1) The document summarizes the SEYLE study, a large European study on adolescent mental health and suicide prevention. It describes the study design, interventions tested, and key findings. 2) Baseline results found high rates of suicidal thoughts and behaviors among adolescents in some European countries. Risk factors identified included depression, anxiety, substance use, and poor sleep. 3) Three suicide prevention interventions were evaluated: QPR gatekeeper training, screening and referral (ProfScreen), and a mental health awareness program (YAM). 4) At 12-month follow-up, YAM demonstrated effectiveness in reducing suicide attempts and severe suicidal ideation compared to the control group.

1. Suicide prevention in adolescents –
from understanding underlying factors
to implementing effective interventions
Merike Sisask
Estonian-Swedish Mental Health and Suicidology Institute (ERSI)
Tallinn University, School of Governance, Law and Society (SOGOLAS)
Nõmme Health Clinic
“Perspectives to suicide prevention” Seminar 26th of October 2017, Helsinki

2. Topics of the presentation
• Introduction
• SEYLE project and study design
• Prevalence of suicidal behaviours and self-inflicted injuries
• Associations with mental health indicators and life-style habits
• SEYLE interventions, evaluation of effectiveness

3. Leading causes of death in youth globally
Patton et al 2009 (the Lancet)

4. Suicide trends in the EU (WHO/Euro-MDB)
Age 65+ Age 15-29
1980 2,1 0,3
1990 2,0 0,4
2000 1,7 0,4
2010 1,6 0,5
SUICIDE RATE RATIO
Sisask 2016

6. • Evidence about effectiveness of restricting access to
lethal means has increased during the past 10 years
(analgetics, hot spots)
• School-based intervention programmes decrease
suicide attempts and suicidal ideation
• Effective pharmacological and psychological
treatments are important in prevention
• Evidence-base is insufficient: screening in primary
care, general public education, media guidelines
• Further investigation is needed: gatekeeper training,
education of physicians, internet and helpline support

9. SEYLE study
• Saving and Empowering Young Lives in Europe
• School-based prevention programme
• Duration 2009-2011 (publication process is ongoing – currently more
than 35 scientific articles in journals with high impact factors)
• Cross-sectional baseline data collected in 2009/2010
• EC 7th Framework Programme project
• Project coordinator Karolinska Institute (Sweden)
• Participating sites from 11 European countries
• Main target group: 14-15-year old schoolchildren
• Self-reported structured questionnaires administered in classrooms

10. SEYLE: participating sites
Austria
Estonia
France
Germany
Hungary
Ireland
Israel
Italy
Romania
Slovenia
Spain
Sweden (coordinator)

11. Main objectives of SEYLE
• To lead adolescents to better mental health through decreased
risk-taking and suicidal behaviours
• To evaluate outcomes of three different suicide-preventive
interventions in multidisciplinary perspective
• To recommend culturally adjusted models for promoting mental
health and preventing suicidal behaviours in different European
countries

12. SEYLE study design
Main objective: Mental health promotion by
preventing risk and suicidal behaviours

14. SEYLE questionnaire for pupils
• Physical health
• Mental health
• Self-esteem
• Relationships within the family
• Relationships with peers
• Lifestyle choices
• Internet use
• Attitudes
• Risk behaviours (smoking, alcohol, drugs, suicidal
behaviour, non-suicidal self-injuries, fighting, bullying)

15. Scales integrated into SEYLE questionnaire
• WHO-5 – subjective well-being index
• SDQ – strengths and difficulties scale
• BDI – Beck depression inventory
• Hopelessness scale
• PSS – Peykel suicide ladder
• YDQ – Young internet addiction questionnaire
• DSHI – deliberate self-harm inventory
• Zung anxiety scale

16. SEYLE sample description
• Total number of subjects N = 12 395
• Gender:
• Boys 44.8%
• Girls 55.2%
• Mean age 14.9 (SD = 0.9)

