So, hello, good morning. I was asked, as the incoming president of the World Psychiatric Association, to speak about possible future collaborations between the World Psychiatric Association and the American Psychiatric Association. Of course, the American Psychiatric Association is one of the 145 associations we have under our umbrella, but still it is a very big association with very many members, so it is important to check, which I did, what we have in common or where we can collaborate. So, I am professor of psychiatry and suicide prevention at Karolinska Institute and the head for the National Center for Suicide Research and Prevention of Mental Ill Health since 1993. It was first a regional institute, but afterwards the Swedish Parliament decided to make it nationwide, so since 1994 we have national responsibility. And since 1997 we are also World Health Organization Collaborating Center on Suicide Preventive Issues. Karolinska Institute is well known because the Nobel Prize in Medicine and Physiology is awarded each year by collegium of professors from the institute. Shortly about World Psychiatric Association, under our umbrella we have 145 psychiatric societies, like Canadian, United States or Latin Americans, and in some countries we have two or three societies, so we are present in 121 countries. We have more than 70 scientific sections, which are very, very active under the leadership of my colleague, Professor Thomas Schulze from Germany, and we have 250,000 psychiatrists worldwide. What is common between WPA and EPA? We have a little longer description than EPA has for their mission, but of course what is the most important is the equity in the access to care, highest quality of evidence-based care, education on different levels, research, and also to think about professional rights and needs. And here we can learn quite a lot from American Psychiatric Association because they have very, very intensive work on the rights of psychiatrists, on reimbursements for the patient's visits, which we are not working on the global level with. So I think that we can really have help from colleagues in United States to direct colleagues from other countries, which are also fighting for their rights. I would like to start to speak about what mental health is. We all know what psychiatric disorders are, but mental health is important because it enables people to cope with the stresses of life, to understand the abilities one has, to learn well, to work, and to contribute to one's life and to the community through being connected by positive relationships, by contributing to communities, by getting a sense of belonging and empathy with others. And of course it requires a good function to apply cognitive skills, to gain an education, to have possibilities to earn a living, make healthy choices, learn new skills, and to cope with stress, adapt, to change, make complex choices, and understand how to manage emotions, and of course to thrive. Global prevalence of mental disorders is high. Approximately 13% of global population is living with mental disorders, 8% of children, and 14% of the adolescents. But only 2% of health expenditures are given to mental health globally. It varies a little bit for some countries. We know that in high-income countries there are bigger budgets for mental health in comparison with low-income countries. But look also at this graph that 31% of people with mental health problems have anxiety disorders and 30% depressive disorders. The state of mental health in America is just an example that 21% of adults are experiences. It means they do not have diagnosis, but they experience mental illness. But only 55%, half of them, has treatment. 15% of adults has substance use disorder in the past year, but 93% do not receive treatment, which means that they are almost zero treatment. 6.5% of people with misuse of alcohol or drugs are treated. Among young people, 16% of youth report suffering for at least one major depressive episode in the past year, but only 40% receive treatment. 60% do not receive treatment. So the gap between needs and opportunities to get treatment is very huge. The global burden of mental disorders is huge. Mental disorders are the leading cause of years lived with disability, and of course depressive disorders alone are the second leading cause of global years lived with disability, following by anxiety disorders. People with severe mental health conditions die 10 to 20 years earlier than the general population, and many of them die due to suicide. When we look at the global rates of suicide, we can see that suicide rates for males are more than double that for females, and it is almost like that in most of the countries globally. There are some exceptions, but the data are not always so valid, because we know that suicide is underestimated due to the different monitoring strategies and registration methods, as well as due to cultural biases. Suicide luckily decreased globally by 36% since the year 2000, but not in the United States. Here is the global trend in green going down, and in the United States the line in red is going up, unfortunately. When we look closer, which groups are more suicidal, when we look at the rates by age, range, and sex, we can see that elderly people, but also younger people, have quite a lot of suicide in relation to the number of the population in this age span. When we look at suicide rates by ethnic groups, we can see that Indian and Alaskan natives have the highest rates in the United States, 21 per 100,000. Afterwards, whites. Afterwards, mixed races. Afterwards, blacks, Hispanics, and Asians have the lowest rate of suicide. Looking even closer, we can see that after two consecutive years of declines in suicide, there was a little bit of a line going down. In 2021, there was again an increase of suicide, and especially for non-Hispanic American Indians, Alaskan