72 Early detection of mental ill-health, harmful stress and suicidal behaviours

Success in early detection of harmful stress, mental ill-health, and suicidal behaviour is substantially dependent on system solutions at the macro level. Suicide prevention interventions and strategies can only be effective if cross-disciplinary knowledge and skills, at different stages of the suicidal process and on different vulnerable groups are combined. In this chapter, traditionally well-known vulnerable groups, such as people with depression and alcohol misuse, are discussed at different stages of the suicidal process, in order to increase early detection. Early recognition is also important in demographic groups that have been neglected to date in suicide prevention, such as mothers with pre-natal and post-natal mental disorders, persons with diabetes mellitus, spinal cord injury disabilities and adult childhood cancer survivors, as well as young vulnerable people for whom harmful stress can be a suicidal trigger. In regard to the implementation and process optimization of individual interventions, lessons from management and, in particular, from social marketing, can provide a key contribution.

The origin of public mental health, as a branch of public health can be traced back to the nineteenth century, when one of the major concerns facing public health doctors was the epidemics of infectious diseases in Europe, namely of cholera. Accordingly, the first role of public health became that of social reform within the field of sanitation: housing, fresh water supply, construction of sewages, etc. The obvious public mental health component of this social intervention was an indirect one, as spending money for the relief of the living conditions of the underprivileged classes simultaneously led to an improvement in mental health.

Public health has remained concerned with primary prevention of diseases ever since, either by eliminating the causes or by enhancing host resistance. Unfortunately, the majority of mental disorders have not yet proved susceptible to this approach. Measures to prevent mental disorders, such as introducing dietary intervention to eliminate pellagra, which is a nicotinic acid deficiency causing somatic symptoms and apathy, depression and dementia; the widespread use of penicillin to eliminate general paralysis of patients with syphilis, and neonatal screening programmes to detect phenylketonuria and congenital hypothyroidism, have over time become common and made an important impact. There are several other opportunities for prevention by early intervention that have not been properly exploited yet, e.g. the detection of perinatal mental disorders in mothers, follow-up and counselling of parents with mental ill-health, prevention of pathological bereavement reactions and of post-traumatic stress disorders, and finally, prevention of suicidal behaviour (Kendell 1997). Early detection and focusing on high-risk groups are two of the main domains of public health, in general, and of public mental health, in particular.

Despite efforts to achieve a conceptual turnaround in understanding mental health in the past few decades, it is evident that the present ‘state of the art’ of mental health has not yet been fully successful in achieving a public health perspective and/or status. In order to improve this situation, we have to answer the question ‘What options should be chosen to involve and integrate mental health within public health?’ Our current understanding of mental health at present tends to be perceived solely in relation to mental disorders and the prevention thereof. There is also harmful stress, an important cause of mental ill-health and, last but not least, suicidal behaviour.

If one considers all these aspects of mental health, it is obvious that public mental health should deal with subpopulations affected by mental ill-health as well as with interventions aimed at the whole population by preventing mental ill-health and promoting mental well-being. It is necessary for public health and mental health experts to replace the notion of mental health as exclusively dealing with health determinants and supplement it with health indicators of the interplay between harmful life circumstances or events, the quality of health care and health promotion. Life events and circumstances are known to have a considerable effect on our health, in general, with mental health being the most acutely responsive and sensitive reaction. For example, harmful stress is an extremely negative life event, especially in people with mental ill health or for those lacking well-functioning mental resiliency.

In the past, public mental health has not figured high on public health agendas due to the relative insusceptibility of mental disorder to prevention and the absence of mental health indicators. These, in turn, have presented an important opportunity for public mental health to develop further as it is appropriate to consider mental health both as health determinant and health indicator. Mental health indicators provide an opportunity to study mental health in the broader social context. According to the so-called concept of sociosomatics (Kleinman and Becker 1998), as opposed to psychosomatics, mind and body interactions are reframed as mind and body in social context. The direct impact of social context on bodily or illness experiences are expected: social forces shape psychophysiological processes, and patterns of symptoms are identified as local idioms of distress and cultural syndromes (Kleinman and Becker 1998). This concept is also relevant for the cross-cultural understanding of suicidal risk.

