European Alliance Against Depression - Suicidal acts, DSH rates

Psychological autopsy studies have shown that more than 90% of suicides are committed in the context of a psychiatric disorder, with affective disorders accounting for 30 – 88% of all cases (Lönnqvist & Koskenvuo, 1988). Treatments with well-documented efficacy are available but are adequately provided only to a minority of depressed persons (Sartorius et al. 1993; Coppen 1994; Spitzer et al. 1995). The EAAD-project aims to reduce suicidal acts by enhancing the access to and the quality of care provided to depressed persons in the community.

Results of the Nuremberg pilot study (please see below) have already shown that the community-based intervention following the 4-level-approach was clearly effective in reducing suicidal acts (about 20 %). When evaluating the efficacy of the EAAD intervention program, the primary outcome criterion is - in general - again changes of numbers of completed and attempted suicides in EAAD intervention regions.

Methodological approach

In order to obtain information about numbers of completed suicides, most EAAD partners are in contact with their central statistical office to have access to regional and/or national suicide registers. Due to considerable variations in suicide statistics the baseline measurement shall be as long as possible (10 years) to identify possible trends over time. At least gender, age group and method and - if available - further socio-demographic data are being assessed.

Suicide attempts are mostly being assessed in co-operation with the psychiatric emergency departments of the largest hospitals in EAAD intervention regions or panels of specially trained GPs and other institutions. Using the EAAD Questionnaire for suicide attempts, a modified version of the monitoring form of the WHO/EURO Multicentre Study on Parasuicide, standardized information about suicide attempts is collected.

During the 2nd general meeting in January 2005, a workshop has been held on terminologies to indicate non-fatal suicidal / self harming behaviour (deliberate self harm – suicide attempt – parasuicide). Different terms exist in parallel but all of them refer to one frequently used definition according to WHO / EURO (Schmidtke et al. 1996). In this context, the EAAD project group agreed upon the common usage of this definition:

“An act with non-fatal outcome, in which an individual deliberately initiates a non-habitual behaviour that, without intervention from others, will cause self harm, or deliberately ingests a substance in excess of the prescribed or generally recognized therapeutic dosage, and which is aimed at realising changes which the subject desired via the actual or expected physical consequences” (Schmidtke et al. 1996).

Case examples help to illustrate how this definition should be applied to concrete situations and to ensure comparability of data assessment to a certain extent. A list of ICD-10 codes for “Hidden Suicides” has been prepared to identify suicides and suicide attempts which are not necessarily labelled as suicidal acts but nevertheless might fall under the definition mentioned above.

Results of the Nuremberg pilot study

Background: The global burden and large diagnostic and therapeutic deficits associated with depressive disorders call for intervention programs. The aim of the Nuremberg Alliance against Depression (NAD) is to establish and to assess the effectiveness of a four-level intervention program for improving the care of patients with depression.

Method: A 2-year intervention program was performed in Nuremberg (480 000 inhabitants) at four levels: training of family doctors and support through different methods; a public relations campaign informing about depression; cooperation with community facilitators (teachers, priests, local media, etc.) ; and support for self-help activities as well as for high-risk groups. The effects of the 2-year intervention on the number of suicidal acts (completed suicides plus suicide attempts, main outcome criterion) were evaluated with respect to a 1-year baseline and a control region (Wuerzburg, 270 000 inhabitants).

Results: Compared to the control region, a reduction in frequency of suicidal acts was observed in Nuremberg during the 2-year intervention (2001 v. 2000: -19.4%, p=0.082; 2002 v. 2000:-24%, p=0.004). Considering suicide attempts only (secondary outcome criterion), the same effect was found (2001 v. 2000: -18.3%, p=0.023; 2002 v. 2000: -26.5%, p<0.001). The reduction was most noticeable for high-risk methods (e.g. hanging, jumping, shooting). Concerning completed suicides, there were no significant differences compared to the control region.

Conclusions: The NAD appeared to be effective in reducing suicidality. It provides a concept as well as many methods that are currently being implemented in several other intervention regions in Germany and in other countries.

More information about the outcome evaluation of the Nuremberg Alliance against Depression can be found at Hegerl et al. (2006).

References

Coppen, A. (1994). Depression as a lethal disease: prevention strategies. Journal of Clinical Psychiatry 55 (Suppl.), 37–45.
Hegerl, U., Althaus, D., Schmidtke, A., Niklewski, G. (2006). The Alliance Against
Depression: Two year evaluation of a community-based intervention to reduce
suicidality. Psychological Medicine 36 (9), 1225-1234.
Lönnqvist, J. & Koskenvuo, M. (1988). Mortality in depressive disorders ; a 3-year prospective follow-up study in Finland. In Depressive Illness: Prediction of Course and Outcome (ed. T. D. R. Helgason), pp. 126–130. Springer-Verlag: Berlin.
Sartorius, N., Üstün, T., Costa de Silva, J., Goldberg, D., Lecrubier, Y., Ormel, J., von Korff, M. & Wittchen, H. (1993). An international study of psychological problems in primary care. Archives of General Psychiatry 50, 819–824.
Schmidtke, A., Bille Brahe, U., DeLeo, D., Kerkhof, A., Bjerke, T., Crepet, P., Haring, C., Hawton, K., Lonnqvist, J., Michel, K., Pommereau, X., Querejeta, I., Phillipe, I., Salander-Renberg, E., Temesvary, B., Wasserman, D., Fricke, S., Weinacker, B. & Sampaio Faria, J. G. (1996). Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989–1992. Results of the WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatrica Scandinavica 93, 327–338.
Spitzer, R. L., Kroenke, K., Linzer, M., Hahn, S. R., Williams, J. B., deGruy, F. V., Brody, D. and Davies, M. (1995). Health-related quality of life in primary care patients with mental disorders. Results from the PRIME-MD 1000 Study. Journal of the American Medical Association 274, 1511–1517.

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Darrera Actualització: 21.07.2010