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Preventing Suicide: A Population Health Approach


DR. ANDREA HORVATH MARQUES: Has been extremely important member of the partnering with this Global Mental Health Research Center and has been participating in every global mental health conference since the beginning, probably. And here we have some pictures of her with us before as a leader in PAHO and now as a leader in WHO.

We have valued her collaborative of initiatives and projects and we are looking forward to our teams continuing to work together. We also are delighted to host Dévora in our second lecture in our annual Global Mental Health Lecture Series.

One year ago, as you can see here, Dr. Shekhar Saxena, the previous WHO director, was invited by the center director and global mental health team at that time, Dr. Beverly Pringle. We'd like to take this moment to thank Beverly for our many contributions that move the global mental health field forward.

And finally, we have many things to look forward for this year and beyond. We are looking forward to the future new director for the center for Global Mental Health who is coming soon. And thank you [inaudible], for being the interim director during this transition time. A new administration is in US is also promising to foster collaborations with the WHO. We are very happy with that. And we also know that we have a new lead mental health team at PAHO, Dr. Renato Oliveira e Souza, who is also joining us today.

So we are looking forward to explore future partnerships with PAHO. And now I'll ask Jane Pearson, leader of the suicide team, to give her remarks. Thank you.

DR. JANE PEARSON: Thanks, Andrea. Welcome from the NIMH Suicide Research Team too, Dévora. Our team is about 40 people and mostly extramural staff. In other words, we're the ones trying to get the grants in and keep the studies going. And we also have our intramural colleagues and we're tasked with trying to be very strategic in our research funding and also engage with external stakeholders who can implement the science so we can try to reduce the suicide rates.

So your talk reminds me of a phone call I got from the editor of The Economist in 2018 who said, "The suicide rates internationally are dropping, but they're not going down in the US. What's going on?" And it was just one of those small questions I've had to deal with in the press. And so we talked a lot about lethal means reduction, and of course, there hadn't been much change here in terms of our reduction in firearm rates.

So anyway, there's still a lot to learn, but we're really looking forward to your talk. We're a little hopeful here in the US that our rates have gone down somewhat in 2019 and maybe the first quarter of 2020 looking good, but we just have no idea what's going to happen, of course, in 2020. So we're just really looking forward to how you're framing this and tracking this worldwide. And thank you for doing this today. So I'll turn it over to our director, Dr. Joshua Gordon.

DR. JOSHUA GORDON: Thanks, Jane and Andrea, and the teams for putting this lecture together. And thank you, Dr. Kestel, for joining us today. Dévora Kestel is a senior global mental health policy expert with more than 25 years of experience, really across the world, implementing and advising governments on national policies related to mental health systems. And she's a strong advocate for the rights of people with mental health issues. Sorry. It's not Dr. Kestel. Mrs. Kestel obtained her MSC in psychology from the Universidad Nacional de La Plata - I hope I pronounced that reasonably well - in Argentina.
Thank many years of high school Spanish for that, as well as an MSC in Public Health at the London School of Hygiene and Tropical Medicine in the UK.

After completing her university studies, she worked for 10 years in the development and supervision of community-based mental health services in Trieste, Italy. And in 2000, she joined WHO as a mental health officer, first in postwar Kosovo and then in Albania, where she served as a WHO representative. In both countries, she worked closely with the Ministries of Health to establish comprehensive community-based healthcare systems.

In 2007, she joined the Pan-American Health Organization with WHO, where she first worked as a mental health advisor and then became unit chief for Mental Health and Substance Use, and then in 2019 was named WHO Director of Mental Health and Substance Use. And, Dévora, we're very much looking forward to your talk today. Thank you.

DEVORA KESTEL: Thank you very much. I think years passed and I need to update that information because now we are talking about more than 30 years of experience. So a lot of time. Thank you very much for this opportunity and it is a pleasure being there, even with this remote modality.