natives, by 26%. For black populations, or African American persons in the United States, increased by 19%. For Hispanic persons by 6.8%, but for white persons there was a decrease. Of course, probably it depends on access to the health care, that those populations which are not Caucasian white persons have less access to good health care. What happened during COVID-19 pandemic? It is very well known now. We have many, many publications, and the World Health Organization performed an umbrella review of systematic reviews and meta-analysis. It was shown that the global prevalence of anxiety and depression increased by 25%, and especially among younger population, among females, and in persons with pre-existing health conditions. What happened with children and adolescents during COVID-19 pandemic? One in four youth globally experienced clinically elevated depression symptoms, and one in five elevated anxiety symptoms. Youth mental health difficulties, other difficulties, doubled during the COVID-19 pandemic, and especially among girls and a little bit older children. So vulnerable groups for mental health problems and suicide during pandemics were females, ethnic minorities, young people, but also COVID-19 survivors, members of the families where somebody died in COVID, health care workers, first responders, and people with pre-existing health conditions. So during COVID-19 pandemic, we could see increased gender and sexual orientation, and education inequalities, because children who were at home had some difficulties to catch up, both with the emotional development, but also intellectual development. And income losses were larger among young people, women, the persons who were self-employed, casual workers, and with the people with lower levels of education. Like always, the part of the population without education, poor health conditions, poor working conditions, poor housing, are the most vulnerable groups. And women were more likely than men to drop out of the labor force in order to care for children probably. And we know also that lockdown and social distancing measures were also important and had a negative impact on mental health of population. Suicide, and during the COVID-19 pandemic, we looked at suicidal ideation and suicide attempts, because we could see increase both in clinical and non-clinical samples, significant increase of both suicidal ideations, which usually goes with depression. So they are two parallel phenomenas. But suicide attempts are not parallel phenomenon, but they increased also. But completed suicide, there was a non-significant downward trend. And in our study, which was published, the first one, during the shorter period of observation, was published in Lancet Psychiatry, and the second one, with a little bit longer period of observation, was published in the Satellite Journal of the Lancet Psychiatry eClinical Medicine. And we looked at the suicide in 33 countries, 24 with high income, 6 upper and middle income, and 3 lower middle income countries. And we couldn't see evidence of greater than expected numbers of suicide in the majority of countries, or areas where we had the data from, within countries. However, there were certain sex, age, and sex by age groups who showed increase, like for example, in Japan and in some European countries. When we look now, we can see that suicide in some countries are increasing, and probably due to the economical situation after post-COVID pandemic. But why did suicide didn't increase during the COVID-19 pandemic? There are several explanations. One is the economical stimuli from many governments, both to healthcare system and housing systems, not to make people homeless during that period, but also by paying individual supportive checks We know also that psychiatry was really, and also other medical specialties, were very good to use digital services for treatment, prevention, communication. Also, people were very skillful to use services to communicate with friends and relatives. There was diminished use of alcohol and drugs in many countries. Family have seen each other much more. They were cooking meals together, they had time to discuss, and to be more with children. And there were massive efforts to increase awareness of healthy lifestyles and compliance to different advices, like to perform physical activities, to have good dietary habits, sleep hygiene, and advice about healthy drinking. So the COVID-19 impact on different risk factors was quite serious in psychiatric disorders due to increasing depression and anxiety, but we also have new studies showing that people were resilient, they came back, they are no longer depressed. There was influence of lifestyles on coping strategies, etc. So what we can do about it together with APA and WPA? Of course, we can be much better in education and to see what we can learn from each other and how we can link to each other, because we have very many educational activities, both in WPA and in APA, and also practical practice advices. We have a lot of resource materials, both at the WPA and the EPA websites, and it could be a task for somebody to compare them and to see how to comment those materials and have some short advices. We have at the WPA a huge educational website, where you can find a lot of information. We also have an educational portal with very, very many activities, and activities also, we are trying to do them in other languages, not only in English. APA has a big learning centre, but the materials are mainly in English and maybe some of those materials could be translated to other languages. We have position statements, guidelines, as well as APA, and of course guidelines are not materials, they are recommendations, but they are not binding materials. And what is very interesting to see are guidelines about migrants and refugee crises we have in Europe, but there is a migrant and refugee