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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. [ABSTRACT FROM AUTHOR]

Background: In Europe, men have lower rates of attempted suicide compared to women and at the same time a higher rate of completed suicides, indicating major gender differences in lethality of suicidal behaviour. The aim of this study was to analyse the extent to which these gender differences in lethality can be explained by factors such as choice of more lethal methods or lethality differences within the same suicide method or age. In addition, we explored gender differences in the intentionality of suicide attempts. Methods and Findings: Methods. Design: Epidemiological study using a combination of self-report and official data. Setting: Mental health care services in four European countries: Germany, Hungary, Ireland, and Portugal. Data basis: Completed suicides derived from official statistics for each country (767 acts, 74.4% male) and assessed suicide attempts excluding habitual intentional self-harm (8,175 acts, 43.2% male). Main Outcome Measures and Data Analysis. We collected data on suicidal acts in eight regions of four European countries participating in the EU-funded “OSPI-Europe”-project (). We calculated method-specific lethality using the number of completed suicides per method * 100 / (number of completed suicides per method + number of attempted suicides per method). We tested gender differences in the distribution of suicidal acts for significance by using the χ2-test for two-by-two tables. We assessed the effect sizes with phi coefficients (φ). We identified predictors of lethality with a binary logistic regression analysis. Poisson regression analysis examined the contribution of choice of methods and method-specific lethality to gender differences in the lethality of suicidal acts. Findings Main Results: Suicidal acts (fatal and non-fatal) were 3.4 times more lethal in men than in women (lethality 13.91% (regarding 4106 suicidal acts) versus 4.05% (regarding 4836 suicidal acts)), the difference being significant for the methods hanging, jumping, moving objects, sharp objects and poisoning by substances other than drugs. Median age at time of suicidal behaviour (35–44 years) did not differ between males and females. The overall gender difference in lethality of suicidal behaviour was explained by males choosing more lethal suicide methods (odds ratio (OR) = 2.03; 95% CI = 1.65 to 2.50; p < 0.000001) and additionally, but to a lesser degree, by a higher lethality of suicidal acts for males even within the same method (OR = 1.64; 95% CI = 1.32 to 2.02; p = 0.000005). Results of a regression analysis revealed neither age nor country differences were significant predictors for gender differences in the lethality of suicidal acts. The proportion of serious suicide attempts among all non-fatal suicidal acts with known intentionality (NFSAi) was significantly higher in men (57.1%; 1,207 of 2,115 NFSAi) than in women (48.6%; 1,508 of 3,100 NFSAi) (χ2 = 35.74; p < 0.000001). Main limitations of the study: Due to restrictive data security regulations to ensure anonymity in Ireland, specific ages could not be provided because of the relatively low absolute numbers of suicide in the Irish intervention and control region. Therefore, analyses of the interaction between gender and age could only be conducted for three of the four countries. Attempted suicides were assessed for patients presenting to emergency departments or treated in hospitals. An unknown rate of attempted suicides remained undetected. This may have caused an overestimation of the lethality of certain methods. Moreover, the detection of attempted suicides and the registration of completed suicides might have differed across the four countries. Some suicides might be hidden and misclassified as undetermined deaths. Conclusions: Men more often used highly lethal methods in suicidal behaviour, but there was also a higher method-specific lethality which together explained the large gender differences in the lethality of suicidal acts. Gender differences in the lethality of suicidal acts were fairly consistent across all four European countries examined. Males and females did not differ in age at time of suicidal behaviour. Suicide attempts by males were rated as being more serious independent of the method used, with the exceptions of attempted hanging, suggesting gender differences in intentionality associated with suicidal behaviour. These findings contribute to understanding of the spectrum of reasons for gender differences in the lethality of suicidal behaviour and should inform the development of gender specific strategies for suicide prevention. [ABSTRACT FROM AUTHOR]

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Background: Declared suicidal intent and physical danger are both considered important components in defining suicidal behaviors (SB). Aims: 1) To investigate characteristics of serious suicidal behaviors (SSB), defined by either suicidal intent or lethality; 2) To determine any difference in terms of socio-demographic, clinical and/or service usage variables between SSB and non-serious suicidal behaviors (NSSB). Methods: A total of 2631 contacts for SB were registered in the context of the MONSUE (Monitoring Suicidal Behavior in Europe) study project. Demographic and clinical information were registered. ICD-10 was used for classifying data about psychiatric diagnoses, methods used for SB and injuries reported. Clear intentionality, high-case fatality methods and serious injuries all defined SSB ( n = 1169; 44.4%) Results: SSB were more often preceded by a contact with an inpatient (either psychiatric or somatic) rather than an outpatient service. Among those having a previous history of SB, SSB subjects had fewer contacts with health services before the previous attempt. The strongest predictors for SSB appeared to be older age and not professing a religion. Conclusion: Many of the known factors contributing to the risk of completed suicide were also present for SSB. Our findings on service usage by suicide attempters show which aspects of mental health services should be strengthened in order to improve suicide prevention. [ABSTRACT FROM AUTHOR]