Presence of mental ill-health has been recognized as being of major importance to all societies and age groups, related to a loss of quality of life, it may cause human suffering, disability, increased social exclusion (mainly due to stigma) and mortality (also due to higher suicidal risk). Accordingly, mental disorders have to be detected as early as possible to improve prognosis and also to decrease mortality—mainly via prevention of suicidal risk. Moreover, as far as primary prevention is concerned, the harmful effect of stress is usually linked to negative life events, which often causes mental disorders and needs to be prevented. The latter cannot be tackled without considering the social context of the interaction between the mind and body.

An assessment of mental health indicators and determinants is a prerequisite for the successful prevention of mental disorders and promotion of mental health. This is even more obvious if we single out the major public mental health concern—suicide. About 70 per cent of deaths worldwide due to suicide occur in the age group 25–64 which, from the socio-economic point of view, are the most productive years. Suicide poses a great economic burden to society due to lost future productivity (see Chapter 49 in this book). However, this burden will differ from state to state and from continent to continent, depending on specific suicide rates in these states and age distribution of suicides in a given country. As far as Europe and North America are concerned, suicide claims substantially more life years, and more personal income, between the ages of 20–64 than either of the other two major killers, cardiovascular diseases and cancer. The average number of years of lost productivity due to suicide is twice the number of those due to cerebrovascular disease and ischaemic heart disease. In Slovenia, which has one of the highest suicide rates in the world, death from suicide is the leading cause of future lifetime income lost; the first leading cause of valued years of potential life lost (VYPLL); the second leading cause of working years of potential life lost (WYPLL) with an average number of 21.7 years per person dying prematurely; the second leading cause of premature years of potential life lost (PYPLL) with 29.7 years per person that died prematurely, and the third leading cause of premature death, 15.9 per 100,000 inhabitants aged 0–64 (Šešok et al. 2004).

Public health measures for screening and early detection of vulnerable groups, especially during times of great change and potentially harmful stress (caused by loss and other life events), are more effective than measures taken in the later stages of suicidal process when suicide risk is known to be higher. Such efforts can only be achieved if mental health indicators and determinants of mental health are well-known and implemented through every day mental health policies.

Any kind of negative thinking, among others feelings of guilt, low self-esteem, lack of confidence, a desire not to wake up in the morning, a wish to be dead, or suicidal thinking—with or without suicidal plan or intent—is frequently associated with low mood, which may occur in the context of various mental disorders, especially depression. Suicide is also more likely in those with an underlying depressive or neurotic personality or those who are emotionally labile (see Figure 72.1). The core problem in this context appears to be poor detection by primary care practitioners (Lepine et al. 1997), although primary care educational programmes that target recognition and treatment of depression show an increase in antidepressant prescriptions and, in some cases, a decrease in suicidal rates (Kelly 1998; Rihmer et al. 2001; Marušič et al. 2004; Szántó et al. 2007). Despite significant improvement in early detection and effective treatment for depression, as evidenced by several studies (Guthrie et al. 2001; Motto and Bostrom 2001; Cedereke et al. 2002; Mann et al. 2005), depression is frequently under-treated or unnoticed in the primary care setting (Thies-Flechtner et al. 1996; Brown et al. 2005) with the majority of people committing suicide having had contact with a primary care physician within the last month of life (Andersen et al. 2000, Luoma et al. 2002). (See also Chapter 62 in this book.)

Enhanced and systematic types of intervention are another step forward in improving detection and treatment of depression and in preventing suicidal behaviour (Mann et al. 2005). In fact, several studies have reported better management of depression in primary care due to more complex interventions and systematic changes that help ensure improved treatment (Katon et al. 1996; Pignone et al. 2002; Gilbody et al. 2003). The success of these interventions may be linked to an improved satisfaction of patients' needs and solution of their problems in relation to depression. It is suggested that better implementation of existing guidelines for treatment by qualitatively improved interventions, which are more flexible and patient-oriented, provide an improvement of delivery of solutions for patients' problems and patients' needs and result in improvement of the patients' adherence to treatment. When we think about tailoring improved interventions for management of depression in primary care settings we must be aware of the time and provision restraints within general practices. In this regard, interventions based on improved systematic collaboration between general practitioners and nurses, beside an enhanced role of the health care provider in the treatment process, is a valuable option. Multifaceted interventions that upgrade common treatment in primary care, like telephone care management with structured cognitive behavioural psychotherapy (Simon et al. 2004), seem feasible as they fit well within the busy primary care setting (Hunkeler et al. 2000).