17. SEYLE baseline evaluation
(cross-sectional study)

18. Very often or always life not worth living
during the past 2 weeks
7
33333222
211
0,0%
1,0%
2,0%
3,0%
4,0%
5,0%
6,0%
7,0%
8,0%
Hungary
Ireland
Italy
EstoniaSlovenia
France
Austria
ALL
C
O
U
NTR
IESRom
aniaG
erm
any
Spain
Israel

19. Very often or always seriously considered
taking own life during the past 2 weeks
2,6
1,7
1,5
1,0
0,90,80,80,7
0,50,5
0,40,3
0,0%
0,5%
1,0%
1,5%
2,0%
2,5%
3,0%
Hungary
Estonia
ItalyRom
ania
Ireland
Spain
AustriaSlovenia
ALL
C
O
U
NTR
IES
FranceG
erm
any
Israel

20. Ever tried to take own life
2,7
0,9
0,60,60,6
0,50,5
0,3
0,10,00,0
0,3
0%
1%
1%
2%
2%
3%
3%
AustriaH
ungary
ItalySlovenia
France
Spain
Estonia
ALL
C
O
UN
TRIES
IrelandR
om
aniaG
erm
any
Israel

21. Suicidal behaviour (SEYLE in Estonia)
During the past 2 weeks (often, very often or always)
0 0,5 1 1,5 2 2,5 3 3,5 4 4,5
Life is not worth living
Wished that you were dead
Thought of taking your life
Seriously considered taking your life
Attempted suicide
%

22. Spoken to anyone about last suicide attempt,
if medical care was not received (SEYLE in Estonia)
47,3%
14,2%
52,7%
85,8%
0 10 20 30 40 50 60 70 80 90 100
Parent
Friend
YES
NO

23. Intentionally injured (any type) themselves
at least once during life
39
36
3333
29282727
212121
18
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
H
ungary
R
om
ania
Ireland
Italy
Austria
Slovenia
ALL
C
O
U
N
TR
IES
Spain
Israel
Estonia
G
erm
any
France

24. Non-suicidal self-injuries (Estonia)
At least once during life
0 2 4 6 8 10 12 14 16 18
Scratched yourself
Cut wrists, hands etc
Banged head or punched yourself
Prevented wounds from healing
Burned yourself
Injury required medical treatment
%

26. Balazs et al 2013
Both subthreshold and threshold-anxiety and depression
were related to functional impairment and suicidality

28. Durkee, Kaess et al 2012
• Internet users were classified into three categories based on
their score in the Young Diagnostic Questionnaire for Internet
Addiction (YDQ):
• Adaptive Internet users
• Maladaptive Internet users (MIU)
• Pathological Internet users (PIU)
• The prevalence of MIU and PIU among adolescents in Europe
was 13.5% and 4.4%, respectively
• Females showed higher rates of MIU and males indicated higher
rates of PIU

29. Kaess, Durkee et al 2013
• PIU is a rising mental health problem among adolescents
which, like other impulsivity-related risk-behaviors, is closely
associated with adolescent psychopathology
• Depression, hyperactivity/inattention, conduct problems and
suicidal behaviours (i.e. suicide ideation and attempts) are
independently associated with PIU

30. Reduced sleep hours per night during school days
in adolescent schoolchildren are associated with
emotional problems and increased suicidal ideation

32. • Low social belonging was associated to serious suicidal ideation
• However, reading books and watching films moderated this
association, especially for those with lowest levels of belonging. This
was true both at baseline and at 12 months of follow-up analyses
• These media may act as sources of social support or mental health
literacy and thus reduce the suicide risk constituted by low sense of
belonging
Kasahara-Kiritani et al 2015

34. Associations between suicidal ideation, multiple risk behaviours
and communication with parents (age group 15-16)
(Estonia, Lithuania, Luxembourg)
Mark et al 2012, HBSC study