But also it is a bit of a challenge because the work that the US has done and the work that-- in suicide specifically and the capacities of your own team are huge if compared to anywhere else in the world. So let's see how do we bring this global perspective in a useful way for your reality.

So, once again, thank you for the invitation and let me go on with the discussion today that is suicide prevention. And I would start by saying that I'm sure that many of us, of us with any clinical background, but also in general human being background, I would say we may remember the first time somebody close to us died by suicide because the issue is so dramatic, it's so intense that we can't forget it. And that in a way, we can imagine the implications of suicide happening to those close to the person and the network in general. And so we want to go today from this individual situation to the global perspective, as I mentioned before.

So let's go to the next slide, please. And I want to bring a bit of history, even if in a very short way, 1996 is the first UN published document on suicide prevention of suicide, guidelines for the formulation and implementation of national strategies. And it was the first and seminal document on suicide produced by a multilateral agency. And the document emphasized much of what we know and say today, which is interesting or sad depending on how we look at that, but definitely to emphasize the needs for countries to have a national suicide prevention strategy and they need to coordinate, to have coordination internally to make sure that the different aspects related to suicide were considered.

There have been other documents and the US again is an example of a country that had their own national policy or document to describe the issue of suicide prior to that. But from this global perspective, that was the first one. And soon after that and between that and 2012, there has been research knowledge of suicide behavior that allow us to understand better the situation and in a way to demonstrate the complexity of the causes of suicide and identifying common risk and protective factors and populations at risk of suicide.

And then in 2012, WHO published the Public Health Action for the Prevention of Suicide, a framework that identified components and clear steps for developing of a comprehensive national suicide prevention strategy. In 2014 comes the main, I would say, WHO published [inaudible] document on suicide giving this global perspective. That was the first-ever, I should say, prevention report and it was called Preventing Suicide, a Global Imperative.

And it was the WHO then-director general, Margaret Chan, that made a call to action for countries to employ this multi-sectorial approach which addresses two sides in a comprehensive way and bringing together different stakeholders based on the updated research and specific context. I think that many of the components of the issues raised in that document are still very relevant and many of them have been used in different contexts for many years.

I recall now the needs that were, for example, introduced there. So for the so-called neglected public health issue, there have been significant efforts and relevance at some points. As you may know, the WHO doesn't come with big reports on every single issue. So it was in a way a recognition of the relevance of the topic. And at the time of the UN report, only one country was known to have a national strategy on suicide prevention and that was Finland. Right now there are 38 countries that have a national suicide prevention strategy. So some progress there could be seen. The next one, please.

And so we were saying so that became suicide a global priority. And you have there in front of you three different global net frameworks that brings suicide as a key issue. The first one as a key issue, as one of the main issues, but definitely the only one from the mental health perspective. In the UN Sustainable Development Goals there is one target, the 3.4, that is about preventing mortality from NCVS and promoting mental health and wellbeing. And the only indicator on any mental health-related issue is suicide mortality rates.

Then taking it from there, when the current director general established his general program of work once he took office, this plan, WHO plan, for five years has one indicator again in the area of mental health and is also on suicide mortality rate and the need to reduce it by 15%. And then more specifically, too, the work that we do, the Global Action Plan on Mental Health, this is only about mental health, but has one of the four objectives is about promotion and prevention and it has a target on suicide prevention. So that is great, right? I mean the visibility and the general understanding one could say about the importance of suicide prevention seems to be there. The UN document is not health, it's governments, presidents, prime ministers deciding which are the priority [inaudible].

So as we said is there we imagine then that the global political will has been developed, generated and so the accountability and the efforts to make those targets met may be the challenge coming. So next one. We just have the latest available information from 2019. So we have been updating this slide. Alexandra Fleischman that couldn't make it today, but she is one of the colleagues working on suicide here. She was working on that and so we can see a bit of the trend and that's what the colleague was saying earlier.