Impulsive and aggressive personality traits, in persons with, for example, bipolar disorder and mental disorder related to disinhibiting psychotropic substance misuse, are also linked to the suicidal process (see Figure 72.1). Impulsivity speeds up the process, while aggression is crucial in the progression from suicidal attempt to completion. Suicidal behaviour associated with aggression is far more likely to be fatal.

Impulsivity and aggression are usually increased in a social network where the likelihood of taking disinhibiting psychotropic substances, such as alcohol or cocaine, is higher. More data is available for alcohol-related suicide risk than drug-induced suicide risk, with acute and chronic alcohol misuse having long been identified as a potential risk factor for suicidal behaviour (Wasserman and Värnik 1998; Wasserman 2001). Studies show that approximately 40 per cent of people with alcohol problems have attempted suicide, and binge drinking in adolescents is often a more accurate indicator of suicidal behaviour than depression and stressful events (Windle 2004). Alcohol increases suicidal risk through psychological distress, aggression and impulsivity, as well as through impaired cognitive function, such as decision-making and problem-solving strategies (Hufford 2001).

If alcohol-related suicidal risk is to be detected earlier we need to be aware of the main covariants of this relationship. Temporary binge drinking, suicidal threats, comorbidity with depression, loss of close friends, poor social support, living alone, unemployment and serious somatic health problems have all been identified as specific risk factors in this high vulnerability group, where the male:female ratio can be as high as 5:1 (Murphy 2000). Individuals with alcohol dependency syndrome who show more significant signs of dependency, who have an associated mental disorder as a result of alcohol dependence, are separated or divorced are at higher risk of suicidal behaviour (Preuss et al. 2003; Värnik et al. 2007). Negative self-image, loss of self-respect, loss of independence and hopelessness are all factors which speed up the suicidal process in individuals combined with harmful alcohol use (Demirbas et al. 2003). If we are to detect and prevent suicidal behaviour in earlier stages of the suicidal process sooner we must focus on:

Suicidal depressed males with atypical (impulsive and aggressive) and clinically unrecognized depression (also relevant in the later stages of the suicidal process) may be overlooked by the medical health care system (Rutz 1999). (See also Chapter 35 in this book.) Accodingly, suicidal ideation and behaviour related to a typical depression is more difficult to prevent.

Availability of violent means of committing suicide, for instance access to firearms, plays an important role in the later stages of the suicidal process and public health legislation which restricts or prevents gun ownership is an important protective factor (see Chapter 77). Other contributing factors that may be important at this stage in the mental state of the suicidal are the presence of role models, either in the individual's social network or through portrayal by the media (see also Chapter 69).

Success in preventing suicidal behaviour is linked to the early detection of high-risk factors. The most relevant risk factor is depression, with a prevalence of major depression in approximately 5% of the population (Lönnqvist 2000; Wasserman 2006) and 60% of suicides being associated with mood disorder, principally major depressive disorder and bipolar disorder (Mann et al. 2005). For an overview of suicidal behaviour in somatic diseases see Chapter 40 in this book.

People with disabilities, chronic physical illness associated with severe pain or painful treatment procedures and dire outcomes are one such group. Any chronic somatic disease is associated with an increased prevalence of mood disorders, depression and related suicidal ideation (Mayou 1997). While more than half of all cases of suicide are diagnosed with depression (Bertolote et al. 2003), the inability to recognize depression is more pronounced in the group with somatic diseases, and associated suicidal ideation and behaviour is more difficult to prevent.

