BMC Public Health BioMed Central

Study protocol Open Access

Optimizing Suicide Prevention Programs and Their
Implementation in Europe (OSPI Europe): an evidence-based
multi-level approach
Ulrich Hegerl1, Lisa Wittenburg1, Ella Arensman7, Chantal Van Audenhove4,
James C Coyne15, David McDaid3, Christina M van der Feltz-Cornelis5,14,
Ricardo Gusmão11, Mária Kopp8, Margaret Maxwell6, Ullrich Meise13,
Saska Roskar9, Marco Sarchiapone12,16, Armin Schmidtke10, Airi Värnik2 and
Anke Bramesfeld*1

Address: 1University of Leipzig, Department of Psychiatry, Germany, 2Estonian-Swedish Mental Health and Suicidology Institute, Estonia,
3London School of Economics, Personal Social Services Research Unit, LSE Health and Social Care, UK, 4Katholieke Universiteit Leuven, LUCAS,

Belgium, 5Trimbos-Instituut/Netherlands Institute of Mental Health and Addiction, The Netherlands, 6University of Stirling, UK, 7National Suicide
Research Foundation, Ireland, 8Semmelweis University Budapest, Institute of Behavioural Sciences, Hungary, 9Institut za varovanje zdravja RS,
Slovenia, 10Bayerische Julius-Maximilians-Universität Würzburg, Department of Clinical Psychology, Clinic for Psychiatry and Psychotherapy,
Germany, 11CEDOC, Departamento de Saúde Mental, Faculdade de Ciências, Médicas da Universidade Nova de Lisboa, Portugal, 12University of
Primorska, PINT, Slovenia, 13Gesellschaft für Psychische Gesundheit - pro mente tirol, Austria, 14VU University Medical Centre Institute of
Extramural Research, Dept. of Psychiatry, Amsterdam, the Netherlands, 15University of Pennsylvania, School of Medicine, Pennsylvania, USA and
16Current address: University of Molise, Health Science Department, Italy

Email: Ulrich Hegerl - [Link]@[Link]; Lisa Wittenburg - lisainleipzig@[Link]; Ella Arensman - [Link]@[Link];
Chantal Van Audenhove - [Link]@[Link]; James C Coyne - jcoyne@[Link];
David McDaid - [Link]@[Link]; Christina M van der Feltz-Cornelis - cfeltz@[Link]; Ricardo Gusmão - [Link]@[Link];
Mária Kopp - kopmar@[Link]; Margaret Maxwell - [Link]@[Link]; Ullrich Meise - [Link]@[Link];
Saska Roskar - [Link]@[Link]; Marco Sarchiapone - [Link]@[Link]; Armin Schmidtke - clips-psychiatry@[Link]-
[Link]; Airi Värnik - airiv@[Link]; Anke Bramesfeld* - [Link]@[Link]
* Corresponding author

Published: 23 November 2009 Received: 1 September 2009

Accepted: 23 November 2009
BMC Public Health 2009, 9:428 doi:10.1186/1471-2458-9-428
This article is available from: [Link]
© 2009 Hegerl et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ([Link]
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: Suicide and non-fatal suicidal behaviour are significant public health issues in Europe
requiring effective preventive interventions. However, the evidence for effective preventive
strategies is scarce. The protocol of a European research project to develop an optimized evidence
based program for suicide prevention is presented.
Method: The groundwork for this research has been established by a regional community based
intervention for suicide prevention that focuses on improving awareness and care for depression
performed within the European Alliance Against Depression (EAAD). The EAAD intervention
consists of (1) training sessions and practice support for primary care physicians,(2) public relations
activities and mass media campaigns, (3) training sessions for community facilitators who serve as
gatekeepers for depressed and suicidal persons in the community and treatment and (4) outreach
and support for high risk and self-help groups (e.g. helplines). The intervention has been shown to
be effective in reducing suicidal behaviour in an earlier study, the Nuremberg Alliance Against
Depression. In the context of the current research project described in this paper (OSPI-Europe)

