Prevention of suicidal behaviour: Results of a controlled community-based intervention study in four European countries

Autoři: Ulrich Hegerl aff001;  Margaret Maxwell aff002;  Fiona Harris aff002;  Nicole Koburger aff003;  Roland Mergl aff004;  András Székely aff005;  Ella Arensman aff006;  Chantal Van Audenhove aff007;  Celine Larkin aff006;  Mónika Ditta Toth aff005;  Sónia Quintão aff008;  Airi Värnik aff009;  Axel Genz aff010;  Marco Sarchiapone aff011;  David McDaid aff012;  Armin Schmidtke aff013;  György Purebl aff005;  James C. Coyne aff014;  Ricardo Gusmão aff008
Působiště autorů: Department of Psychiatry, Psychosomatics, and Psychotherapy, Goethe-Universität Frankfurt, Frankfurt, Germany aff001;  Nursing, Midwifery and Allied Health Professions Research Unit, University of Stirling, Stirling, Scotland, United Kingdom aff002;  Department of Research Services, University of Leipzig, Leipzig, Saxonia, Germany aff003;  Department of Psychology, Bundeswehr University Munich aff004;  Institute of Behavioral Sciences, Semmelweis University Budapest, Budapest, Hungary aff005;  National Suicide Research Foundation and School of Public Health, University College Cork, Cork, Ireland aff006;  Center for care research and consultancy at KU Leuven (LUCAS), University of Leuven, Leuven, Belgium aff007;  CEDOC, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal aff008;  Estonian-Swedish Mental Health and Suicidology Institute (ERSI), Tallinn, Estonia & Tallinn University, Tallinn, Estonia aff009;  Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Otto-von-Guericke University, Magdeburg, Saxonia-Anhalt, Germany aff010;  Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy aff011;  London School of Economics and Political Science, London, United Kingdom aff012;  Department of Psychiatry, Psychosomatics and Psychotherapy, University of Wuerzburg, Wuerzburg, Bavaria, Germany aff013;  Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America aff014;  ISPUP, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal aff015
Vyšlo v časopise: PLoS ONE 14(11)
Kategorie: Research Article
doi: 10.1371/journal.pone.0224602


The ‘European Alliance Against Depression’ community-based intervention approach simultaneously targets depression and suicidal behaviour by a multifaceted community based intervention and has been implemented in more than 115 regions worldwide. The two main aims of the European Union funded project “Optimizing Suicide Prevention Programmes and Their Implementation in Europe” were to optimise this approach and to evaluate its implementation and impact. This paper reports on the primary outcome of the intervention (the number of completed and attempted suicides combined as ‘suicidal acts’) and on results concerning process evaluation analysis. Interventions were implemented in four European cities in Germany, Hungary, Portugal and Ireland, with matched control sites. The intervention comprised activities with predefined minimal intensity at four levels: training of primary care providers, a public awareness campaign, training of community facilitators, support for patients and their relatives. Changes in frequency of suicidal acts with respect to a one-year baseline in the four intervention regions were compared to those in the four control regions (chi-square tests). The decrease in suicidal acts compared to baseline in the intervention regions (-58 cases, -3.26%) did not differ significantly (χ2 = 0.13; p = 0.72) from the decrease in the control regions (-18 cases, -1.40%). However, intervention effects differed between countries (χ2 = 8.59; p = 0.04), with significant effects on suicidal acts in Portugal (χ2 = 4.82; p = 0.03). The interviews and observations explored local circumstances in each site throughout the study. Hypothesised mechanisms of action for successful implementation were observed and drivers for ‘added-value’ were identified: local partnership working and ‘in-kind’ contributions; an approach which valued existing partnership strengths; and synergies operating across intervention levels. It can be assumed that significant events during the implementation phase had a certain impact on the observed outcomes. However, this impact was, of course, not proven.

Klíčová slova:

Community based intervention – Depression – Germany – Hungary – Ireland – Mental health and psychiatry – Portugal – Suicide


1. World Health Organization (WHO). Preventing suicide. A resource for media professionals. Update 2017. Geneva: WHO; 2017.

2. Chesney E, Goodwin GM, Fazel S. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry. 2014;13: 153–160. doi: 10.1002/wps.20128 24890068

3. Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jönsson B, et al. The size and burden of mental disorders and other disorders of the brain in Europe 2010. Eur Neuropsychopharmacol. 2011;21: 655–679. doi: 10.1016/j.euroneuro.2011.07.018 21896369

4. Zalsman G, Hawton K, Wasserman D, van Heeringen K, Arensman E, Sarchiapone M, et al. Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry. 2016;3: 646–659. doi: 10.1016/S2215-0366(16)30030-X 27289303

5. Rush AJ. Problems associated with the diagnosis of depression. J Clin Psychiatry. 1990;51(Suppl.6): 15–22.

6. Brody DS, Thompson TL, Larson DB, Ford DE, Katon WJ, Magruder KM. Recognizing and managing depression in primary care. Gen Hosp Psychiatry. 1995;17: 93–107. doi: 10.1016/0163-8343(94)00093-s 7789790

7. Henkel V, Wambach V, Möller H-J, Hegerl U. Diagnostik der Therapie von Depression. Schlüsselrolle für den Hausarzt. Fortschr Med. 2001;143(Sonderheft 2): 495–501.