Early detection of the risks of suicidal behaviour amongst patients with somatic diseases is essential, particularly those with comorbid depression, with a public health emphasis on the following:

Diabetes is unique in its combination of the burden of diet and exercise, coupled with invasive blood glucose monitoring and, often, multiple daily insulin injections on the individual (Harris et al. 2003). Further, the chronic nature of the course of this disease makes it a high risk factor for suicide. Recent studies have estimated the prevalence of depression in individuals with diabetes may be at least twice the rate observed in the general population, negatively impacting on patients' quality of life and glycaemic control (Anderson et al. 2001). There is a surprising lack of studies on the suicidal behaviour of diabetics. Although 90–95 per cent of those diagnosed have non-insulin dependent diabetes mellitus (NIDDM) (Boswell et al. 1997), the most widely reported cases are of insulin misuse among the young with insulin-dependent diabetes mellitus (IDDM). Goldston et al. (1997) observed an association between suicidal thoughts and non-compliance of medical regimen amongst this group, whilst Kyvik et al. (1994) discovered suicide might be an underestimated cause of death among people with IDDM, and Dahlquist and Kallen (2005) reported an increased, but statistically insignificant, suicide rate. A recent study of 420 people with NIDDM and IDDM (Kozel and Marušič 2006) showed that more than 40% had a prevalence for depressive symptoms, with 32.8% of those showing symptoms admitting to active suicidal ideation, in marked contrast to the 8.5% with active suicidal ideation where serious depressive symptoms were absent.

Cancer is another chronic somatic illness associated with depression, which can, understandably, lead to an increased suicidal risk. Depressive symptoms associated with cancer range from normal sadness, through acute stress response, to major depression (Massie and Holland 1990). Steps similar to those outlined for patients with diabetes mellitus should be taken at all non-governmental levels as well as at primary and secondary health care levels.

An especially interesting vulnerable group is that of childhood cancer survivors in adulthood. There is growing evidence that the experience of cancer in childhood, or adolescence, may lead to long-term physical or psychosocial consequences of illness and its treatment, due to having faced a potentially deadly illness and possibly traumatic hospitalization, feelings of helplessness and anxiety and altered contacts with social circles. Jereb (2000) reported on emotional consequences found in 79 per cent of long-term survivors, and Bürger-Lazar (1999) showed these patients have different personality characteristics compared to their peers without a history of cancer. Cancer survivors are found to be more introverted and emotionally unstable, less persistent and assertive, with lower self-esteem, having difficulty gaining independence and, as a result, often lack social support. When compared to their siblings, childhood cancer survivors report depressive symptoms around 1.6 times more frequently (Zebrack et al. 2002). Even though long-term survivors may be cancer-free for a number of years, many of them are faced with an increased risk of cancer recurrence (Jazbec et al. 2004) and physical impairments. These have been described as risk factors for both depression and suicidal behaviour at all stages—negative thoughts, passive and active suicidal thoughts, suicidal plan and intent, and attempted and completed suicide. Indeed, Recklitis et al. (2003) detected suicidality in 13.9 per cent of the adult survivors of childhood cancer, all of them also showing significant psychological distress associated with their dissatisfaction with physical appearance and poor physical health.

Our study, which was one of the first investigations to tackle the problem of depression and suicidality in adulthood childhood cancer survivors, showed that significant depressive symptoms are three times more frequent in cancer survivors (13 per cent) than in their controls (Svetičič et al. 2005). The symptoms were often coupled with being female, having lower education, being single or divorced, not attending association group meetings and reporting weaker sociability. The latter was also associated with suicidal thoughts and plans. Groups did not differ in frequency of suicidal features, but, interestingly, suicide-related variables were in association with having depressive symptoms only in the cancer survivors group.

We should, however, also point that other studies show a certain appreciation for life found in individuals who survived cancer, possibly as a result of having fought a battle with a potentially deadly disease in their early years, the battle that could possibly protect them from suicidal behaviour (e.g. Chesler et al. 1992; Zeltzer 1993). These studies, including our investigation (Svetičič et al. 2005) have not shown an increased risk of suicidal behaviour among adult childhood cancer survivors. Nevertheless, special attention should be paid to those with depressive disorders. Depression is approximately twice as frequent as in a population with no history of chronic childhood disease. Primary health care workers, specialists and non-governmental organizations in touch with survivors need to be aware of the increased likelihood of depressive symptoms and the associated suicidal risk in this group. Furthermore, strategies aimed at de-stigmatization of the disease, patients' integration into society and working on their often lowered self-esteem and weakened sociability should also be considered.