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the EAAD model is enhanced by other evidence based interventions and implemented
simultaneously and in standardised way in four regions in Ireland, Portugal, Hungary and Germany.
The enhanced intervention will be evaluated using a prospective controlled design with the primary
outcomes being composite suicidal acts (fatal and non-fatal), and with intermediate outcomes being
the effect of training programs, changes in public attitudes, guideline-consistent media reporting. In
addition an analysis of the economic costs and consequences will be undertaken, while a process
evaluation will monitor implementation of the interventions within the different regions with
varying organisational and healthcare contexts.
Discussion: This multi-centre research seeks to overcome major challenges of field research in
suicide prevention. It pools data from four European regions, considerably increasing the study
sample, which will be close to one million. In addition, the study will gather important information
concerning the potential to transfer this multilevel program to other health care systems. The
results of this research will provide a basis for developing an evidence-based, efficient concept for
suicide prevention for EU-member states.

Background from non-lethal to lethal acts are complex phenomena,

Public health relevance of suicide in the European Union complicated by access to lethal means, gender, and cul-
Fatal and non-fatal suicide acts are a significant public tural and social factors including attitudes towards suicid-
health issue. This is especially the case in Europe where ality, as well as personality factors such as impulsivity.
the highest rates for completed suicide in the world are Because of the multi-factorial nature of suicidality, inter-
found [1]. Every year more than 58,000 persons die by ventions that address the problem on multiple levels are
suicide within the European Union. According to World considered to be most effective. However, strong evidence
Health Organization (WHO data), suicide is among the delineating the most effective strategy to prevent suicidal-
10 leading causes of death for all ages [2]. Suicidal acts ity and the necessary components of suicide prevention
pose a considerable burden of disease and death. Suicide programs is lacking [6,11].
needs to be viewed not only as the premature end of a
human life but as affecting and traumatising family mem- In the face of the complexity of risk for suicide, and scarce
bers and other persons involved. Therefore, in 1984 the evidence but nevertheless a high need for on effective sui-
WHO's European Member States defined the reduction of cide prevention on a community level, the European
suicide as one of its main health policy targets and rein- Commission recently committed to financing a research
forced this target in several position papers [3]. In addi- project within the seventh Framework Program with the
tion, preventing suicide is one of the five areas of priority goal of optimizing suicide prevention programs and their
of the European Pact for Mental Health and Well-Being, implementation in Europe (OSPI-Europe).
which was launched by the European Commission in
2008 [4]. The aim of OSPI-Europe is to provide diverse regional pol-
icy makers and the European Commission with an evi-
Closely related to completed suicides are non-fatal sui- dence based, efficient concept for suicide prevention
cidal acts. The rate of non-fatal suicidal acts is estimated to along with the corresponding materials and instruments
be about 10 times higher than that of suicides. Non-fatal for the multifaceted intervention and guidelines for the
suicidal acts are the strongest predictor for completed sui- implementation process.
cide, especially in males [5]. Thus, every global strategy to
prevent suicide should also include the prevention of The specific study objectives include:
non-fatal suicidal acts, not only as a goal in itself, but as
an efficient means of preventing completed suicides. 1. To develop a state of the art intervention concept for the
prevention of suicidality that considers current evidence
Rates of non-fatal suicidal acts and suicides depend on based best practices and international experiences with
many factors. It is estimated that in Europe 90% of sui- multilevel interventions.
cides occur within the context of a psychiatric disorder [6].
Depression is most commonly associated with suicide, 2. To implement a multilevel community based interven-
but other affective disorders, alcohol and substance abuse tion in four culturally different European model regions
disorders, and schizophrenia also frequently underlie sui- in a comparable manner.
cidal behaviour [7-10]. Yet, suicidality and the transition