Background: Studies report high rates of suicide attempts for female immigrants. This study assesses variations in the distribution of suicide attempts across gender in immigrant and non-immigrant groups in Europe. Method: Data on 64 native and immigrant groups, including 17 662 local and 3755 immigrant person-cases collected, between 1989 and 2003, in 24 million person-years were derived from the WHO/EURO Multicentre Study on Suicidal Behaviour. Female-to-male ratios of suicide attempt rates (SARs) were calculated for all groups. Results: The cases were combined into four major categories: hosts; European and other Western immigrants; non-European immigrants; and Russian immigrants. The non-European immigrants included higher female SARs than the Europeans, both hosts and immigrants. Unlike the other groups, the majority of suicide attempters among the Russian immigrants in Estonia and Estonian hosts were male. This was also true for immigrants from Curaçao, Iran, Libya and Sri Lanka. When the single groups with a male majority were excluded, the correlation between female and male SARs was relatively high among the European immigrants (r = 0.74, P < 0.0005) and lower among the non-European immigrants (r = 0.55, P < 0.03). Generalized estimating equation analysis yielded a highly significant difference (P < 0.0005) in gender ratios of suicide attempts between hosts (ratio 1.52) and both non-European immigrants (ratio 2.32) and Russian immigrants (0.68), but not the European immigrants. Conclusions: The higher suicide attempt rates in non-European immigrant females compared with males may be indicative of difficulties in the acculturation processes in Europe. Further understanding of factors underlying suicidal behaviour in immigrant and minority groups is necessary for planning effective prevention strategies. [ABSTRACT FROM AUTHOR]

Purpose: This study compares the frequencies of attempted suicide among immigrants and their hosts, between different immigrant groups, and between immigrants and their countries of origin. Methods: The material, 27,048 persons, including 4,160 immigrants, was obtained from the WHO/EURO Multicentre Study on Suicidal Behaviour, the largest available European database, and was collected in a standardised manner from 11 European centres in 1989-2003. Person-based suicide-attempt rates (SARs) were calculated for each group. The larger immigrant groups were studied at each centre and compared across centres. Completed-suicide rates of their countries of origin were compared to the SARs of the immigrant groups using rank correlations. Results: 27 of 56 immigrant groups studied showed significantly higher, and only four groups significantly lower SARs than their hosts. Immigrant groups tended to have similar rates across different centres. Moreover, positive correlation between the immigrant SAR and the country-of-origin suicide rate was found. However, Chileans, Iranians, Moroccans, and Turks displayed high SARs as immigrants despite low suicide rates in the home countries. Conclusions: The similarity of most immigrant groups' SARs across centres, and the correlation with suicidality in the countries of origin suggest a strong continuity that can be interpreted in either cultural or genetic terms. However, the generally higher rates among immigrants compared to host populations and the similarity of the rates of foreign-born and those immigrants who retained the citizenship of their country of origin point to difficulties in the acculturation and integration process. The positive correlation found between attempted and completed suicide rates suggests that the two are related, a fact with strong implications for suicide prevention. [ABSTRACT FROM AUTHOR]

This cross-cultural study investigates whether religiosity assessed in three dimensions has a protective effect against attempted suicide. Community controls (n = 5484) were more likely than suicide attempters (n = 2819) to report religious denomination in Estonia (OR = 0.5) and subjective religiosity in four countries: Brazil (OR = 0.2), Estonia (OR = 0.5), Islamic Republic of Iran (OR = 0.6), and Sri Lanka (OR = 0.4). In South Africa, the effect was exceptional both for religious denomination (OR = 5.9) and subjective religiosity (OR = 2.7). No effects were found in India and Vietnam. Organizational religiosity gave controversial results. In particular, subjective religiosity (considering him/herself as religious person) may serve as a protective factor against non-fatal suicidal behavior in some cultures. [ABSTRACT FROM AUTHOR]

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) 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. [ABSTRACT FROM AUTHOR]