As well as coming to terms with permanent physical disability, and all its consequences, spinal cord injury patients also need to face the additional burden placed on them by society. The permanent physically disabled are often treated differently, for example people may be especially kind to them, they speak louder, feel tense, ask too much about the illness or disability and patronise them as if they were either younger or in some way inferior (Zaviršek 2000). An individual's self view is highly influenced not only by important restrictions due to disabilities (Prout and Prout 1996), but also by the reactions of the social environment, which can affect the disabled's self-esteem. For example, due to a noticeable difference in their physical appearance, individuals with physical disabilities attract more attention than others that do not have instantly visible handicaps. Nosek and his colleagues (1996) claim that low quality of life in spinal cord injury individuals is more a consequence of barriers set by the environment than the disability itself as far as psychological and psychopathological adjustment are concerned. However, depression, sleep disturbance, suicidal thoughts and guilt can occur in 60 per cent of patients (de Carvalho et al. 1998), whereas the suicide rate can be up to ten times higher among paraplegics than their uninjured peers (Rish et al. 1997). In general, this group suffers from psychosocial maladjustment and substance abuse, which is an additional generator of vulnerability. Five years after trauma, suicide statistics for spinal cord injured patients are significantly lower, although they never drop to the same level as their uninjured peers. Our results on individuals with paraplegia, tetraplegia or amputation following a motor vehicle accident in Slovenia (Jurišič and Marušič in press) showed extremely high suicidality rates for all the groups, which correlated with low total self-esteem, presence of post-traumatic stress disorder symptoms and, interestingly, but not surprisingly, a history of suicide in the family. Intrusive thoughts, feelings and images of the accident correlated with suicidal thinking and planning of suicide.

We can conclude that patients with spinal cord injury need good psychosocial rehabilitation, especially paying attention to patients' self-image following their medical care, in particular when they return to their own social contexts. These results also support our intent to seriously consider self-image and especially suicide risk in patients with permanent physical disabilities, something that has been rather neglected so far.

In several countries, suicide is now the second or third most frequent cause of death amongst 15–24-year-olds (Evans et al. 2004). An increased rate of suicide towards the end of adolescence indicate youths as another important vulnerability group where early detection should be of primary concern from a public health perspective. Change is an important risk factor for adolescent suicides. Adolescence brings about physical growth, maturation and development. Adolescents need to become familiar with these changes, which often cause confusion and difficulties. Low self-esteem, for example, as a negative development outcome represents a risk factor for suicide by itself and in correlation with depression (Hawton and van Heeringen 2002). Psychological autopsies of suicide show that depression is present at the time of death in most adolescents who die by suicide (Hawton and James 2005). Depression, anxiety, hopelessness and low self-esteem are important risk factors for adolescent suicide. Conduct disorders, substance abuse, impulsivity and aggressiveness as personality traits, together with a history of suicide attempt(s) and a family history of suicide in this vulnerability group were also pointed out by Zametkin et al. (2001).

Adolescent suicide can be accelerated by psychosocial stressors, such as recent loss, rejection and failure, which are a significant and very common characteristic of adolescence. The most influential environmental factors are a history of abuse, other adverse life events, school problems, problems in peer-relations and a dysfuntional family (Evans et al. 2004). The family is a predominant source of influence on the adolescent's suicidal behaviour. Family risk factors can be divided into three groups: loss of social support (death, parental separation or divorce), variability in parental functioning (affective disorders, suicidal tendencies, alcohol misuse) and physical and psychological violence. The strong influence of adverse events on adolescents may be due to a more limited capacity of younger people to cope with such stressors (Dube et al. 2001).