crisis here as well, about prison mental health, and I think those problems are much bigger in the United States, but they are quite big in other continents also, that we have many people with mental health disorders in prisons. And you are very good here about rights for persons with mental illnesses and also different legal problems. We could work together to increase access to diagnosis and treatment through telepsychiatry and to learn from APA's telepsychiatry toolkit. And of course we should collaborate on research and innovation, because funds, European funds from European union bodies, granting bodies, and American funds, it is a very huge amount of money which could be used in a more coordinated way by using our organisation's knowledge in which direction should we go at the moment. For me, I know that we know a lot, but I know that we are not implementing very well our knowledge. We are implementing our clinical guidelines in the individual situation, patient to doctor face-to-face meetings, and everybody is very keen to have the highest quality of treatment and evidence-based treatment. But as we see, it is not sufficient, because we need also to look at the population trials, how to increase mental health, to help to preserve mental health, and how to prevent, for example, suicidal behaviours. So I will give you one example here of the project which I am running on the global level with World Psychiatric Association, Kaulinska Institute, and indirectly with American Psychiatric Association, because one of my main educators is from United States, Natalie Riblett. So we have a clinical, a randomised control trial during COVID-19 period and post-COVID period, where we follow up suicide attempters after discharge from hospital. We are randomising them to two groups. One group is getting treatment as usual, and the other group treatment as usual, and in addition, follow up, and also motivational interview when discharge takes place, that they should follow up recommendations of the doctor which is giving treatment as usual. And this study is built upon a study I, together with my colleagues who are on this paper, which was published in the year 2008 by W. H. O. Burettin, Effectiveness of Brief Intervention and Contact for Suicide Attempters. We performed the study at that time in Brazil, India, Sri Lanka, Iran, and China, and the follow up of patients who get treatment as usual in comparison with brief intervention and intensive contact during 18 months after discharge from the hospital, after suicide attempt, during week 1, 2, 4, 7, 11, and then 4, 6, 12, and 18 months, and this follow up was conducted by students or volunteers through phone calls or visits, just to be there, just to show that I can help you if something is needed, showed amazing results that death by suicide was significantly reduced in the group which get this follow up and motivational interview to comply with doctor's advice and treatment, and even death from other causes, violent causes of death, was decreased in this group which get follow up. And Natalie Riblett, she did some kind of meta-analysis from the studies which already exist and also showed that the effects were significant. She showed also in her research that the role of connectivity between caregiver and the suicide attempter was one of the most important factors, so not only to stick to the treatment but also feeling of that somebody cares about me and connect with me. She works in United States in veteran hospitals with veteran populations and run this study very successfully in Dartmouth University in New Hampshire. So what we could do more? As you remember, I showed you that 96.5% of people in United States have no treatment for alcohol misuse or other drugs use. Similar situation is in other countries, so it is a huge problem globally. And we need to find new, innovative, preventive methods and test them in field trials because we need to prevent it early. We need to have trials for school children. We need to have trials for young people. We need to have trials in working places how to prevent alcohol and drug misuse and abuse. And I will give you an example from my own studies in years 85, 87 to 90s during the period of perestroika, which means restructuring, and glasnost, which means enlightening, during Gorbachev time. And Gorbachev was a leader who was working very closely with your President Reagan and English President Chacher. They were very reactive, but they had very good ideas for the world. And I mean, they had good ideas to open the world and they helped to some degree Gorbachev to open Soviet Union. And Gorbachev had also have seen that they have big problems with alcohol misuse, that the people are dying when they are very young. And they were losing the workforce, both among males and females. So he introduced alcohol restrictions in former Soviet Union, in all 15 Soviet republics, but he also introduced better rehabilitation centers, a lot of detention and rehabilitation centers, and also tried to change attitudes. So for example, during the official meetings of party leaders, they were not making cheers in alcohol, they were drinking soft drinks at that time. And as you can see here, the suicide decreased during those years of perestroika by 32% in males and 19% in females. We compared those data with Europe and we could see that in Europe, male suicide decreased only by 3% in comparison with 32% in the former Soviet Union. Females were similar. So I call this experiment they had in the former Soviet Union as the most successful suicide preventive field activity. So what about future? In future, according to me and my thoughts and my planning committee in the World Psychiatric Association, we need to have a structure and to build our future work not only on the individual contact and improving the care that we are doing all the time of psychiatric patients, but