An objective way to measure the severity of suicide attempt is to use different psychometric scales. Aspects of suicide risk like suicidal intent, depression, hopelessness and well-being can be assessed and different practical scales are in use to facilitate the risk assessment procedure. The aims of current study were: 1) to analyse the association between the severity of suicide attempt measured by suicidal intent scale and characteristics of emotional status of suicide attempters measured by depression, hopelessness and well-being scales in different gender and age groups; 2) to test the applicability of well-being measured by the World Health Organisation well-being index (WHO-5) in suicide risk assessment. The data on suicide attempters (n=469) was obtained in Estonia (Tallinn) by the WHO Suicide Prevention—Multisite Intervention Study on Suicidal Behaviours (SUPRE-MISS) methodology. Different psychometric scales were used to measure suicidal intent (Pierce Suicidal Intent Scale) and emotional status (Beck Depression Inventory for depression, Beck Hopelessness Scale for hopelessness, WHO-5 for well-being). All psychometric scales correlated well with each other (P<0.05). Low level of well-being associated with high level of suicidal intent, depression and hopelessness. Suicidal intent correlated the most strongly with well-being. Analysis by gender and age groups revealed also significant correlations with two exceptions only: correlation between suicidal intent and hopelessness did not reach the significant level in males and in older adults (40+). The WHO-5 well-being scale, which is a short and emotionally positively loaded instrument measuring protective factors, can be used in settings without psychological/psychiatric expertise in preliminary suicide risk assessment. [ABSTRACT FROM AUTHOR]

Action programmes fostering partnerships and bringing together regional and national authorities to promote the care of depressed patients are urgently needed. In 2001 the 'Nuremberg Alliance Against Depression' was initiated as a community-based model project within the large-scale 'German Research Network on Depression and Suicidality' (Kompetenznetz 'Depression, Suizidalität'). The 'Nuremberg Alliance Against Depression' was an action programme, conducted in the city of Nuremberg (500,000 inhabitants) in 2001/2002, addressing four intervention levels (Hegerl et al. Psychol Med 2006;36:1225). Based on the positive results of the Nuremberg project (a significant reduction of suicidal behaviour by more than 20%) 18 international partners representing 16 different European countries established the 'European Alliance Against Depression' (EAAD) in 2004. Based on the four-level approach of the Nuremberg project, all regional partners initiated respective regional intervention programmes addressing depression and suicidality. Evaluation of the activities takes place on regional and international levels. This paper gives a brief overview of the background for and experiences with the EAAD. It describes the components of the programme, provides the rationale for the intervention and outlines the current status of the project. The aim of the paper is to disseminate information about the programme's potential to reduce suicidal behaviour and to provide examples of how European community-based 'best practice' models for improving the care of depressed patients and suicidal persons can be implemented using a bottom-up approach. EAAD is mentioned by the European commission as a best practice example within the Green Paper 'Improving the mental health of the population: Towards a strategy on mental health for the European Union' (European Commission 2005). [ABSTRACT FROM AUTHOR]

Abstract: The purpose of this study was to analyze the differences in the disposition and frequency of recent life events preceding suicide in two cities with different socio-political backgrounds: Tallinn in Estonia and Frankfurt/Main in Germany. The information about 156 suicidents in Tallinn and 163 suicidents in Frankfurt was compiled using the psychological autopsy technique [Shneidman, E. S. (1981). The psychological autopsy. Suicide and Life-Threatening Behavior, 11, 325–340; Jacobs, D., & Klein-Benheim, M. (1995). The psychological autopsy: A useful tool for determining proximate causation in suicide cases. Bulletin of American Academy of Psychiatry Law, 23(2), 165–182]. General population controls were matched by age and sex. The occurrence of recent life events was similar among suicidents in Tallinn (81%) and Frankfurt (77%). However, in both sites only male suicides had higher risk of occurrence of any life event than controls (Tallinn: OR′=1.9; 95% CI=1.1–3.7; Frankfurt: OR′=2.0; 95% CI=1.0–4.1) and the mean number of life events was significantly higher among male suicidents in Tallinn in comparison with controls. This may indicate that males are more sensitive to the rapid changes in a society undergoing transition. It seems that it is not the number of life events, but rather their meaning and disposition that creates the risk of suicide. Family discord (weighted OR=4.5; 95% CI=2.5–8.1), loss of job (weighted OR=2.6; 95% CI=1.0–6.4) and financial deterioration (weighted OR=2.2; 95% CI=1.3–3.8) were more prevalent among suicides in Tallinn in comparison with those in Frankfurt. The most significant differences between suicides and controls were family discord, separation and loss of job in Tallinn and somatic illness in Frankfurt. These differences between the two societies, post-Soviet Estonia and Germany, could be explained by the different positions of Estonia and Germany on the survival/self-expression dimensions recorded by the World Value Survey. People in Estonia tend to emphasize economic and physical security above all other goals, and feel threatened by the changes taking place in society. In Germany, good health is considered a necessity for a consumer and self-expressive style of life, and poor health is perceived as a serious threat to the quality of life in a post-materialistic value system. [Copyright &y& Elsevier]