Now in the in the five years since 2014, that is when we came up with the report, and now the global WHO standardized CSAD rate decreased by 8% and that means that it decreased in five of the six WHO region. And the region where the number did not increase was the region of the Americas. And for a number of reasons we tend to believe, maybe my colleague Renato Souza that is connected also, Renato Souza, he could maybe come up with something later on and comment on this. The evidence tells that the weight of the data from the US is very big in the context of the region. So that's something that we need to understand better, right? And that is up to 2019 precisely. We need to see what's coming. We know that data is a core component in system prevention efforts and this is how we monitor progress and how we see what's coming.

Next one please. When we look at the global issue altogether, we see that again, according to the latest numbers we got, we are talking about 700,000 people losing their life to suicide each year. And that means still that a person dies by suicide every 40-something seconds. And that right now, again 2019, suicide is the 17th leading cause of death worldwide and there are more deaths due to suicide than to malaria or breast cancer or war or homicide.

And still nevertheless, suicide do not receive-- not as much, but I would say one-tenth of the support that those other areas receive. And one needs to wonder why and what needs to happen in order to change that and to get more attention to suicide. We talked today about suicide being 1.3% of all deaths worldwide, and that will remain, according to the WHO projections, up to 2030.

We all know that for every person that dies by suicide, there are around 20 others that are affected that have attempted suicide. And that means that if you also have the people that are surrounding those persons and how that suicide or suicides affect them, then we have really millions of people affected by suicide. We know that suicide occurs everywhere, but actually, the majority of numbers are in low-middle-income countries. 77% of death by suicide are happening in low-middle-income countries.

