Creating an Evidence-Based Approach to Lifespan Suicide Prevention

Dennis D. Embry, Ph.D.
Crea%ng
an
Evidence-‐Based
Approach

President/Senior Scientist
to
Lifespan
Suicide
Preven%on
PAXIS Institute

Monday, April 15, 13 1

38,000


The Polio Epidemic


The Polio Epidemic

3,000


A recent
webinar
experience
on the topic


Is this early
prevention?


Thinking way upstream
What might be the early malleable predictors?

What if we started
here with early
suicide prevention?


Could we actually change those predictors easily
and reliably?
And what else might change as a consequence
of the prevention or protection strategies.


risk factors during development from early
childhood to adolescence
Psychiatric problems in childhood and/or
adolescence, including depression
Child and/or adolescent externalizing disorders
Childhood adversity (especially with the above)
Low self-efﬁcacy
Aggressive or delinquent behavior
Poor peer relations

Prax Kinderpsychol Kinderpsychiatr. 2012;61(1):32-49.


risk factors during development from early
childhood to adolescence
Psychiatric problems in childhood and/or
adolescence, including depression
Child and/or adolescent externalizing disorders
Childhood adversity (especially with the above)
Low self-efﬁcacy
Aggressive or delinquent behavior
Poor peer relations

And prenatal and post-natal

Prax Kinderpsychol Kinderpsychiatr. 2012;61(1):32-49.


Could we actually change those predictors easily
and reliably?
And what else might change as a consequence
of the prevention or protection strategies.


Surveying the Past Foretells Our Futures

Consider the cohort trends…#1 mental health disorder



Born NOW?



Born NOW?

These trends are not
the result of over-
diagnoses


Cumulative
prevalence of
psychiatric

Cumulative Prevalence
disorders by
young
adulthood: a
prospective
cohort analysis
from the Great
Smoky
Mountains
Study.

9 10 11 12 13 14 15 16 19 21

AGE
Copyright © 2012-2013, PAXIS Institute. May be reproduced in entirety with copyright notice • 1-877-GO-PAXIS • www.paxis.org

Cumulative
prevalence of
psychiatric

disorders by Oldest Cohort
young
adulthood: a
prospective
cohort analysis
from the Great
Smoky
Mountains
Study.

9 10 11 12 13 14 15 16 19 21

AGE

Cumulative
prevalence of
psychiatric Middle Cohort

young
adulthood: a
prospective
cohort analysis
from the Great
Smoky
Mountains
Study.

9 10 11 12 13 14 15 16 19 21

AGE

Cumulative
Youngest Cohort
prevalence of

young
adulthood: a
prospective
cohort analysis
from the Great
Smoky
Mountains
Study.

9 10 11 12 13 14 15 16 19 21

AGE

Cumulative
Youngest Cohort
prevalence of

young
adulthood: a
prospective
cohort analysis
from the Great
Smoky
Mountains
Study. EARLIER START;
Higher Prevalence

9 10 11 12 13 14 15 16 19 21

AGE

Lifetime Prevalence of Disorders in US Adolescents (N=10,123)

40%

35%

30%

25%

20%

15%

10%

5%

Merikangas et al., 2010
0%
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age in Years


40%

35%
Anxiety

30%

25%

20%

15%

10%

5%

0%
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age in Years


40%

35%
Anxiety

30%

25%

Behavior
20%

15%

10%

5%

0%
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age in Years


40%

35%
Anxiety

30%

25%

Behavior
20%
Mood

15%

10%

5%

0%
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age in Years


40%

35%
Anxiety

30%

25%
Substance
Behavior
20%
Mood

15%

10%

5%

0%
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age in Years


40%
1-out-2 USA
35%
young adults will
be aﬄicted with Anxiety

30%
one or more of
these disorders
25%
Substance
Behavior

by age 18
20%
Mood

15%

10%
NOTE
5% EARLY START
0%
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Age in Years

The US had 75
million children
and teens 2009

Wall Street
Journal,
12-28-2010


The US had 75
million children
and teens 2009
40.4 million kids had
one psychotropic
med in 2009

Wall Street
Journal,
12-28-2010


How many of you
know a blue-collar,
middle-class, or
upper-class family
who is reasonably
intact…


How many of you
know a blue-collar,
middle-class, or
upper-class family
who is reasonably
intact…

with a child, teen, or adult child with a
mental, emotional, or behavioral disorder?


How do we handle this problem of mental illnesses?


Prevalence rates
are increasing
rapidly in
North America

How do we handle this problem of mental illnesses?