we need also to help communities and the general population, as well as us as professionals, to have a better health and better lifestyles. And the frame for my future work is the United Nations Sustainable Development Goals Agenda to transform our world, both concerning working places, climate, etc., equality. And for us within the health and mental health, education, equality, gender equality, reducing inequalities and partnership for our goals, not only with other professionals, but also with other sectors of the society are very important. So what I will try to do is to promote healthy lifestyles together with my colleagues working in different groups, using videos, short videos, as adjuvants to existing preventive and treatment strategies to increase physical activity, to be more aware what to do to have a good sleep hygiene, to have good eating habits, but also among both general population, psychiatric patients, but also among us, psychiatrists and other health and mental health professionals. So for example, now we are preparing some short videos for the group of patients. We will try to encourage now in our 145 psychiatric associations to test them and to see if our mental health staff and doctors could do those short physical activities at least once a day. They will be not longer than five, six minutes. And to see if we can not only improve the physical fitness of our health, but also to get better connections on the equal status between the staff and the patients. Because when you are doing those activities together and you have both drawbacks and you are successful, you feel the same joy in the group. And probably it will have a secondary effect for our patients' well health and those people who have poor health as well. And that we could test in different trials. What is also important that we need to look at the work environments and health in the working places. And I mean also our working places, hospitals, clinics, how doctors and other health care staff is feeling. And to see depression, anxiety and maybe substance use problems and to really deal with them. And what kind of possibility we have in our places to decide about our working conditions, which will also improve health and mental health of our staff. We need to look at the school environment and not only on preventive programs for children, but also the same for teachers. How they are feeling, what can we do to improve mental health, to increase awareness about it and to give them some instruments how to improve their mental health. Because then they will be able to help our kids to better health or to find help when they need it. My European colleagues in European Psychiatric Association will work also a lot about environments, green environments in the city and also climate change, how it influences our emotional experiences and especially experiences in young children who have a lot of anxiety. We have it also, but maybe we cope better or we deny it. But children and young adults are not doing that. They are not denying and they have a lot of anxiety and depression about it. So maybe we can learn then from European colleagues what they found and what methods they recommend. So we need to have a partnership between WPA or associations and EPA, because we need your knowledge, but we need your also intellectual power and economical power to have more intercontinental projects than we have now. And you have in American Psychiatric Association a lot of programs for schools, for workplace already, justice and community. We don't have yet so many. We have very good section on those specific topics and I think that the partnership concerning new research project, field projects and randomized controlled trials in the field could be a very good way for the future collaboration. What I would love also that we have one big meeting with the American Psychiatric Association. As you know, we are organizing meetings around the globe. We had a meeting in Canada, in Australia, in Latin American countries, in Asia, but we didn't have a common meeting with American Psychiatric Association. So why not do the common meeting in New York or Hawaii and have exchange of thoughts, but also experiences and to learn each other better. If you cannot make the world congress with us, then regional congresses or thematic congresses together with us could be a solution because they are much smaller to the format and much more focused. So I would like to end my presentation with a very important committee we have at the WPA, which is called ACRE Committee. So it is committee for humanitarian help for all countries who have problems or are in crisis. At the moment, we are focusing to help Ukraine and Ukrainian association, they are two association, are working now and trying to think what kind of psychiatry they would like to have after the war ended. And also, Lancet is interested and they organized now Lancet Commission on this topic. But, of course, our Ukrainian colleagues need money, I know the American Psychiatric Association gave a donation to WPA and we are holding those donations now to use them in the best way for the future planning of psychiatry in Ukraine. So thank you for your donation, they are also individual donations, not only by the association, so everybody can contribute with a few dollars, euros or other currency. So thank you very much for listening to my presentation. This is a picture of Stockholm and of the Golden Gate Bridge in San Francisco. We have water in common. You have lack of water in San Francisco, but we have plenty of water in Sweden still. And we are using it for generating electrical power, so it is a very good investment in Sweden for our water and good climate. Thank you very much.

World Psychiatric Association

American Psychiatric Association

mental health

collaboration

telepsychiatry

sustainable development goals

suicide prevention