Let's move to the next one. We see here by gender, we see that for both sexes rates are highest in the African, European and Southeast Asia regions. For males, the rates are highest in the African and European regions. For females, rates are highest in the Southeast Asia region and globally, the age-standardized suicide rate is 2.3 times higher in males than in females. But males are three times higher in high-income countries, while in low-income countries the ratio between men and women is more equal.
The next one, please. Suicide occurs across the lifestyle, but still we see that most of the suicides are in adulthood, youth and adulthood, the productive life of people, after following road injury, tuberculosis, and interpersonal violence, suicide becomes as the fourth leading cause of death in young people aged 15 to 29 years old for both sexes, and is the third leading cause of death in 15 to 19. So after tuberculosis and maternal conditions comes suicide, I think that that should give us enough reason for us to work on these fields and to get countries doing what they should do to prevent that. But still we are far from being there.
We are informed that most adolescents who died by seaside, 90% of them were from low and low-income countries, which is again something that is a serious concern. The next one, please. We will go through briefly some of the challenges and we said earlier, no? That 38 countries have a dedicated national suicide prevention strategy. Yes, we move forward from the one that was before, but we, in WHO, we are 194 countries.
So this is merely 20% of countries have a national suicide prevention strategy. And I know that in the US or in some big countries, national may not be the main issue, the federal level versus the states or province or whatever it is the organization of the country, but otherwise, in many other countries, the national suicide prevention is what will be the priority and will make clear the multisectoriality around and will make clear that the government commits to do something and allocates resources and there are efforts coordinated, etc., etc. When we don't see this happening is when there may be some concerns that for a number of reasons, including stigma, suicide is not prioritized. And when stigma is strong in the case of suicide, I'm sure you know this very well, there are a number of consequences as well in terms of data collection and the evidence that we can generate and made available for the same commitment and things to change. We will go back to that.
Next one, please. COVID and I interpreted the comments from Jane at the beginning, the concerns about what could be coming, COVID-19, we know that may pose a challenge for suicide, self-harm, and the need for suicide prevention. It's only to tell for the impact on suicide rates because the national statistics, you said it yourself, are still on its way and not every country will make them so soon, so read available.
And so we'll take time and for the time being we hear from isolated experiences or some countries that are mentioned or are coming up with preliminary information. But we know that COVID-19 has recognized risk factors for suicide such as the financial crisis, employment loss, violence, increase of alcohol consumption, and isolation itself, etc.
And in the recent publication we have it is the one that we have there that we were assessing, it was a rapid assessment of services for mental neurological interference use conditions; the services for suicide prevention were reduced by a quarter. And since we know that there are not so many, that is a significant reduction. So we are trying to see how countries are responding and what innovative ways have been put in place to respond in some cases thanks to technology. But we know that not everybody in north all countries have access to technology as one could hope for. So more on these two to come for sure.
Next one, please. The issue of availability and data, the quality-- the availability and the quality and that is the main issue and that is a big challenge. The statistics that we collect that member states provide to us on regular basis, including causes of death, will be impacted in the case of suicide for a number of reasons, whether it is the same stigma we mentioned before, the fragmented system that there should be communication between different entities in order to report suicide. There should be interest to talk about, there should be not criminalization of suicide a number of issues that in summary makes that only 80 countries have good quality, vital registration data, and 44 of those 80 are from high-income countries.
So again, we know a lot less about what is really happening in low-income countries. We have some data from 37 and a half years from low-income countries that with the data that accounts for 20% of all estimated suicides in low-income countries. So it's really a big challenge and something that we continue to promote, but that is still on its way.
The next one, please. I will talk now then about what it is that we are prioritizing right now and what is this Live Life initiative that we are discussing. And the Live Life is the next one, please. It's a double approach for suicide prevention. We know that countries with national asset prevention strategies are more advanced in suicide prevention.
So we are proposing a number of interventions that should be leading to the action that countries have to take. And we have four evidence-based interventions that we are proposing here. No new, you know them, they have free notes included in our image gap for example, for several years, but we articulated them together trying to make sure that countries follow them all or as many as possible. And we are talking about limit access to means of suicides such as highly hazardous pesticides. And this was recently included last year in a World Health Assembly decision that we are promoting about these pesticides.