Common set of conditions producing these negative trends…

Poor Health
RNA
IL6 DNA

Epigenetic Changes

Inspirational Credit: Clyde Hertzman


Common set of conditions producing these negative trends…
HIgh Exposure to Toxic Inﬂuences/ACEs

Exposure to Low Psychological Flexibility

HIgh Exposure to Problematic Behaviors

High Reinforcement of Anti-Social Behavior

Poor Health • Mental Disorders
RNA • Emotional Disorders
IL6 DNA • Behavioral Disorders
• Related Physical Disorders
Epigenetic Changes
Evolutionary Adaptations to
a Predatory, Stressful World;
Inspirational Credit: Clyde Hertzman worse social determinants


Multi-Inﬂammatory Brain & Body Response

Major Connected Causes of the Adverse Trends Predicting MEBs & Related Illnesses

Reinforcement Antecedents Physiological Verbal Relations
more for anti-social cue anti-social inﬂuences trigger occasion perceived
than prosocial acts and threats adverse biological threats and related
behaviors mechanisms reactions

The Same Mismatches Predict Multiple MACH Disorders

Mood Lo Reward Lo Executive Lo Behavioral
Inattention Function
Instability Delay Competencies
Poor Immune-
Motor Healing
Skills Multi-Inﬂammatory Brain & Body Response Dysfunction




Substance Work Obesity,
Early Mental Illness Violence Cancer School
Abuse Problems etc
Sex Failure

Mood Lo Reward Lo Executive Lo Behavioral
Inattention Function
Instability Delay Competencies
Poor Immune-
STD’s Motor Healing Special
Skills Multi-Inﬂammatory Brain & Body Response Dysfunction Ed




The America’s First Peoples…
26,000 to 12,000 B.E. 1491 AD Disease & War Extermination,
OriginalHuman Marginalization,
Migrations to & Suppression
North America
30,000,000
300,000
≈ Souls in ≈ Souls
North America
Residential
Schools;
Western Diet

Evolutionary bottleneck


The America’s First Peoples…
26,000 to 12,000 B.E. 1491 AD Disease & War Extermination,
OriginalHuman Marginalization,
Migrations to & Suppression
North America
30,000,000
300,000
≈ Souls in ≈ Souls
Today
North America
Residential
Schools;
Western Diet



Slavery The Great
African Americans 1863
Middle
… 1500’s to Passage
Institution
of Slavery
Jim
Crow
Migration
North
Original Human
Populations in Africa
Continuing
≈ Capture Trauma

30% to Separation,
Exposure
50% + violence,
to Toxins
mortality malnutrition



Slavery The Great
African Americans 1863
Middle
… 1500’s to Passage
Institution
of Slavery
Jim
Crow
Migration
North
Original Human
Populations in Africa
Continuing
≈ Capture Trauma
today

30% to Separation,
Exposure
50% + violence,
to Toxins
mortality malnutrition



Example Lasting Effects of Evolutionary Bottlenecks

US Blacks Barbados St. Lucia Jamaica
Political pundits say: Cameroon (urban) Cameroon (Rural) Nigeria (Rural)

40%
“Slavery is over. Jim Slavery Exposure No Slavery Exposure

Crow is over. Everybody 30%

should be over all this.”
20%
Evolution is bigger than
10%
pundits, and epigensis is
a solution to a past 0%
evolutionary problem Hi Blood Pressure Percentage

that might come back. Source: Scientiﬁc American, February, 1999
Evolution is conservative.


Epigenetic Mechanisms Health & Behavior
Yes, the social and • Nurturing environments • Obesity, asthma, diabetes
physical environment • Toxic environments • Early sex, pregnancy
of humans changes
gene expression. • Development/aging • Violence, DSM-IV
• Cancer, auto-immune
Epigenetic
Factor
Add slide here about the epigenetic mechanisms;
this shows how what children see, hear, do and feel in the brain,
then cascades through neuro-hormones to change the genes.
This will show that micro-environments matter


Ignore the What shall we do? Make
problem? everybody
Pretend mentally and
everything is physically
ﬁne? healthier?