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3. To evaluate the intervention in a controlled, cross- 3. Training sessions on depression and suicidality for
country comparable design including primary and sec- community facilitators such as priests, social workers,
ondary outcomes, as well as to perform process and eco- geriatric care givers, teachers and journalists who are
nomic evaluations. gatekeepers in a position to direct vulnerable and high
risk persons into effective treatment
An outline of the research concept is presented in Figure 1.
4. Overtures to high risk groups (persons after non-
Groundwork fatal suicidal acts), establishment of help lines and
The groundwork for the OSPI-Europe project was estab- support of self-help activities involving patients and
lished through a community based multifaceted interven- relatives
tion program for improving care of depression and for
preventing suicidality that was implemented in Nurem- The NAD was rigorously evaluated according to a control-
berg, Germany, a city with a population of 500,000 inhab- led pre-post design with the number of suicidal acts (fatal
itants (Nuremberg Alliance Against Depression, NAD) and non-fatal) as primary outcome. After two years of
[12]. The Nuremberg intervention approached the pre- intervention, a major reduction in the number of suicidal
vention of suicide and non-fatal suicidal acts by focusing acts was found compared to the baseline year (-24%, p <
not only on improving the treatment of depression but 0.005). This reduction was clearly significant compared to
also by implementing other measures, such as influencing corresponding changes in the control region (Wuerz-
the media to report suicide in a responsible, non-sensa- burg). The reduction was even more pronounced (-53%,
tional and respectful manner. The hypothesis was that p < 0.01) in secondary analyses examining only the five
improvement in depression awareness and treatment most lethal suicide attempt methods [13].
would lead to a reduction in suicidal behaviour on a pop-
ulation basis. The NAD comprised a 4-level intervention: The 4-level intervention concept of NAD was further
refined and transferred to other EU countries. Thereby the
1. Training and practice support for primary care phy- European Alliance Against Depression (EAAD) came
sicians in detecting and treating depression together [14-16]. The EAAD was an EU-funded network of
partners from 17 countries that all aimed to implement
2. Public relations activities for informing the general the 4-level intervention concept in their regions, adapting
public about depression, including anti-stigma cam- it to local conditions even while preserving what were
paigns. viewed as the key components. The strong evidence base,
materials, concepts and evaluation tools of the NAD,
combined with the network and experience of the EAAD

Figure 1
OSPI-Europe Research Concept
OSPI-Europe Research Concept.

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constitutes the background, as well as the starting point EAAD four-level intervention is enhanced by the inclu-
from which OSPI-Europe was developed. sion of additional strategies that have recently demon-
strated a potential for efficacy. Thus, as part of the
Methodological challenges in assessing the effectiveness of optimisation process, efforts to restrict access to lethal
suicide prevention programs means will comprise a fifth intervention level of OSPI-
One of the challenges of field research on suicide preven- Europe. The main focus of the fifth level will include