Many risk factors for adolescent suicide may not be identified in time, thereby making it difficult to predict and prevent suicide. Adolescents tend to appear as rather unpredictable, and although there may be warning signs, they are often uncommon and hard to identify. Depression or distress symptoms in adolescents are also different from those of the adult population. However, suicidal ideation is relatively common in the adolescent population (Zametkin et al. 2001) and simply focusing on these would help detect early suicidal risk. An Australian programme that trained primary care physicians to recognize and respond to psychological distress and suicidal ideation in young people led to an increased identification of suicidal patients (Huey et al. 2004). A substantial number of adolescents in need do not search for appropriate help, which is why more accessible clinical help and crisis services are needed. Prevention should be based on raising awareness of the problem of adolescent suicide, training gatekeepers (general practitioners, teachers etc.) to identify those at risk and providing education about community mental health resources. There is a need for better cooperation between different professions as well as the formation of concrete activities for young people, such as how to develop a positive attitude to life and to improve coping abilities and problem-solving, etc.

Success in early detection of harmful stress, mental ill-health, and suicidal behaviour is substantially dependent on systematic solutions at the macro level. Good policy-making is essential in order to select and implement cost-effective interventions that can optimize the use of usually modest or limited resources. Suicide prevention interventions and strategies can only be effective by the combination of knowledge and skills used in different disciplines at different stages of the suicidal process and on different vulnerability groups. Lessons from management and in particular from social marketing, both until now, scarcely employed approaches in suicide prevention, can provide a key contribution to the implementation and process optimization of individual interventions.

Social marketing is the application of commercial marketing technologies to the analysis, planning, execution, and evaluation of programmes designed to influence the voluntary behaviour of target audiences in order to improve their personal welfare and that of their society (Andreasen 1995). In previous decades, the social marketing approach has proven to be effective in tackling social issues like improving physical activity, tobacco use prevention, prevention of drunk driving and so on, all via the so-called marketing behavioural change (Malafarina and Loken 1993; Andreasen 1995; Kotler et al. 2002). The social marketing approach is based on the following two key points (Andreasen 1995):

The social marketing conceptual perspective and inventory of tools, like customer orientation, audience segmentation, marketing research, strategic planning, competitive positioning and so on, could provide a valuable opportunity for suicide prevention, due to the explicit focus on tailoring evidence-based and cost-effective programmes. In fact, providing cost-effective and evidence-based interventions is an essential argument in the advocacy of preventive programmes to policy-makers in general, and suicide preventive action in particular. Hence, evaluation of interventions should be planned and incorporated in the programme outline from the outset of the strategy planning process in order to foresee possibilities and limitations of the evaluation for single interventions. From this perspective, social marketing can be considered a promising possibility, due to a broad inventory of concepts and tools that are almost unknown to the field of mental disease and suicide prevention, and that can be applied for designing and improving cost-effective and evidence-based interventions.

Based on social marketing information (Andreasen 1995; Weinreich 1999; Kotler et al. 2002) a summary of necessary steps in establishing and setting up effective suicide prevention services is proposed. ‘Steps’ is perhaps not the most appropriate term as the actions listed below are not necessarily performed in sequence:

Generic strategies for suicide prevention should be culturally sensitive and targeted to the specific understandings and attitudes of those to whom the messages are directed (Jenkins and Singh 2000). In addition to the adequate understanding of target users, services should meet their needs in order to improve user participation. This kind of perspective, which has already been used in social marketing theory and practice, was named the ‘customer-centred mindset’ by Andreasen (1995). In our case, the orientation is high-risk groups for suicide, thus it is from there that the establishment of cost-effective interventions should start.

In many countries, suicide prevention is left to the enthusiasm of a few individuals and is, consequently, disorganized and without a proper national programme or strategy. A lack of vision is often coupled with a lack of strategy. The question ‘Why?’ has yet to be fully answered, while the following have often not even been asked ‘Who?’ ‘With whom?’ ‘What’, ‘Where’ and ‘How?’ Suicide prevention is usually based on a combination of the best possible pharmacological approach together with some psychotherapeutical appproaches, but there is a lack of communication between health and social care sectors, governmental and non-governmental organizations. Consequently, there is great need for continuity in preventive work, which requires, among other things, greater communication between sectors and disciplines dealing with the suicidal process. If we follow the suggestions of the social marketing perspective, it should depend on a country's capacity to form an effective social network with effective suicide prevention as the aim. The following aspects are necessary for suicide prevention to be truly effective:

Finally, the ethical question that suicide prevention should always balance: the person's right to freedom versus their right to be safe and healthy needs. This topic needs to be examined more deeply in a sophisticated scientific and ethical discussion.