We are also promoting about the interaction with the media for responsible reporting so that society is not internationalized in order to prevent the copycat right, imitation, and provide stories of hope. I think that we have also some good experiences coming from your country on how to do things properly, although not always under control, maybe. Foster socio-emotional life skills in adolescence to help build skills to cope with the challenges they face through life and that's through education and the start of their careers to begin with.
And then the last one is early identification, assessment, managing, management and follow-up of people with suicidal behaviors and anyone affected in the context of the person and that is mostly what has been developed through the [inaudible] too that I mentioned earlier. And we advocate for this comprehensive approach, and we recognize that implementation for suicide prevention can often be neglected as compared to other issues.
And so we really promote countries to work on a strategy that considers all these elements in one way or the other. The next one, please. So let's go through some of them with the main issues briefly. The access to means. We know that the banning of the highly hazardous pesticides is cost-effective and we did that study two years ago, and then was included in the menu of cost-effective interventions or the Best Advice for Mental Health that was approved last year in the WHO [inaudible] capacity, as I mentioned earlier.
And there are examples of successes on these policies in countries such as Sri Lanka or Korea, other countries are trying to implement it. We have the means restrictions, of course, restrictions, sorry, should focus on the most commonly used means and those which have the highest fatalities. The countries using pesticides are in many cases big countries and so the numbers are really impacting the overall data.
The means will change nationally or locally of course, and depending on the groups and I'm sure you have also and I would like to hear some updates on some of the main means that are used in the US. For example, some of them very generating different kind of conflicts when trying to intervene. In the case of pesticides, we require multicultural working with of course ministers of agriculture, industry, and pesticides registers and the regulators on health. And we produce guidance for this trying to help countries moving forward to advise pesticides registers and regulators and a booklet on clinical management of the intoxication itself.
We move to the next one and here we are talking about interaction with the media. This is you have there a booklet that was old but then updated a couple of years ago, precisely updated with what is happening today with social media for example that was not back then and we know that collaborating with the media is essential and media can influence one way or the other. In terms of the negative, some of the first studies came from the US. I know you're familiar with all of that, how the invitation could be happening after some coverage of high-impact or high-profile stories, and the reviews have helped us in developing strategies to deal with that. And in terms of positive stories of hope, reference to help lines or some educative media documentation coming in the context of CSI is also helpful.
The second method that you have there is the resource for filmmakers and other sporting on stage, on screen is also related to what we have seen happening a few years ago in terms of some TV shows that generated some challenges in many countries, actually. And so in that context we have a couple of countries working on that and trying to implement policies and activities with media to improve that area.
The next one then is foster social-emotional life skills in young people. Again a number of studies, research showing that giving young people tools, life skills that are needed to cope with challenges helps. And we released recently the heart guidelines that are there helping adolescents drive and those are guidelines on mental health promotion and prevention interventions for adolescents, and we are now working on the follow-up that hopefully will be released in a few months. But there are very clear recommendations about the need to deliver universally delivered psychosocial interventions as you see in the text in the slide.
We need to promote that kind of intervention as much as possible. There are interesting studies. I mean the famous one was run by [inaudible] a few years ago that was massively undertaken in a number of European schools and was looking very promising and good positive results. So we need to keep working in that field.
The next one already briefly mentioned before early identification, assessment, management, and follow-up. These guidelines were developed more than 10 years ago already, but of course, they are being updated. And right now we are in the process of reviewing that and we are talking about capacity of health sector at primary care level on how to identify, assess, and then manage and follow-up people with at risk of suicide or with suicide attempts, but also in the context of a person dying by suicide and how to pay attention and what is needed there.
This is a very friendly tool that is appreciated by those who receive that training as useful. And I recall some training done years and years ago, how the issue of suicide was one of those identified as very useful for those receiving the training. The next one then is okay, those were the four main interventions. These are what we call foundational pillars and the interventions will not be successful unless we have this kind of cross-cutting public health pillars supporting the implementation. So we are talking about the situation analysis, trying to identify the specific problem in the specific context of country, what are the vulnerable groups, what are the communities, the common means-- sorry, the vulnerable groups that should be targeted for intervention, etc. We talk about smart sector and collaboration because in many cases it is a school or it is agriculture but it's not something that should be managed exclusively by the health sector. It will not be successful.