tion is that because of a low base rate in completed sui- actions such as working with local councils to install
cides, it has been notoriously difficult to provide strong higher railings at bridges and encouraging the prescrip-
evidence concerning suicide-preventive effectiveness for tion of antidepressants that are less likely to be lethal in
any particular measure (e.g. interventions with high risk overdoses.
groups, public relations campaigns, etc) [11]. The smaller
the population under observation, the higher the risk to Implementation of a multilevel community based
miss statistically even highly relevant effects on suicide intervention
rates. In order to address this issue OSPI-Europe seeks to The intervention concept developed will be implemented
increase statistical power by two approaches: (1) Increas- and tested in regions of four countries (Ireland, Germany,
ing the size of the population under observation (denom- Hungary, Portugal) in a comparable manner. The coun-
inator) by aggregating data from four regions that tries were chosen to represent different EU-health systems
implement a similar suicide prevention program, and (2) and different socio-cultural characteristics as outlined in
increasing the numerator by constructing a composite pri- Table 1.
mary outcome, consisting of completed suicides but also
non-fatal suicidal acts. It was considered unrealistic to randomly select interven-
tion regions from all EU member states because of the
Methods/design multiple factors on which representativeness could be
Development of a state of the art intervention concept called into question.
Prior to designing the optimal intervention, the literature
was been systematically reviewed and experts in suicidal- Within each of the four model countries, intervention
ity research consulted. The criterion for selecting individ- regions are established. Interventions are implemented in
ual preventive strategies was scientific evidence for4 a standardised and synchronized way to ensure compara-
effectiveness. In addition to evaluating the effects of the bility across the regions. This means that interventions
five intervention levels separately, the synergistic effects of contain the same core elements (defined by minimum
the multifaceted approach will also be taken into account. standard of implementation type and intensity) that are
The target population, in which suicide is to be prevented, defined as "obligatory interventions" and are imple-
ranges from adolescence to old age (high rate of suicide in mented in a similar time frame, and in each of the four
most countries). regions. In addition "optional interventions" are also
defined. These can be implemented in the regions accord-
A core element of the state of the art intervention devel- ing to local requirements and resources. By distinguishing
oped through OSPI-Europe is the EAAD/NAD 4-level between obligatory and optional interventions some
intervention concept and the available materials which modification and adaptation to local needs in the differ-
are already in use within the EAAD. There is lower level ent regions is allowed, but the basic concept is preserved
evidence available that the individual strategies combined across intervention sites. The intervention will be imple-
within the 4-level intervention concept may be effective mented in the four regions over a period of at least 18
[6,11]. However, strong evidence is available showing that months, starting in 2009.
the four-level intervention is effective as a package [13]. In
the context of the research presented here, the original