8. Hahn SR, Kroenke K, Williams JBW, Spitzer RL. Evaluation of mental disorders with the Prime-MD. In: Maruish M-E, editors. Handbook of psychological assessment in primary care settings. Mahwah, New Jersey: Lawrence Erlbaum Associates; 2000. pp. 191–254.

9. Ormel J, Tiemens B. Depression in primary care. In: Honig A, van Praag HM, editors. Depression: Neurobiological, psychopathological and therapeutic advances. Chichester, New York, Weinheim, Brisbane, Singapore, Toronto: John Wiley & Sons; 1997. pp. 83–108.

10. Jorm AF, Barney LJ, Christensen H, Highet NJ, Kelly CM, Kitchener BA. Research on mental health literacy: what we know and what we still need to know. ANZJP. 2006;40: 3–5. doi: 10.1080/j.1440-1614.2006.01734.x 16403031

11. Schnyder N, Michel C, Panczak R, Ochsenbein S, Schimmelmann BG, Schultze-Lutter F. The interplay of etiological knowledge and mental illness stigma on healthcare utilisation in the community: A structural equation model. Eur Psychiatry. 2018;51: 48–56. doi: 10.1016/j.eurpsy.2017.12.027 29518618

12. Carpiniello B, Pinna F. The reciprocal relationship between suicidality and stigma. Front Psychiatry. 2017;8: 35. doi: 10.3389/fpsyt.2017.00035 28337154

13. Hegerl U, Heinz I, Hug J. Best-practice and multilevel approaches in adult suicide prevention. 2019.

14. World Health Organization (WHO). Preventing suicide: a global imperative. Geneva: WHO; 2014.

15. Harris FM, Maxwell M, O’Connor RC, Coyne J, Arensman E, Székely A, et al. Developing social capital in implementing a complex intervention: a process evaluation of the early implementation of a suicide prevention intervention in four European countries. BMC Publ Health. 2013;13: 158.

16. Harris FM, Maxwell M, O'Connor R, Coyne JC, Arensman E, Coffey C, et al. Exploring synergistic interactions and catalysts in complex interventions: longitudinal, mixed methods case studies of an optimised multi-level suicide prevention intervention in four European countries (Ospi-Europe). BMC Publ Health. 2016;16: 268.

17. Szanto K, Kalmar S, Hendin H, Rihmer Z, Mann JJ. A suicide prevention program in a region with a very high suicide rate. Arch Gen Psychiatry. 2007;64: 914–920. doi: 10.1001/archpsyc.64.8.914 17679636

18. Motohashi Y, Kaneko Y, Sasaki H, Yamaji M. A decrease in suicide rates in Japanese rural towns after community-based intervention by the health promotion approach. Suicide Life Threat Behav. 2007;37: 593–599. doi: 10.1521/suli.2007.37.5.593 17967126

19. Ono Y, Sakai A, Otsuka K, Uda H, Oyama H, Ishizuka N, et al. Effectiveness of a multimodal community intervention program to prevent suicide and suicide attempts: a quasi-experimental study. PloS One. 2013;8: e74902. doi: 10.1371/journal.pone.0074902 24130673

20. Hegerl U, Althaus D, Schmidtke A, Niklewski G. The alliance against depression: 2-year evaluation of a community-based intervention to reduce suicidality. Psychol Med. 2006;36: 1225–1233. doi: 10.1017/S003329170600780X 16707028

21. Hegerl U, Mergl R, Havers I, Schmidtke A, Lehfeld H, Niklewski G, et al. Sustainable effects on suicidality were found for the Nuremberg alliance against depression. Eur Arch Psychiatry Clin Neurosci. 2010;260: 401–406. doi: 10.1007/s00406-009-0088-z 19921299

22. Hübner-Liebermann B, Neuner T, Hegerl U, Hajak G, Spiessl H. Reducing suicides through an alliance against depression? Gen Hosp Psychiatry. 2010;32: 514–518. doi: 10.1016/j.genhosppsych.2010.06.008 20851273

23. Székely A, Thege BK, Mergl R, Birkás E, Rózsa S, Purebl G, et al. How to decrease suicide rates in both genders? An effectiveness study of a community-based intervention (EAAD). PLoS One. 2013;8: e75081. doi: 10.1371/journal.pone.0075081 24086443

24. Collings S, Jenkin G, Stanley J, McKenzie S, Hatcher S. Preventing suicidal behaviours with a multilevel intervention: a cluster randomised controlled trial. BMC Publ Health. 2018;18: 140.

