Focus on Mental Health Care Reforms in Europe: The European Alliance Against Depression: A Multilevel Approach to the Prevention of Suicidal Behavior

Suicide is a major public health problem that both reflects and creates considerable human suffering. Every year more than 58,000 persons in the European Union die as a result of suicide. According to data from the World Health Organization (WHO), suicide is among the ten leading causes of death for all ages ( 1 ). In 1998 suicide represented 1.8% of the global burden of disease, and the figure is expected to increase to 2.4% by 2020 ( 2 ).

The number of attempted suicides (nonfatal) is estimated to be ten to 20 times higher than that of completed suicides. Although there is no single cause for suicidality, most suicidal acts occur in the context of a psychiatric disorder, most commonly a depressive disorder ( 3 ). It is estimated that 18.4 million Europeans have had depression, an estimation based on 12-month prevalence rates ranging between 3.1% and 10.1% in various European studies ( 4 ). Thus it is reasonable that efforts to reduce suicidality would include efforts directed at targeting people with depression as a major risk group. This column describes the European Alliance Against Depression (EAAD) and the four-level intervention that has been used to implement the program in EAAD partner countries.

The European Alliance Against Depression

The EAAD was formed in 2004 with funding from the European Commission to establish a network of experts across Europe with the objective of implementing action-oriented, community-based public health interventions to improve depression treatment and to reduce suicidality ( 5 ). The four separate levels of the approach are designed to work together to influence community attitudes about depression, improve treatment of depression at the primary care level, encourage help seeking, and directly address high-risk members of the community. The four levels are education of primary care physicians, a public relations campaign, training of community facilitators, and interventions with affected persons and high-risk groups.

Strong empirical evidence of the effectiveness of programs for the prevention of suicidality is rare. The EAAD is unique in that it rests on evidence from a pilot program conducted in Germany in 2001–2002—the Nuremberg Alliance Against Depression (described below). The strength of the EAAD approach led to its recognition in 2005 by the European Commission as a best-practice approach to reducing suicidality ( 6 ). The experience of implementing the multilevel approach in culturally diverse countries has clearly shown that the approach can be adapted for wide use. The EAAD multilevel approach is currently employed in 17 European countries. [A map showing the EADD partner countries is available as an online supplement to this column at ps.psychiatryonline.org .] The EAAD has recently expanded its target population to include children and adolescents. In addition, in several countries the four-level intervention has been expanded to other regions of the country and nationwide, and other countries are joining the EAAD as new partners.

The Nuremberg Alliance Against Depression

The EAAD intervention approach is based on a pilot program that was first tested in Nuremberg, Germany, in 2001–2002. The Nuremberg Alliance Against Depression included an intervention region (Nuremberg, population 500,000) and a control region (Würzburg, population 270,000). The intervention region received the four-level community intervention (with general practitioners, general public, community facilitators, and high-risk groups) for two years. Because suicide is a rare event, a population of 500,000 would not be sufficient to detect a statistically significant reduction in suicide rates of less than 30%. Therefore the combined number of completed and attempted suicides was selected as the primary outcome indicator. Having a history of attempted suicide is one of the strongest predictors of future completed suicide. Attempted suicides in the 12 months preceding the intervention were also measured.

During the two intervention years, the number of suicidal acts (attempted plus completed) decreased by 24% in the intervention region, a significant difference compared with the control region, where the rate remained stable. The effect was not only short term; a further decline was observed in the year after the two-year intervention (32% decline from the baseline year). When only nonfatal suicidal acts involving the five most lethal methods of suicide were examined, the reduction was even more pronounced—53% during the two intervention years ( 7 ). The success of this multilevel intervention is likely attributable not only to the effectiveness of the single interventions at the four levels but also to synergistic effects across the intervention levels. Because these results provided considerable evidence for the effectiveness of the four-level intervention concept, the same concept was used for EAAD.

Four-level intervention

Because many factors contribute to suicidality, interventions that address the problem at multiple levels through multifaceted programs are considered to be most effective ( 8 , 9 ). This approach is in line with evidence from other fields of prevention, such as tobacco control ( 10 ) and HIV prevention ( 11 ), showing that tackling a public health problem on multiple levels and with multiple strategies is more effective than using only a single strategy. The four levels of the EAAD intervention are described below.

Level 1: primary care physicians

The aim of this level of intervention is to improve the identification and treatment of depressed and suicidal persons. This is achieved through forming connections with primary care physicians in a local community by offering advanced training and offering suggestions regarding systemic factors that could improve the quality of treatment in local communities. The flexible nature of EAAD allows for variation in the duration and content of training to fit the specific needs of the target community. Partners may adapt the goals and materials of training as appropriate.

A literature review published in 2002 estimated that 83% of people who die from suicide have contact with a primary care physician in the 12 months before death ( 12 ). In addition, over 75% of people who seek treatment for an anxiety or depressive disorder from a primary care provider in Europe do not receive minimally adequate treatment ( 13 ). This points to an important opportunity for intervention and serves as a call to action for the primary care community. The EAAD recommends use of short screening tools, such as the WHO-5 ( 14 ), in primary care practices as a first-level depression screen. EAAD interactive training sessions with general practitioners cover such topics as how to address the topic of depression and suicidality with patients and how to treat suicidal patients and interact with patients and their families. The use of role-plays is an important part of training.