Table 1: Main characteristics of intervention countries and intervention and control regions

Country Health System intervention region control region

Hungary Centralised national health insurance fund, limited private sector Miskolc population 180,000 Szeged population 170,000
Ireland Tax funded public health service, with supplemental voluntary Limerick population 184,055 Galway population 231,670
insurance
Portugal mix of National Health Service, special social health insurance schemes Amadora population 200,000 Almada population 110,000
for certain professions and private health insurance
Germany Bismarckian/social health insurance system with strong public-private Leipzig population 500,000 Magdeburg population 230,000
partnership

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Evaluation of the intervention Public attitudes

The intervention is evaluated according to a prospective A population survey on attitudes and knowledge towards
and controlled design. Therefore control regions are cho- depression and suicidality is performed in the interven-
sen in each intervention country. Control regions are tion and control regions at baseline and about 12 months
comparable to intervention regions in terms of urbanity following intervention implementation. The survey is
(please see Table 1 for further details). Evaluations will be based on existing validated instruments: the Depression
performed based on primary and intermediate outcomes. Stigma Scale (DSS), [18] and the Attitude Toward Seeking
Additionally, a process evaluation and an evaluation of Professional Psychological Help (ATSPPH-SF) question-
the economic costs and consequences of the intervention naire [19]. Five hundred people sampled from the general
will be conducted. population will complete baseline and follow-up tele-
phone interviews in all intervention and control regions.
Primary and secondary outcomes These will be conducted by a single independent survey
The primary outcome for evaluating the effect of the company to ensure consistency of implementation across
intervention is the rate of suicidal acts (fatal + non-fatal) all regions.
in the intervention and the control regions at baseline (six
months prior to the start of the intervention), during the Treatment of depression
18 months of the intervention and six months after. The As a proxy for the treatment of depression, prescription
main hypothesis is that the number of suicidal acts will rates for antidepressants and other psychopharmaceuti-
decrease in each intervention region compared to baseline cals will be monitored in the intervention regions by
(six months prior to the start of the intervention) and that using health insurance data or equivalents, available in
this decrease is significantly stronger than changes the intervention countries.
observed in the corresponding control regions.
Training programs
For the rates of completed suicides in intervention and Effects of training for community facilitators and general
control regions, the rates published by the respective sta- practitioners will be evaluated. Evaluation will be based
tistical offices are used. Data on non-fatal suicidal acts are on questionnaires such as the DSS [18], Suicide Interven-
collected in general hospital emergency rooms, where per- tion Response Inventory (SIRI-2) [20], confidence scales
sons after non-fatal suicidal acts seek medical help. Infor- [21,22], intervention knowledge test [23], Depression
mation on non-fatal suicidal acts is recorded using the Attitude Questionnaire (DAQ) [24,25] and the Attitude
instrument of the Monitoring Suicidal Behaviour in Toward Suicide Prevention Scale [26]. Questionnaires will
Europe (MONSUE) project which is based on the WHO/ be tailored to the specific target groups where necessary.
Euro Multicentre Study on Suicidal Behaviour [17]. In addition, general practitioners' referral to psychological
treatment will be evaluated, before and after trainings, as
Intermediate outcomes well as at four months follow-up.
In order to further measure the effectiveness of the OSPI-
Europe intervention, the study aims to assess intermediate Media reporting
outcomes associated with the single interventions that Media reports on suicide (such as articles in the local
make up the OSPI-Europe intervention package. These newspapers) will be collected in the intervention and con-
foci on more short term effects are directly linked to the trol regions. The number (quantitative assessment) and
operational goals and the content of the interventions, the content of the reporting (qualitative analyses) will be
such as improved awareness, knowledge, confidence, and compared before and after the intervention. The desired
attitude change. outcome is media reporting that is in line with WHO and
IASP guidelines for responsible suicide reporting.
Prior to the baseline assessment in the four participating
intervention regions, a standard evaluation methodology Economic evaluation
for intermediate outcome criteria is developed based on It is important in a situation where resources are limited
review of the relevant literature, a review of the existing to consider not only if something works, and in what con-
EAAD evaluation catalogue and consultation with EAAD I text, but also at what costs. Economic evaluation can help
and EAAD II partners, as well other researchers/experts in aid decision makers address this question. It compares the
suicide prevention. costs and effectiveness of two or more interventions. Our
hypothesis is that the intervention will lead to reductions
The evaluation of intermediate outcomes includes the fol- in the numbers of completed suicides and non-fatal sui-
lowing factors: cidal acts; this in turn will be associated with an overall
reduction in the use of resources, such as health care and
emergency services.