25. Cepoiu M, McCusker J, Cole MG, Sewitch M, Belzile E, Ciampi A. Recognition of depression by non‐psychiatric physicians–A systematic literature review and meta‐analysis. J Gen Intern Med. 2007;23: 25–36. doi: 10.1007/s11606-007-0428-5 17968628

26. Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve‐month use of mental health service in the United States: Results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62: 629–640. doi: 10.1001/archpsyc.62.6.629 15939840

27. Coppens E, van Audenhove C, Gusmão R, Purebl G, Székely A, Maxwell M, et al. Effectiveness of general practitioner training to improve suicide awareness and knowledge and skills towards depression. J Affect Disord. 2017;227: 17–23. doi: 10.1016/j.jad.2017.09.039 29049931

28. Coppens E, van Audenhove C, Scheerder G, Arensman E, Coffey C, Costa S, et al. Public attitudes toward depression and help-seeking in four European countries baseline survey prior to the OSPI-Europe intervention. J Affect Disord. 2013;150: 320–329. doi: 10.1016/j.jad.2013.04.013 23706876

29. Kohls E, Coppens E, Hug J, Wittevrongel E, Van Audenhove C, Koburger N, et al. Public attitudes toward depression and help-seeking: Impact of the OSPI Europe depression awareness campaign in four European regions. J Affect Disord. 2017;217: 252–259. doi: 10.1016/j.jad.2017.04.006 28437762

30. Arensman E, Coffey C, Griffin E, Van Audenhove C, Scheerder G, Gusmão R, et al. Effectiveness of depression–suicidal behaviour gatekeeper training among police officers in three European regions: Outcomes of the Optimising Suicide Prevention Programmes and Their Implementation in Europe (OSPI-Europe) study. Int J Soc Psychiatry. 2016;62: 651–660. doi: 10.1177/0020764016668907 27647606

31. Coppens E, Van Audenhove C, Iddi S, Arensman E, Gottlebe K, Koburger N, et al. Effectiveness of community facilitator training in improving knowledge, attitudes, and confidence in relation to depression and suicidal behavior: Results of the OSPI-Europe intervention in four European countries. J Affect Disord. 2014;165: 142–150. doi: 10.1016/j.jad.2014.04.052 24882192

32. Marzano L, Smith M, Long M, Kisby C, Hawton K. Police and suicide prevention. Crisis. 2016;37: 194–204. doi: 10.1027/0227-5910/a000381 27040129

33. Painter NA, Kuo GM, Collins SP, Palomino YL, Lee KC. Pharmacist training in suicide prevention. JAPhA. 2018;58: 199-204.e2.

34. Terpstra S, Beekman A, Abbing J, Jaken S, Steendam M, Gilissen R. Suicide prevention gatekeeper training in the Netherlands improves gatekeepers’ knowledge of suicide prevention and their confidence to discuss suicidality, an observational study. BMC Publ Health. 2018;18: 637.

35. Hegerl U, Rummel-Kluge C, Värnik A, Arensman E, Koburger N. Alliances against depression–A community based approach to target depression and to prevent suicidal behaviour. Neurosci Biobehav Rev. 2013a;37: 2404–2409. doi: 10.1016/j.neubiorev.2013.02.009 23438891

36. Dopson S, Locock L, Gabbay J, Ferlie E, Fitzgerald L. Evidence-based medicine and the implementation gap. Health. 2003;7: 311–330.

37. Haines A, Kuruvilla S, Borchert M. Bridging the implementation gap between knowledge and action for health. Bull World Health Organ. 2004;82: 724–731. 15643791

38. Pawson R, Tilley N. Realistic evaluation. Sage: London; 1997.

39. van der Feltz-Cornelis CM, Sarchiapone M, Postuvan V, Volker D, Roskar S, Tancic Grum A, et al. Best practice elements of multilevel suicide prevention strategies. Crisis. 2011;32: 319–333. doi: 10.1027/0227-5910/a000109 21945840

40. Pirkis J, Spittal MJ, Cox G, Robinson J, Cheung YT, Studdert D. The effectiveness of structural interventions at suicide hotspots: a meta-analysis. Int J Epidemiol. 2013;42: 541–548. doi: 10.1093/ije/dyt021 23505253

41. Hegerl U, Wittenburg L, Arensman E, Van Audenhove C, Coyne JC, McDaid D, et al. Optimizing suicide prevention programs and their implementation in Europe (OSPI Europe): an evidence-based multi-level approach. BMC Publ Health. 2009;9: 428.