Level 2: public relations campaign

Stigma surrounding mental disorders and lack of knowledge about them are barriers to treatment, which affect all community members at many stages in their lives. The EAAD media campaign targets the general public with the aim of encouraging treatment seeking by destigmatizing depression and challenging commonly held misconceptions about depression. In all regions where EAAD is implemented, the media campaign has three key messages: "Depression is treatable." "Depression can affect anyone." "Depression has many faces." [Public relations materials presenting the three messages are available as an online supplement to this column at ps.psychiatryonline.org .]

The media campaign also includes distribution of guidelines to journalists to encourage responsible reporting of suicides. It is well known that the manner in which suicide is reported can have an impact on further suicides. In particular, when the act is romanticized or sensationalized, copycat suicides (known as the Werther effect) can result.

Level 3: community facilitators

Training is provided for key individuals, or community facilitators, who are in contact with high-risk groups and vulnerable populations. Key facilitator groups include teachers, police, clergy, social workers, persons who provide care for elderly persons, and prison workers. The needs and resources in a particular community and other social and cultural factors determine which groups will be targeted.

Level 4: affected persons and high-risk groups

Depression is known to be a chronic illness, and persons who have engaged in nonfatal suicidal acts are considered to be a high-risk group for future suicidality. Therefore, interventions at this level direct resources to those affected by depression and those who have engaged in suicide attempts. Specific interventions include offering individuals an emergency card after a suicide attempt and providing aftercare resources and support through self-help groups.

Evaluation of the four-level intervention

To evaluate the efficacy of the implemented measures, a set of evaluation indicators were defined that cover the following areas: suicide, suicide attempts and deliberate self-harm, rates of prescription of psychopharmaceutical drugs (mainly antidepressants), and attitudes toward and knowledge of depressive disorders and suicidality in the general public as well as among general practitioners and community facilitators. [A figure showing the EAAD outcome criteria is available as an online supplement to this column at ps.psychiatryonline.org .] Further, to assess, plan for, and promote sustainability of the individual regional networks, each EAAD region in the partner countries performed an assessment of key capacity-building areas: network partnerships, knowledge transfer, problem solving, and infrastructure.

As noted above, experiences in Nuremberg showed that the four-level intervention approach was effective in reducing suicidal behavior by 24% ( 7 ). These results have been replicated in Regensburg, Germany (Spiessl H, Hübner-Liebermann B, Schmid R, et al., unpublished manuscript, 2009). However, it has yet to be shown whether the approach is equally successful in other countries and regions in Europe. Some EAAD partners are evaluating their intervention activities, and baseline data have been published ( 15 , 16 ). One area of particular interest is the analysis of suicidal behavior and suicide methods in 15 EU countries ( 16 ). Hanging (50%) was identified as the most prevalent suicide method among women and men in the 15 countries, followed by poisoning by drugs 13%) and jumping from a high place (10%). However, considerable gender differences and differences between countries were observed ( 15 ). These data suggest setting country-specific foci in awareness campaigns and suicide prevention strategies.

Lessons learned

What can be learned from the experiences of the EAAD? Several points are discussed below that may be helpful to stakeholders in other community-based mental health interventions.

First, public health messages can be translated across different European cultures. The EAAD is currently active in 17 European countries, and other countries are in the process of joining. In many countries, local alliances in model regions have expanded to other regions, and some EAAD partner countries have expanded the alliance nationwide. These wide-ranging activities show that the four-level intervention concept and the EAAD materials can be readily adapted to different cultures. Also, the strategy of beginning in each country with a regional pilot project and then building on local experiences and adapted materials to promote expansion to other regions of the country has been successful.

Second, it is important to begin at the local level. Although differences in health care systems may necessitate some modifications, a strong bottom-up approach in the process of expansion of the regional alliances is recommended. This enables community members to identify with a local alliance against depression and boosts motivation and civil commitment.

Third, the message should be carefully considered. Whereas the public campaign focused on depression, suicidality was a major issue in the intervention with health professionals. This strategy was chosen because the effects of a public campaign focusing on suicidality are difficult to predict and might be negative for some vulnerable persons.

Fourth, the intervention will have broader destigmatizing effects. Although the public campaign focuses on depression, its effects are likely to generalize to other areas of mental health. Feedback from persons with anxiety disorders, schizophrenia, and other disorders indicated that the public campaign was perceived as helpful in reducing the stigma surrounding psychiatric disorders.

Conclusions

The EAAD offers an evidence-based concept and materials for conducting a community-based four-level intervention aimed at improving the care of depressed persons and preventing suicidality. The EAAD has shown that the model developed in Nuremberg and optimized by the experiences of all EAAD partners can be adapted to different countries and cultures with only minor changes.

Acknowledgments and disclosures

The European Alliance Against Depression is funded by grant number 20035323 from the Public Health Executive Agency, the European Commission.