We are talking about awareness-raising and advocacy. We also promote actively the World Suicide Prevention Day but we are trying to use the opportunity to address stigma in any possible context. But also, for example, we are in the current update of the World Mental Health Action Plan, the Global Mental Health Action Plan that has been updated and is being hopefully approved in May this year, the updated sections.
There is one component about the decriminalization of suicide which is still happening in many countries and that is something also it has to be deal with stigma and advocacy. Capacity building. We talk about it's about staff health stuff, mental health staff, but also community actors and school partner colleagues and beyond that needs to be aware of suicide and what needs to happen. Financing of course, because without resources that is very challenging and this is something that we are also discussing interestingly in [inaudible] here as well in WHO because the resources, I mean, the stigma that we see everywhere is also reflected on our own capacity from resources allocated for WHO to work on suicide and it's very limited. So we are trying to increase that capacity as well. And the same should happen at [inaudible] and that's part of the discussion that we try to bring.
Surveillance we did not talk enough about, but the data is crucial in all of that, and I think a lot again, to learn from the work that the US has been doing from the different agencies over the years and keeps doing. And then monitoring and evaluation is part of any project or any initiative that needs to happen, right? So this is what we are trying to do in terms of the Live Life approach and we are discussing with our regional colleagues in order to make sure that this is being implemented in the near future in a few countries at once, so we start in a way rolling the ball more actively than before.
The next one then, really I travel always with this topic because it is so obvious for those of us who are working in this field to the needs to work on suicide prevention. The idea that suicides are preventable and that we are not doing enough, the issue that young people are dying by suicide and that could be prevented and we may not be doing enough, that is something that I think deserves all our attention every time that we can give it to.
So there is a lot more that we need to do to know and to do [inaudible]. There is a lot more. Maybe also in terms of advocacy and raising attention and support for countries to work. Suicides are very complicated. It's not just one intervention that will solve the problem. But again, I think we could all do more than what we are doing.
So thank you very much for the opportunity to-- and the next one, I think is only that. Thank you for the opportunity to be here with you and to share where we are and what is our perspective. I hope I didn't go too far in the discussion and over to you then. Thank you.
DR. PEARSON: That was perfect. Thank you so much.
DR. HORVATH MARQUES: Thank you, Devora.
DR. PEARSON: Andrea, do you want to go first? Do you have any questions?
DR. HORVATH MARQUES: Yeah, I mean, I just want to say so everybody it’s open for questions and the Q&A again. Jane, please go ahead.
DR. PEARSON: Okay, great. Thank you so much, Dévora. That was a terrific overview. I'm just looking at the questions now.
So we just have information on the US national strategy for people viewing who don't know about it. I'm sure you've seen it, Dévora, and then more recently the National Action Alliance for Suicide Prevention in the US did think about how to respond to COVID with people becoming more aware, I think, of mental health issues and suicide prevention and saw it as an opportunity to educate people, and because there was so much discussion about suicide rates possibly going up, we wanted to let people know what could be done. So Dr. Gordon co-chairs that we just wanted to let people know about that. Let's see, "How does WHO help countries that don't have a suicide prevention program or strategy?"
KESTEL: That's great. Thank you for asking that. I use this as an opportunity to say that I have other colleagues joining me. And I mentioned before, Renato de Souza, that is the regional advisor in the Pan American Health Organization. I understand Maristela Monteiro from PAHO is also connected that she is the senior advisor on alcohol in the Pan American Health Organization. And I have also Aisha Malik working here with us in WHO [Geneva?], and I invite three of them to jump in and answer any of the questions.
But let me start with the first one to give a quick answer to that. And we work with, as I said before, 194 countries, and we work through the regional offices that work with the colleagues in the country offices. We have 150 country offices, more or less, and in each one, each country, including the US, every country in the world has a collaboration plan agreed with the regional office, the global office, every two years. So it may be that the country at some point in time say, "You know what? We need to do something on suicide prevention and we need your help on suicide prevention." So we work. How do we help?