42. National Institute for Health and Clinical Excellence (NICE). CG23 Depresion–NICE guideline. Management of depression in primary and secondary care. London: NICE; 2004.

43. DGPPN, BÄK, KBV, AWMF (Eds.). S3 Praxisleitlinien in Psychiatrie und Psycho-therapie–Nationale Versorgungsleitlinie Unipolare Depression. Heidelberg: Springer; 2010.

44. World Health Organization (WHO). International statistical classification of diseases and related health problems. Geneva: WHO; 2008.

45. Platt S, Bille-Brahe U, Kerkhof A, Schmidtke A, Bjerke T, Crepet P, et al. Parasuicide in Europe: the WHO/EURO multicentre study on parasuicide. I. Introduction and preliminary analysis for 1989. Acta Psychiatr Scand. 1992;85: 97–104. doi: 10.1111/j.1600-0447.1992.tb01451.x 1543046

46. Perry IJ, Corcoran P, Fitzgerald AP, Keeley HS, Reulbach U, Arensman E. The incidence and repetition of hospital-treated deliberate self harm: Findings from the World's First National Registry. PLoS One. 2012;7: e31663. doi: 10.1371/journal.pone.0031663 22363700

47. Mergl R, Koburger N, Heinrichs K, Székely A, Tóth MD, Coyne J, et al. What are reasons for the large gender differences in the lethality of suicidal acts? An epidemiological analysis in four European countries. PLoS One. 2015;10: e0129062. doi: 10.1371/journal.pone.0129062 26147965

48. Cibis A, Mergl R, Bramesfeld A, Althaus D, Niklewski G, Schmidtke A, et al. Preference of lethal methods is not the only cause for higher suicide rates in males. J Affect Disord. 2012;136: 9–16. doi: 10.1016/j.jad.2011.08.032 21937122

49. Moore GF, Audrey S, Barker M, Bond L, Bonell C, Hardeman W, et al. Process evaluation of complex interventions: Medical Research Council guidance. BMJ. 2015;350: h1258. doi: 10.1136/bmj.h1258 25791983

50. Richie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess B, editors. Analysing qualitative data. London: Routledge; 1994. pp. 173–194.

51. Koburger N, Mergl R, Rummel-Kluge C, Ibelshäuser A, Meise U, Postuvan V, et al. Celebrity suicide on the railway network: Can one case trigger international effects? J Affect Disord. 2015;185: 38–46. doi: 10.1016/j.jad.2015.06.037 26143403

52. Hegerl U, Koburger N, Rummel-Kluge C, Gravert C, Walden M, Mergl R. One followed by many?–Long-term effects of a celebrity suicide on the number of suicidal acts on the German railway net. J Affect Disord. 2013b;146: 39–44. doi: 10.1016/j.jad.2012.08.032 23040873

53. Ladwig KH, Kunrath S, Lukaschek K, Baumert J. The railway suicide death of a famous German football player: impact on the subsequent frequency of railway suicide acts in Germany. J Affect Disord. 2012;136: 194–198. doi: 10.1016/j.jad.2011.09.044 22036798

54. Teismann T, Schwidder J, Willutzki U. Mediale Berichterstattung über den Suizid von Robert Enke. Zeitschrift für Gesundheitspsychologie. 2013;21: 113–121.

55. Schäfer M, Quiring O. The press coverage of celebrity suicide and the development of suicide frequencies in Germany. Health Communication. 2015; 30: 1149–1158. doi: 10.1080/10410236.2014.923273 25365759

56. Corcoran P, Griffin E, Arensman E, Fitzgerald AP, Perry IJ. Impact of the economic recession and subsequent austerity on suicide and self-harm in Ireland: An interrupted time series analysis. Int J Epidemiol. 2015;44: 969–977. doi: 10.1093/ije/dyv058 26082406

57. Central Statistics Office (CSO). This is Ireland. Highlights from Census 2011, Part 2. 2012. Available from:,%20P2%20Full%20doc.pdf Cited 22 July 2015.

58. Hegerl U, Kohls E. Synergistic effects of multi-level suicide preventive interventions: Important, but difficult to disentangle. ANZJP. 2016;50: 178–179. doi: 10.1177/0004867415621398 26744518

59. Krysinska K, Batterham PJ, Tye M, Shand F, Calear AL, Cockayne N, et al. Best strategies for reducing the suicide rate in Australia. ANZJP. 2016;50: 115–118. doi: 10.1177/0004867415620024 26698822

60. Milner A, Maheen H. Suicide prevention in Australia: Does the funding match the burden? ANZJP. 2018;52: 596–598. doi: 10.1177/0004867418773873 29726276

Článek vyšel v časopise


2019 Číslo 11