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In order to calculate the economic costs and consequences standing of differences in outcomes between each pair of
of the interventions, firstly the costs of suicide and non- intervention and control regions, as well as across the four
fatal suicidal acts will be estimated in each of the four interventions sites.
countries. This will be done from both a public purse and
societal perspective. A questionnaire will be developed to In addition, key stakeholders across all four intervention
collect information on the typical resource use for suicidal sites will be interviewed at six monthly intervals on the
events, for instance police time inputs and the need for progress in the implementation process using semi-struc-
ongoing treatment and support for non-fatal suicidal acts. tured interviews, which will be transcribed and translated
Lifetime productivity losses to the economy due to prema- into English. This will include gathering information on
ture mortality will be valued using age adjusted average the local context (and any important intervening events)
wage rates. Intangible costs associated with suicide such as as well the actual implementation process. This includes
the pain and shock experienced by family members will information on whether the intervention will succeed in
be imputed using data on the economic impacts of sud- involving all necessary stakeholders, information on the
den death from road traffic accidents. These data have pre- activities that are implemented in the region and the
viously been used in valuing the costs of suicide in Ireland resources available. Of particular interest is additional
and Scotland [27,28]. funding/support, that is made available to the local activ-
ities, the barriers and facilitators that have impacted on
Secondly, resources, including unpaid volunteer inputs, the implementation process and the sustainability of the
required to deliver the intervention will be collated using interventions. The Community Capacity Index (CCI) [30]
expert responses to a modified version of the Client Serv- will be used to assess the added value for regions in engag-
ice Receipt Inventory (CSRI) [29]; in addition, this instru- ing in a multi-level intervention and the sustainability of
ment will also gather data on some of the costs associated local activities. This will compliment more quantitative
with the initial development and implementation of the outcomes from the OSPI-Europe intervention.
OSPI-Europe intervention.
Finally, the number of activities that form part of the
Using this data we will then be able to construct a cost intervention such as public events, leaflets distributed,
effectiveness analysis comparing changes in the rate of training sessions held and self-help groups founded will
suicidal acts in the intervention and control areas with the be documented in the intervention regions.
costs of delivering the interventions less the costs avoided
as a result of suicides averted. Sensitivity analysis will be Funding and Consortium
used to test how varying assumptions on costs, effective- The project is funded by the 7th Research Framework Pro-
ness and fidelity of implementation impact on the likeli- gram of the European Union for the duration of four
hood that the intervention will be cost effective. This will years. The consortium consists of 14 partners, most of
be demonstrated visually using cost effectiveness accepta- whom took part in EAAD. Therefore, the project will ben-
bility curves. Finally we will also use decision analytical efit from previously developed working alliances and a
modelling to help project the long term potential costs culture of discussion and mutual understanding already
and consequences of the OSPI-intervention of beyond the existing in the EAAD.
duration of our empirical study period.
Ethical principles
Evaluation of the implementation process The study is planned and will be executed in accordance
Data about the actual process of implementation will pro- with the principles laid down in the Helsinki declaration
vide valuable information about the obstacles encoun- (Edinburgh, Scotland amendment, October 2000). The
tered and the fidelity of the implementation in the study protocol was approved both by the Data Protection
intervention regions. Specifically at play are the character- Commission of Saxony, Germany and the Medical Ethical
istics of the local environment which have the potential to Board of the Leipzig University. In addition the other
influence both suicidal behaviour and the effective imple- study centres in Hungary, Ireland and Portugal are cur-
mentation of a prevention program. Key issues to be con- rently seeking ethical approval from their local authority.
sidered beyond prevailing local attitudes toward mental
health treatment (which is assessed also as an intermedi- Discussion
ate outcome) and patterns of suicidality, concern local OSPI-Europe aims to provide the EU-member states with
health care structures and resources, ongoing local actions realistic evidence-based recommendations and decision-
or national actions targeting suicidality, and other factors support regarding the design and implementation of
affecting mental well-being such as unemployment rates. effective programs to reduce suicidality. The concrete
This contextual information is gathered at both national focus on implementation allows to study the efficiency of
and local level and is used to aid comparisons and under- the prevention program, as well as a process evaluation of

