depressão em adolescentes, em Portugal. Foram recolhidas duas amostras, uma não clínica, formada por jovens em contexto escolar (n=773; 52,4% rapazes) e outra amostra clínica (n=134; 44% rapazes). Foram também utilizados o Beck Depression Inventory (BDI-II) e o Children's Depression Inventory (CDI). A análise fatorial revelou a unidimensionalidade da medida. A KADS-6 demonstrou boa consistência interna (alfa de Cronbach) nas amostras não clínica (.74) e clínica (.80). A validade convergente com a BDI-II e CDI foi, respetivamente, r = .44; r = .61 na amostra clínica e r = .60; r = .57 na amostra não clínica. Conclui-se que a KADS-6 mostrou boas características psicométricas em termos de consistência interna e validade convergente em comparação com o BDI-II e o CDI. Dada a sua facilidade de uso e interpretação, a KADS-6 pode ser considerada para uso em contexto escolar e em ambientes clínicos, para avaliar a depressão adolescente. (AU)

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.

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.

Validity study of the Beck Anxiety Inventory (Portuguese version) by the Rasch Rating Scale model / Estudo de validade da versão portuguesa do Beck Anxiety Inventory mediante o modelo Rasch Rating Scale

Our objective was to conduct a validation study of the Portuguese version of the Beck Anxiety Inventory (BAI) by means of the Rasch Rating Scale Model, and then compare it with the most used scales of anxiety in Portugal. The sample consisted of 1,160 adults (427 men and 733 women), aged 18-82 years old (M=33.39; SD=11.85). Instruments were Beck Anxiety Inventory, State-Trait Anxiety Inventory and Zung Self-Rating Anxiety Scale. It was found that Beck Anxiety Inventory's system of four categories, the data-model fit, and people reliability were adequate. The measure can be considered as unidimensional. Gender and age-related differences were not a threat to the validity. BAI correlated significantly with other anxiety measures. In conclusion, BAI shows good psychometric quality...

Foi objetivo a validação da versão portuguesa do Beck Anxiety Inventory (BAI) mediante o modelo Rasch Rating Scale e a sua comparação com as escalas mais usadas de ansiedade em Portugal. A amostra consistia de 1160 adultos (427 homens e 733 mulheres) com idades entre 18-82 anos (M = 33,39; DP = 11,85). Os instrumentos utilizados foram: BAI, State-Trait Anxiety Inventory e Zung Anxiety Scale. Verificou-se que o sistema de quatro categorias, o ajuste dos dados ao modelo e a fidelidade das pessoas eram adequados. A medida é unidimensional. O género e as diferenças relacionadas com a idade não se mostraram ameaças à validade. O BAI correlaciona-se significativamente com as restantes medidas de ansiedade. Conclui-se que o instrumento apresenta boa qualidade psicométrica...

[Burnout in teachers: its relationship with personality, coping strategies and life satisfaction]. / Burnout em professores: a sua relação com a personalidade, estratégias de coping e satisfação com a vida.

INTRODUCTION/OBJECTIVES: Burnout Syndrome is characterized by feelings of physical and emotional exhaustion, depersonalization, and low personal fulfillment and teaching has been considered one of the contexts of work where the professionals seem to be more exposed to suffer from Burnout. The aim of this study was to relate Burnout, personality, affectivity, Coping strategies and life satisfaction. MATERIAL AND METHODS: It was used a sample of 404 teachers aged between 23 and 64 years (M = 41.20; SD = 9.79), ranging from the first cycle to university education. The following instruments were used: Coping Responses Inventory (CRI), Big Five Inventory (BFI), Positive and Negative Affective Schedule (PANAS), Maslach Burnout Inventory (MBI) and Satisfaction with Life Scale (SWLS). RESULTS: The results showed that teachers with higher levels of neuroticism presented more Burnout, on the other hand teachers with a higher level of extraversion and agreeableness showed more personal accomplishment. Teachers who were high on negative affectivity where also high on Burnout, those who presented Coping strategies focused on the problem had higher results on personal accomplishment, conscientiousness, extraversion and openness to experience. Teachers who presented strategies more focused on emotions also revealed higher levels of neuroticism and Burnout. Results also showed that greater the satisfaction with life is correlated with higher personal accomplishment and extraversion and lower Burnout. Those who teach in higher levels of education revealed higher satisfaction with life and those who teach in lower levels showed higher emotional exhaustion. CONCLUSIONS: We cannot understand Burnout ignoring personality processes and selection of coping strategies that accompany it.

[Depression and suicidal ideation in elderly institutionalized and non-institutionalized in Portugal]. / Depressão e ideação suicida em idosos institucionalizados e não institucionalizados em Portugal.

INTRODUCTION/OBJECTIVES: Depression has shown as the more common mental disorder in elderly community and suicide is it worst consequence. In the Portuguese context suicide rates among the elderly take values higher than in other age groups. The present study aimed to compare elderly institutionalized and not institutionalized in terms of depression, suicidal ideation, dependency and leisure activities. MATERIAL AND METHODS: The sample was collected in Algarve, Alentejo and Lisbon, in 155 elderly, 85 institutionalized and 71 not institutionalized, with similar proportions between genders. The instruments were The Activity and Leisure Index (IAL), the Geriatric Depression Scale (GDS), The Barthel Index and the Beck Scale for Suicide Ideation (BSI). RESULTS: The results showed that the elderly institutionalized did not presented higher depression, loneliness, suicidal thoughts or lowest level of activity and leisure, but were less independent. The participants with highest suicidal thoughts had more depression. A self-perception of worse health and more loneliness were related with more depression. A higher activity and leisure was related with less suicidal ideation. CONCLUSIONS: The data seem to show that the institutionalization of elderly is not related negatively with depression and suicidal ideation.