First, Devise Early Wins NOW Across Age Groups
Trajectory of Mental, Behavioral, and Emotional Disorders
(illustrative graph only)

Past Predicted Possible Future
Future with Prevention
Science

Pre-Conception
Prevalence Rate

ers
i sord Pre-Natal
al D
ehavior
B Infancy
and
o nal,
oti Early Childhood
l, Em
fM enta
ath o Elementary
ent P
Curr Adolescence
Young Adults
Adulthood

Years


Conditions producing positive trends…

Health
RNA
IL6 DNA

Epigentic Changes

Inspirational Credit: Clyde Hertsman


Conditions producing positive trends…
Low Exposure to Toxic Inﬂuences

Exposure to High Psychological Flexibility

Low Exposure to Problematic Behaviors

High Reinforcement of Prosocial-Social Behavior

Health • Mental Health
RNA • Emotional Health/Balance
IL6 DNA • Behavioral Competence
• Related Physical Health
Epigentic Changes
Evolutionary Adaptations to
a Safe, Supportive World
Inspirational Credit: Clyde Hertsman


Devise Early Wins NOW with multiple footprints

Universal multiple
outcome
Acccess to focus

Prevention &
Promotion
Science

multiple
age-stage
focus



Mental Health
Emotional Health
Universal multiple
outcome Behavioral Health
Acccess to focus
Physical Health
Prevention & Can
imp Cognitive Ability
Promotion rove
multiple
health outcomes for all ages
Science
Pre-conception
multiple Infancy, Childhood
age-stage
focus
Adolescence
Young Adults & Adults
Seniors



Mental Health Biglan, Flay, Embry, & Irwin, 2012

Emotional Health Prosocialty
Rich Reinforced
Nurturing Low Problem
Behaviors
Universal multiple
outcome Behavioral Health
Environments
Logic Model for
Acccess to focus
Physical Health
population-level
benefits
Prevention & Can Low Toxic
Psychological
Better
imp Cognitive Ability Influences
Flexibility
Promotion rove
multiple Futures
health outcomes for all ages
Science for All
Pre-conception
Health

multiple Infancy, Childhood IL6
RNA
DNA
age-stage
focus
Adolescence
Epigensis
Young Adults & Adults
Seniors Inspirational Credit: Clyde Hertsman


Suicide Rates Not Evenly Distributed


Mothers and children
in North America do
not get sufﬁcient
Vitamin D via
sunlight

Mothers and children
in North America do
not eat foods
sufﬁcient in Vitamin D

This evolutionary mismatch harms mental health


D. K. Kinney et al.
Mismatch, Latitude & Schizophrenia

Schizophrenia Bulletin vol. 35 no. 3 pp. 582–595, 2009
doi:10.1093/schbul/sbp023
Advance Access publication on April 8, 2009

Relation of Schizophrenia Prevalence to Latitude, Climate, Fish Consumption, Infant
Mortality, and Skin Color: A Role for Prenatal Vitamin D Deﬁciency and Infections?

Dennis K. Kinney1–3, Pamela Teixeira2, Diane Hsu2, Siena derlie variations in schizophrenia prevalence deserves high
C. Napoleon2,4, David J. Crowley2, Andrea Miller2, priority.
William Hyman2, and Emerald Huang2
2
Genetics Laboratory, McLean Hospital, Belmont, MA; 3De- Key words: epidemiology/etiology/immune function/
partment of Psychiatry, Harvard Medical School, Boston, MA; prenatal/geography/risk factor
4
Wellesley College, Wellesley, MA
Fig. 1. Schizophrenia Prevalence and Latitude by Continent and Infant Mortality.
Note: South Asia sites were from India and Indonesia; those sites had higher infant mortality rates than all but one of the East Asian sites. For the
Monday, April 15, 13 regressionlinesinNorth America, those withinfantmortalityrates above 30 per 1000 weregroupedas having a higherrate, those below30 as having
Introduction 35
Previous surveys found a large (>10-fold) variation in

D. K. Kinney et al.
Mismatch, Latitude & Schizophrenia
Semmelweis
Reﬂex



2
4
Fig. 1. Schizophrenia Prevalence and Latitude by Continent and Infant Mortality.
Note: South Asia sites were from India and Indonesia; those sites had higher infant mortality rates than all but one of the East Asian sites. For the
Monday, April 15, 13 regressionlinesinNorth America, those withinfantmortalityrates above 30 per 1000 weregroupedas having a higherrate, those below30 as having
Introduction 35

D. K. Kinney et al.
Mismatch, Fish Intake & Schizophrenia



2
4
Fig. 2. Schizophrenia Prevalence and Latitude by Fish Intake.
Note: Error bars represent 95% confidence limits. The slopes of linear regression lines were 0.03 for sites with high fish intake, 0.21 for sites with
Monday, April 15, 13 moderate fish intake, and 0.17 for sitesIntroduction
with low fish intake. For the subset of Scandinavian sites, the slope of linear regression for was 0.03 for 36