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the implementation itself. Further, the practicability of the consortium is built on the foundations of the EAAD, and
developed materials and instruments, possible shortcom- thus draws on the networks, expertise, prior collaboration
ings, potentials for improvement will be identified and and knowledge exchange culture that has been developed
improvements will be made based on lessons learned. in the different EAAD countries and during EAAD co-
Thereby, the OSPI-Europe project seeks to bridge the gap operations since its foundation in 2004.
between theoretical recommendations and practical
application. For OSPI-Europe to make a contribution to suicide pre-
vention in the European Community, OSPI-Europe needs
The limitations of the study design originate in the chal- not only to construct a strong intervention and conduct
lenges of simultaneously implementing comparable inter- high level research, but it also needs to disseminate results
ventions in four different countries and health systems. effectively. Dissemination strategies, which are not pre-
However, process evaluation will entail the collection of sented in detail in the context of this paper, remain a key
important information regarding the transferability of the component of the project. Strategies tailored to different
intervention to different health systems. The close moni- audiences can help facilitate the translation of research
toring of the implementation process will help to control results into policies and action. This article is meant to be
and explain differences in implementation that might a contribution to this dissemination strategy.
occur at the four intervention sites.
Competing interests
The existence of different health care systems may also The authors declare that they have no competing interests.
complicate evaluation of the intervention. Availability of
health services and specialised mental health care, access Authors' contributions
to psychotherapy, as well as requirements for out of UH is principle investigator, all participants have contrib-
pocket payments for medication and health services differ uted their part of expertise and read and approved the lat-
in the four intervention countries. Data for antidepressant est version of the article.
prescriptions are available in some countries as health
insurance data (Germany), and in others as IMS (Inter- References
continental Marketing Services) data. Close cooperation, 1. Varnik A, Wasserman D, Dankowicz M, Eklund G: Age-specific sui-
cide rates in the Slavic and Baltic regions of the former
harmonisation of terms and definitions as well as con- USSR during perestroika, in comparison with 22 European
senting on minimum standards within the project consor- countries. Acta Psychiatr Scand Suppl 1998, 394:20-25.
tium are needed to address the challenges with 2. WHO/Europe: SDR, suicide and self inflicted injury all ages per
100000, last available (2001-2003). WHO, European health for all
simultaneous data collection. database (HFA-DB) 2004.
3. World Health Organization: Suicide Prevention in Europe. The WHO
Further challenges emerge by conducting research within European monitoring survey on national suicide prevention programmes
and strategies WHO, Geneva; 2002.
real world local environments where it is impossible to 4. European Pact for Mental Health and Well-being [http://
control other intervening activities such as the introduc- [Link]/health/ph_determinants/life_style/mental/docs/
pact_en.pdf]
tion of National Suicide Prevention strategies (which may 5. Hawton K, Arensman E, Wasserman D, Hulten A, Bille-Brahe U,
or may not include specific prevention activities) or other Bjerke T, Crepet P, Deisenhammer E, Kerkhof A, De Leo D, et al.:
local initiatives on depression. Other intervention factors, Relation between attempted suicide and suicide rates
among young people in Europe. J Epidemiol Community Health
such as the current economic downturn, which may, for 1998, 52:191-194.
instance, lead to significant job losses in some study areas, 6. Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, Hegerl
U, Lonnqvist J, Malone K, Marusic A, et al.: Suicide prevention
may also blur the effectiveness of the intervention. Moni- strategies: a systematic review. JAMA 2005, 294:2064-2074.
toring of intermediate effects, as well as precisely docu- 7. Ilomaki E, Rasanen P, Viilo K, Hakko H: Suicidal behavior among
menting environmental conditions prior to and during adolescents with conduct disorder--the role of alcohol
dependence. Psychiatry Res 2007, 150:305-311.
the study within intervention and control regions, should 8. Bukstein OG, Brent DA, Perper JA, Moritz G, Baugher M, Schweers
allow for more robust interpretation and understanding J, Roth C, Balach L: Risk factors for completed suicide among
of primary and secondary outcomes. adolescents with a lifetime history of substance abuse: a
case-control study. Acta Psychiatr Scand 1993, 88:403-408.
9. Rich CL, Fowler RC, Fogarty LA, Young D: San Diego Suicide
The strengths of the design relate to its being grounded in Study. III. Relationships between diagnoses and stressors.
Arch Gen Psychiatry 1988, 45:589-592.
an intervention and evaluation concept that has previ- 10. Bertolote JM, Fleischmann A, De Leo D, Wasserman D: Suicide and
ously been shown to be effective [13]. Moreover, the Euro- mental disorders: do we know enough? Br J Psychiatry 2003,
pean Alliance Against Depression (EAAD) has 183:382-383.
11. Althaus D, Hegerl U: The evaluation of suicide prevention
demonstrated that it is possible to implement basic ele- activities: state of the art. World J Biol Psychiatry 2003, 4:156-165.
ments of the OSPI-Europe intervention in different Euro- 12. Hegerl U, Nikelewski G, Pfeiffer-Gerschel T, Althaus D: Das Bünd-
pean countries and health systems according to a nis gegen Depression: ein Projekt zur Prävention von
Depression und Suizid. In [Link]. Impulse, Wirkungen
standardised procedure [15]. Finally, the OSPI-Europe und Erfahrungen Gesellschaft für Versicherungswissenschaft und -