35. Low-risk, high-risk and invisible-risk students
Carli et al 2014

36. Carli et al 2014
Low-risk, high-risk and invisible-risk students – mental health

37. SEYLE follow-up evaluation
(intervention study)

38. Control group
Minimal intervention

40. QPR
Question, persuade, refer – training and information
materials for teachers and other school personnel

41. Question,Persuade,Refer-QPR

42. How to ask about suicidal thoughts?
How to persuade to seek help?
How to refer to get help?
Warning signs of suicide
Who is gatekeeper?
QPR for suicide prevention

43. Better satisfaction with
general school climate,
higher psychological well-
being, and the ability to
understand pupils’ mental
health problems increased
the odds of teachers’
readiness to help pupils
with mental health
problems

44. ProfScreen
Individual screening interviews and referral

45. Screening risk behaviours (stage 1)
• Depression (BDI)
• Anxiety (ZUNG)
• Suicidal inclination
• Non-suicidal self injury
• Body mass index (BDI)
• Sensation seeking and delinquent
behaviour
• Misusing substances
• Media influence
• Social relationships
• Bullying
• Truancy
ProfScreen interview
(stage 2)
No significant risk
factors identified 
life-style
suggestions
Significant risk factors
identified 
psychiatric
consultation

47. • In stage one 61 % of participants (n = 1,865) were identified as
being at-risk
• In stage two 12.5 % of the original sample (n = 384) were
found to require subsequent mental healthcare during semi-
structured, clinical assessment
• 18.5 % of pupils were identified due to screening for
psychopathology alone
• 29.4 % due to screening for risk-behaviours alone
• 52.1 % by a combination of both
Kaess et al 2014

48. Awareness
Raising awareness about mental health among students

49. AffectandImprovetheWayYouFeel

50. Mental health
Self-help advice
Stress and crisis
Depression and suicidal thoughts
Helping a troubled friend
Getting advice: who to contact
AffectandImprovetheWayYouFeel

51. WEEK 1:
WEEK 2:
WEEK 3:
OPENING SESSION
ROLE-PLAY II
Awareness about feelings and how to
manage stress and crisis situations
CLOSING REMARKS
ROLE-PLAY I
Awareness about choices (dilemmas)
ROLE-PLAY III
Awareness about depression and
suicidal thoughts

54. Findings – suicidal behaviours
• No significant differences at 3 month follow-up
• At 12 month follow-up, YAM (compared with the control group) was
associated with significant reduction of:
• incident suicide attempts (OR=0.45, 95% CI 0.24-0.85; p=0.014)
• 14 students (0.70%) reported incident suicide attempts at the 12 month follow-up in the
YAM versus 34 (1.51%) in the control group
• severe suicidal ideation (OR=0.50, 95% CI 0.27-0.92; p=0.025)
• 15 students (0.75%) reported incident severe suicidal ideation in the YAM group versus
31 (1.37%) in the control group
• No participants completed suicide during the study period
Wasserman et al 2015

55. Findings – depression
• At 12 months, YAM provided statistically significant protective effects
against clinically significant depression (adjusted odds ratio (AOR),
0.63; 95% confidence interval (CI) 0.45 to 0.90, p=0.0107)
• No significant differences were observed for PROF-SCREEN or QPR
Hoven et al manuscript

56. Interpretation
• YAM was effective in reducing the number of suicide attempts and
severe suicidal ideation in school-based adolescents
• These findings underline the benefit of this universal suicide
preventive intervention in schools
Wasserman et al 2015

57. Thank you for your attention!
Merike Sisask, PhD
Phone +372 51 66 543
sisask.merike@gmail.com
Tallinn University, School of Governance, Law and Society
Professor in Public Health
Estonian-Swedish Mental Health and Suicidology Institute (ERSI)
Management Board Member and Senior Researcher
Õie 39 Tallinn 11615 Estonia
Phone/Fax +372 651 6550
www.suicidology.ee
Nõmme Health Clinic
www.tervisekliinik.ee