D. K. Kinney et al.
Mismatch, Fish Intake & Schizophrenia
Semmelweis
Reﬂex



2
4
Fig. 2. Schizophrenia Prevalence and Latitude by Fish Intake.
Note: Error bars represent 95% confidence limits. The slopes of linear regression lines were 0.03 for sites with high fish intake, 0.21 for sites with
Monday, April 15, 13 moderate fish intake, and 0.17 for sitesIntroduction
with low fish intake. For the subset of Scandinavian sites, the slope of linear regression for was 0.03 for 36

e increased markedly economic status and healthcare, as indexed in our anal-
ysis by the infant mortality rate, appears to be a much
renia prevalence with weaker predictor of risk for schizophrenia than are lati-
d is not due simply to Mismatch, Skin Color & Schizophrenia
tude and winter temperature. A high infant mortality rate
tic and ascertainment
alysis of data collected
particularly informa-
t controlled for possi-
ences in prevalence at
investigative person-
were used to obtain
ent sites within the
studied schizophrenia

ites in the same time
iagnostic criteria and
data showedSkin very A Role for Prenatal Vitamin D Deﬁciency and Infections?
Mortality, and a Color:
with both latitude
w temperature (r =
cially wide variation in
2 Key words: epidemiology/etiology/immune function/
3
Genetics Laboratory, McLean Hospital, Belmont, MA; De-
he equator, prevalenceSchool, Boston, MA; prenatal/geography/risk factor
partment of Psychiatry, Harvard Medical
4
Fig. 3. Schizophrenia Prevalence and Latitude by Skin Color.
at is, for all groups and Note: Error bars represent 95% confidence limits. The slopes of the
Monday, April 15, 13 Introduction 37

e increased markedly economic status and healthcare, as indexed in our anal-
ysis by the infant mortality rate, appears to be a much
renia prevalence with weaker predictor of risk for schizophrenia than are lati-
d is not due simply to Mismatch, Skin Color & Schizophrenia
tude and winter temperature. A high infant mortality rate
tic and ascertainment
alysis of data collected Semmelweis
particularly informa- Reﬂex
t controlled for possi-
ences in prevalence at
investigative person-
were used to obtain
ent sites within the
studied schizophrenia

ites in the same time
iagnostic criteria and
data showedSkin very A Role for Prenatal Vitamin D Deﬁciency and Infections?
Mortality, and a Color:
with both latitude
w temperature (r =
cially wide variation in
2 Key words: epidemiology/etiology/immune function/
3
Genetics Laboratory, McLean Hospital, Belmont, MA; De-
he equator, prevalenceSchool, Boston, MA; prenatal/geography/risk factor
partment of Psychiatry, Harvard Medical
4
Fig. 3. Schizophrenia Prevalence and Latitude by Skin Color.
at is, for all groups and Note: Error bars represent 95% confidence limits. The slopes of the
Monday, April 15, 13 Introduction 37

Latitude and Infantile Autism

Grant, W. B. and C. M.
Soles (2009).
"Epidemiologic evidence
supporting the role of
maternal vitamin D
deﬁciency as a risk factor
for the development of
infantile autism."
Dermatoendocrinol 1(4):
223-228.


Latitude and Infantile Autism
Semmelweis
Grant, W. B. and C. M.
Soles (2009).
Reﬂex
"Epidemiologic evidence
supporting the role of
maternal vitamin D
deﬁciency as a risk factor
for the development of
infantile autism."
Dermatoendocrinol 1(4):
223-228.


Estimated deaths
per year would fall
by 37,000 people,
or about 16%-22%
of annual mortality
in Canada.

And, $14 billion


Estimated deaths Semmelweis
per year would fall
by 37,000 people, Reﬂex
or about 16%-22%
of annual mortality
in Canada.

And, $14 billion


Among pregnant women, lower Vitamin
D is associated with:
• Adverse fertility • Primary cesarean section
parameters (n = 2), (n = 1),

• Preeclampsia (n = 5), • Few days' (n = 2) shorter
gestation,
• Gestational diabetes or
higher blood glucose • And, postpartum
(n = 6), depression (n = 1)

• Bacterial vaginosis
(n = 4),
Acta Obstet Gynecol Scand. 2012 Dec;91(12):1357-67. doi: 10.1111/
aogs.12000. Epub 2012 Oct 17.
The impact of vitamin D on pregnancy: a systematic review.
Christesen HT, Falkenberg T, Lamont RF, Jørgensen JS.