Depending on the country and the capacities of the country we will visit the country. We will organize a meeting with stakeholders. We will help the country discuss, do the assessment and analyze it, and help drafting this list of priorities and what are the main issues to take into consideration and how much that will cost. I mean from A to Z, the different steps that are needed. So what we do is we facilitate that process.
And in some cases, in order to promote the interest we may have done-- we do actually some regional meetings. And so one of the regions convenes mental health focal points from the different countries. And we have invited, for example, NAMH to some of these meetings, or CDC to some of those meetings to get inputs also from those who have a bit more expertise in running similar projects.
And so we bring those together to a room and for a couple of days, when that was possible, we will discuss together what are the priorities, what are the challenges, how to overcome them, presenting case studies, illustrating by examples of whatever have done or achieved. And then everybody goes back home, talks to their superior, colleagues, whoever, and say, "We need to do something," and then we start-- so it's a bit of a different kind of advocacy that we do. It's not the advocacy that we do with the social media, but this advocacy with the technical people. There is always in every country that our colleagues are interested to do something, but not always the colleagues who have the technical expertise are the ones that are sitting at the policy level. So sometimes what we do is try to facilitate dialogue between the technical and the policymakers to make sure that things move.
DR. PEARSON: That's great. I was a part of one near Trinidad and Tobago, and just to give an example, the way they were counting suicides was not by ethnicity because they said everybody's equal in our culture, so we don't have to look at those subcategories, which was really interesting in terms of thinking about how to approach this.
And there was a lot of discussion. I don't know what's changed since I haven't been involved in that. But it was so important to hear how people viewed this and started working on it. So thank you. And we're always appreciative when WHO has that convening power to do all of that. Andrea, do you want to take some of the questions? You want me to keep rolling? You can.
DR. HORVATH MARQUES: That's okay. Yeah. One of the questions here, Dévora, is that about the data on younger kids under 15 globally. If you have some data on that and the major causes of death from 15 to 19 seems like you were sharing. So if you can share with us something on that.
KESTEL: I'm not sure I have it. One of the challenges that the data we get is the data that countries collect and provides to us. And so not many countries have that. We have some countries going between 5 to 9 and 10 to 14, but not many. Some will give bigger, broader information. And so we don't have a lot of feedback. I'm asking Aisha, who is more familiar than me maybe. Aisha is saying that she doesn't have the option to speak, and I don't know if you can unmute her. Otherwise, we'll do it in this way.
DR. AIYSHA MALIK: Hi. I think the unmuted worked. Dévora is very right. We rely on the data that comes from countries, and then we rely also on the need to have to estimate in some cases where the data quality is very low. So we are at the hands of the existing mortality data that countries present to us. But when it comes to young people in particular, or even data, I think this is really why we're saying better data is essential as part of this work going forward because we cannot understand clearly if we're making the changes and the differences that are needed without that data.
I saw a report from the UK today that was indicating that the rates of self-harm in young people, much younger than I think adolescent age, are increasing during this time. So the information that we can also rely on is good quality research as well. So that in itself is quite concerning. But that would be the other source is really relying on good quality research, and we need to see much more of that research coming out of lower-middle-income settings as well. Thank you.
KESTEL: Thank you, Aiysha.
DR. PEARSON: I should mention that NIMH is really trying to understand some of the young child depths, and it's a struggle. We're having a series of roundtable meetings right now with developmental psychologists. Lisa Horowitz, who asked that question is a part of that meeting, and a number of our extramural staff are trying to understand what science we could bring to this. So we're still moving through those meetings, but it's a huge issue, and we know medical examiners and coroners struggle with this, trying to understand what it is. So it's a huge issue internationally.
DR. HORVATH MARQUES: Dévora, there is another question from Nida and our colleagues from Nida asking about this nice report from the impact of COVID and asking if there's going to be some follow-up and data for each country that could be available.
KESTEL: Thank you. Thank you, Andrea. Thank you, [inaudible]. The report is published already, was published a few months ago. What it's going on now, and we have 130 countries answering and the data is available there, what we are doing now is that we are integrating the questions that most of the questions that we develop into the one that is going on comprehensive on the health system altogether to countries and so the mental health and psychology-- I'm sorry. The mental, neurological, and substance use one is incorporated into the general one. That's another button that we want.