Page 7 of 8
(page number not for citation purposes)
BMC Public Health 2009, 9:428 [Link]

gestaltung e.V. Köln: Akademische Verlagsgesellschaft Aka GmbH,

Berlin; 2005:179-188.
13. 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.
14. Hegerl U, Pfeiffer-Gerschel T: The 'European Alliance against
depression'. European Journal of Public Health 2006, 16:48.
15. Hegerl U, Wittman M, Arensman E, van Audenhove C, Bouleau JH,
Feltz-Cornelis C van der, Gusmao R, Kopp M, Löhr C, Maxwell M, et
al.: The European Alliance Against Depression (EAAD): A
multifaceted, community-based action programme against
depression and suicidality. World J Biol Psychiatry 2008,
9(1):51-59.
16. Hegerl U, Wittenburg L: Focus on mental health care reforms
in Europe: the European alliance against depression: a mul-
tilevel approach to the prevention of suicidal behavior. Psy-
chiatr Serv 2009, 60:596-599.
17. Bille-Brahe U, Kerkhof A, De Leo D, Schmidtke A: Definitions and
terminology used in the WHO/EURO Multicentre Study. In
Suicidal Behaviour in Europe, Results from the WHO/EURO Multicentre
Study on Suicidal Behaviour Edited by: Schmidtke A, Bille-Brahe U,
Kerkhof AJFM, De Leo D. Hogrefe & Huber; 2004:11-14.
18. Griffiths KM, Christensen H, Jorm AF, Evans K, Groves C: Effect of
web-based depression literacy and cognitive-behavioural
therapy interventions on stigmatising attitudes to depres-
sion - Randomised controlled trial. British Journal of Psychiatry
2004, 185:342-349.
19. Fischer EH, Farina A: Attitudes Toward Seeking Professional
Psychological Help - A Shortened Form and Considerations
for Research. Journal of College Student Development 1995,
36:368-373.
20. Neimeyer RA, Bonnelle K: The suicide intervention response
inventory: A revision and validation. Death Studies 1997,
21:59-81.
21. Capp K, Deane FP, Lambert G: Suicide prevention in Aboriginal
communities: application of community gatekeeper train-
ing. Aust N Z J Public Health 2001, 25:315-321.
22. Morriss R, Gask L, Battersby L, Francheschini A, Robson M: Teach-
ing front-line health and voluntary workers to assess and
manage suicidal patients. Journal of Affective Disorders 1999,
52:77-83.
23. Tierney RJ: Suicide intervention training evaluation: a prelim-
inary report. Crisis 1994, 15:69-76.
24. Botega NJ, Silveira GM: General practitioners' attitudes
towards depression: A study in primary care setting in Bra-
zil. International Journal of Social Psychiatry 1996, 42:230-237.
25. Botega NR: General Practitioners and depression - first use of
the depression attitude questionnaire. Int Jour Med Psych Res
1992, 2:169-180.
26. Herron J, Ticehurst H, Appleby L, Perry A, Cordingley L: Attitudes
toward suicide prevention in front-line health staff. Suicide and
Life-Threatening Behavior 2001, 31:342-347.
27. Platt S, Halliday E, Maxwell M, McCollam A, McLean J, Woodhouse A,
Blamey A, Makenzie M, McDaid D: Evaluation of the first phase of
Choose Life. Final Report Edinburgh: Scottish Executive; 2006.
28. Kennely B, Ennis J, O'Shea E: Economic cost of suicide and delib-
erate self harm. In Reach Out. National Strategy for Action on Suicide
Prevention 2005 - 2014 Dublin: Department of Health and Children;
2005.
29. Beecham J, Knapp M: Costing psychiatric interventions. In Meas- Publish with Bio Med Central and every
uring Mental Health Needs Edited by: Thornicroft G, Brewin CR, Wing
J. London: Gaskell; 1992:163-183. scientist can read your work free of charge
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