Among pregnant women, lower Vitamin
D is associated with: Semmelweis
• Adverse fertility • Primary cesarean section Reﬂex
parameters (n = 2), (n = 1),

• Preeclampsia (n = 5), • Few days' (n = 2) shorter
gestation,
• Gestational diabetes or
higher blood glucose • And, postpartum
(n = 6), depression (n = 1)

• Bacterial vaginosis
(n = 4),
Acta Obstet Gynecol Scand. 2012 Dec;91(12):1357-67. doi: 10.1111/
aogs.12000. Epub 2012 Oct 17.
The impact of vitamin D on pregnancy: a systematic review.
Christesen HT, Falkenberg T, Lamont RF, Jørgensen JS.


Suicidal ideation during pregnancy
Pregnant
moms with
Suicidal ideation and omega-3 intake from seafood
during pregnancy ALSPAC-Bristol suicidality or

Prevalence of any suicidal thoughts (32wk)
11 postpartum
10 depression
9 confer higher
8
lifetime risk
7
for their child.
6
The same
5
study shows
4
n3 intake
protects mom
and infant
through 8th
year of life.


And Omega-3 protects their children
Child&early&developmental&risks&with&low&n3&during&pregnancy&

Strength"and"Diﬃcul2es"
Ques2onnaire"Results"at"Age"7"
20.00%&
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&P

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>2&Servings&per&Wk&


How might we reduce
alcohol, tobacco, and
other drugs among
women of child
bearing age


Which warning labels might work?

Trend line for humorous warnings on
binge drinking by women of child-rearing

No Warnings Humorous Warnings


Trend line for humorous warnings on
binge drinking by women of child-rearing

No Warnings Humorous Warnings
20

16
Percentage

12

8

4

0
1995 1997 1999 2001 2002 2003 2004 2005 2006 2007


Rewarding Clerks & Stores for Not Selling to Minors
Youth Who Smoked During the Last 30 Days
Baseline Reward and Reminder
Youth Who Smoked Every Day the Last 30 Days
Baseline Reward and Reminder
45.0% 18.0%
Wyoming Wyoming
Source: Youth Risk 40.0% Youth Who Smoked During the Last 30 Days 16.0% Youth Who Smoked Every Day the Last 30 Days
Behavior Survey
35.0%
45.0%
Baseline Reward and Reminder 14.0%
18.0%
Baseline Reward and Reminder A meta-analysis
30.0% 12.0%

(YRBS), Centers for 25.0%
40.0%
Wyoming
16.0%
10.0%
Wyoming robustly
Disease Control 20.0%
35.0%
8.0%
14.0%
demonstrates that
15.0%
30.0%
10.0%
6.0%
12.0%
cigarette smoking
4.0%

5.0%
25.0% 2.0%
10.0%
is associated with
0.0%
20.0% 8.0%
18.0%
an increased risk
40.0%
15.0%
Wisconsin
16.0%
6.0%
Wisconsin
of completed
35.0%
10.0%
14.0%
4.0%
suicide, consistent
with a dose–
30.0% 12.0%

5.0%
25.0% 2.0%
10.0%
20.0%
0.0% 8.0% response
15.0% 6.0%
18.0% relationship. This
10.0% Wisconsin Wisconsin
40.0%
5.0%
4.0%
16.0%
2.0%
conclusion has an
35.0%
0.0% 14.0% important public
18.0%
30.0%
40.0%
United States 12.0%
16.0%
United States health message.
25.0%
35.0% 10.0%
14.0%

30.0%
20.0% 12.0%
8.0% Journal of
25.0% 10.0%
15.0%
20.0% 6.0%
8.0%
Psychiatric
10.0%
15.0% 4.0%
6.0% Research, Vol
10.0%
5.0% 4.0%
2.0% 46(10), Oct 2012,
5.0% 2.0%
0.0%
0.0%
Source: YRBS, US Centers for Disease Control
0.0%
Source: YRBS, US Centers for Disease Control
1257-1266.
1995 1997 1999 2001 2003 2005 2007 18.0% 1995 1997 1999 2001 2003 2005 2007
United States United States
40.0% = Trend = Wyoming
16.0% = Wisconsin =United States

35.0% 14.0%

Monday, April 15, 13 30.0% 12.0% 46

Creating an Evidence-Based Approach to Lifespan Suicide Prevention

Creating an Evidence-Based Approach to Lifespan Suicide Prevention

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