When the general one came out, the first one, there was one question about mental disorders and so we said, "Well, no way. We have to come up with our own." Now the next round is incorporated, so hopefully more countries will get into some kind of routine answer. Now for the specifics on [inaudible] through COVID have been trying to also work on that and dig a bit more. I don't think we know enough about the impact that COVID-19 has or is having in alcohol and substances increase and therefore consequences linked to suicide or others. I don't think we know enough and we are discussing what they need to work on that. But we are not yet there. If Maristela is connected and she wants to have something-- Maristela? I don't see the name.
KESTEL: You are muted, I guess? I don't know.
DR. HORVATH MARQUES: I think is Maristela Monteiro somebody was giving permission to speak if she's here.
KESTEL: I don't see in the meantime anyway.
DR. HORVATH MARQUES: Yeah. So thank you, Dévora. Let's see if she's getting connected. Meanwhile, we have another question. You briefly mentioned about a successful program in one country. Has the WHO been able to publicize internationally successful programs or promising pilot programs of implementing this Live Life, I think.
KESTEL: Thank you. Thank you very much. There has been a publication on pesticides. I'm looking there because I have my published documents there, but I can't see the name. But there has been one on pesticides a few years ago. In terms of the Live Life, not yet. We are struggling, but we need to do that because it's the way we have for countries to disseminate. Any suggestion or guidance on that will be appreciated. Hopefully, we will do it, but not yet. And I see that Maristela is there. I don't know if you have them. Yes, go ahead.
DR. MARISTELA MONTEIRO:  Yes, thank you. You're right that we don't know yet what happened. In terms of alcohol and substance use. There are reports of decrease in use. It depends on the country and depends on [inaudible] COVID-19 as well. In the beginning, there were more reports of an increase and people may be stabilized.
And some countries also banned altogether alcohol sales like South Africa. In the Americas, we had a percentage of people who had increased, a percentage who had decreased. We did research on alcohol only in all countries of the region and what was found was also that the increase, especially in heavy episodic drinking, happened to those with higher levels of anxiety and depression. So there was a link with mental health symptoms and increase in alcohol consumption during the pandemic.
DR. HORVATH MARQUES: Thank you so much. I think we have time for a few more questions. Jane, you want to go?
DR. PEARSON: Sure. One question is about there's been, at least in the US, attention paid to increase suicide rates in the military where before they had been lower than the population is matched by gender. And now it's caught up. And the question is how does that get factored in globally in terms of WHO? And I'm guessing it's whatever countries decide to report would be my assumption. But yeah.
KESTEL: I have to say that I don't know. That's my first answer. I can guess that not many countries have done the work that you guys have done in terms of veterans and have this information. But I'm asking my colleagues to jump in. If, Aisha, maybe if you know. Otherwise we'll owe you that.
DR. MALIK: Yeah. I think the US is really at the forefront when it comes to looking at veteran mental health and veteran suicide. And I think that to me already screams an opportunity for that to be shared across the world. Now, we don't have separate data from countries on that population specifically, but we do have examples of where countries have implemented successful suicide prevention with military or others, for example, firearm-carrying occupations. I'm thinking Israel and Switzerland, for example. So we have those examples. We don't have the data. US is leading on it. If we could have the data for other at-risk groups for suicide, this would be fantastic, but we only have it by age and sex. Thank you very much.
DR. PEARSON: I would just mention, in the military, it's a workforce, so you have the opportunity to look at who's going into the workforce, administrative policies, and so on. It's not an easy thing to do because they're not used to thinking about research or injury prevention in that way. But yes, after many years it is possible to start looking at it, and should we take one more question, Andrea?
DR. HORVATH MARQUES: Yes, our last question, right? Now, I think we have a question from our friends from USAID and asking some thoughts on how to advocate for attention and resources to address suicide that can be shared, in one minute.
KESTEL: If I would have the answer. I will not be struggling as I am in getting those funds, but I think I have to say that suicide prevention and reducing suicide mortality is one of the indicators to achieve the Sustainable Development Goals. And I think that we need to make that connection when we talk to senior level policymakers that commit to achieve those goals and so we need to help globally to do programs on suicide prevention. We need to link it to that.
I think that could be the main strategy we could advise. And second one is if we can put up those case studies together where we see things work that is a good-selling product as well. Right? We can say, "Okay, this is what we are trying to do. This is going to be the result." And so, hopefully we will be able to with good data monitor impact so that could get us some more attention and then funds. But if anybody has any suggestions, please feel free to make them.
DR. HORVATH MARQUES: Yeah, I think we are already on this time for 10:30 and I really appreciate Dévora and also WHO and PAHO's staff who are here joining us, and all the members from NIMH and all our ICS and colleagues here. Thank you so much, Dévora. We're going to follow up with you some other questions that we couldn't share with you, but we're going to talk to you soon. Again, thank you so much.
KESTEL: Thank you.
DR. PEARSON: Bye-bye.
DR. HORVATH MARQUES: I think we're going to go to the other one.