This report describes the investigation of care recommendations in the medical system across European countries to immigrants who attempted suicide. Data from seven European countries with 8865 local and 2921 immigrant person-cases were derived from the WHO/EURO Multicentre Study on Suicidal Behaviour and ensuing MONSUE (Monitoring Suicidal Behaviour in Europe) project. The relationship between immigrant status and type of aftercare recommended was analysed with binary logistic regression, adjusting for gender, age, method of attempt and the Centre collecting the data. Clear disparities were identified in the care recommendation practices toward immigrants, compared with hosts, over and above differing policies by the European Centres. [ABSTRACT FROM PUBLISHER]

Background: Reproductive and mental health are key domains of adolescent wellbeing but possible interrelationships are poorly understood. This cross-sectional study evaluated the association between psychopathology and reproductive health risk among European adolescents. Methods: A structured self-report questionnaire was delivered to 12,395 pupils of 179 randomly selected schools in 11 European countries within the EU funded "Saving and Empowering Young Lives in Europe" (SEYLE) project. The questionnaire included items about sexual initiation and reproductive health risk factors, such as number of sexual partners, frequency of condom use, and pregnancy involvement. Psychopathology was evaluated with validated instruments and/or ad-hoc questions. Results: Of 11,406 respondents (median age 15; interquartile range [IQR] 14–15; 57% females), 18.8% reported sexual initiation. Sixty percent of them also reported at least one reproductive risk factor. Sexual initiation was significantly more common among pupils older than 15 years (38% versus 13.2% younger pupils) and males (21.3% versus 16.9% females). It was also more common among pupils with depression (age/sex-adjusted odds ratio [aOR] 1.871), anxiety (aOR 2.190), severe suicidal ideation (aOR 2.259), self-injurious behaviour (aOR 2.892), and suicide attempts (aOR 3.091). These associations were particularly strong among pupils ≤15 years old and, for overt psychopathology, among pupils with low non-sexual risk behaviour profile and females. Depression (aOR 1.937), anxiety (aOR 2.282), severe suicidal ideation (aOR 2.354), self-injurious behaviour (aOR 3.022), and suicide attempts (aOR 3.284) were associated with higher reproductive health risk, defined by an increasing number of coexisting reproductive risk factors. Conclusions: These findings suggest an alignment between mental and reproductive health risk and support the value of cross-domain collaboration in adolescent health. The association between psychopathology and reproductive health risk, as well as its variations with age, sex, and associated risk behaviours, should be considered when designing health-promoting or disease-preventing interventions for adolescents. [ABSTRACT FROM AUTHOR]

Presents the results of a study on the suicide rate among Russians in Estonia. Claim that migration presents an important risk factor for suicide; Details of a study on suicide rates before and after the dissolution of the Soviet Union, during which Estonia gained independence; Statistics of the ethnic makeup of Estonia's population; Report that suicides among Estonian Russians increased during the dissolution of the Soviet Union; Potential impact of social status and political events on the suicide rate among Estonian Russians.

A letter to the editor is presented about a report on suicide prevention in Greece released by Minister of Citizen Protection Christos Papoutsis.

Abstract: Depressive disorders as well as fatal and non-fatal suicidal behaviour continue to be important mental health issues. Because of the close relation between depression and suicidal behaviour, it is likely that preventive actions improving care and optimising treatment for depressed patients result in a reduction of suicidal acts. This was shown in the Nuremberg Alliance against Depression, a two-year four-level community based intervention program associated with a 24% reduction of suicidal acts (completed and attempted suicides combined) compared to a baseline year and a control region. Serving as a model project, this approach has up to now been adopted in more than 100 regions in Germany and Europe. Within the suicide prevention project OSPI-Europe, the four-level-approach was optimized and further implemented and evaluated in different European regions. [Copyright &y& Elsevier]

Objective To determine whether brief intervention and contact is effective in reducing subsequent suicide mortality among suicide attempters in low and middle-income countries. Methods Suicide attempters (n = 1867) identified by medical staff in the emergency units of eight collaborating hospitals in five culturally different sites (Campinas, Brazil; Chennai, India; Colombo, Sri Lanka; Karaj, Islamic Republic of Iran; and Yuncheng, China) participated, from January 2002 to October 2005, in a randomized controlled trial to receive either treatment as usual, or treatment as usual plus brief intervention and contact (BIC), which included patient education and follow-up. Overall, 91% completed the study. The primary study outcome measurement was death from suicide at 18-month follow-up. Findings Significantly fewer deaths from suicide occurred in the BIC than in the treatment-as-usual group (0.2% versus 2.2%, respectively; X2 = 13.83, P < 0.001). Conclusion This low-cost brief intervention may be an important part of suicide prevention programmes for underresourced lowand middle-income countries. [ABSTRACT FROM AUTHOR]