66 Education and awareness programmes for adults: Selected and multilevel approaches in suicide prevention

Awareness campaigns and multilevel intervention programmes from different countries and continents, their effects on suicidality, as well as limitations of these programmes, are presented and discussed.

Experiences from multilevel interventions, such as the Nuremberg Alliance Against Depression in Germany, show that awareness campaigns develop the strongest effect when combined with other measures to create a synergistic effect. Awareness campaigns draw the attention and interest of primary care providers to activities focusing on depression and suicidality, and make it easier for them to consult with patients with psychiatric diagnoses and motivate them concerning treatment, not least because awareness campaigns can contribute to improving community mental health knowledge. Finally, for those affected by depression or other mental disorders, public campaigns reduce the perceived stigma, thus, lessening the isolation which contributes to despair and suicide risk.

Psychiatric disorders are among the most relevant factors contributing to suicide worldwide. Other risk factors for suicide, in most Western countries, are old age, male gender, social conditions, availability of lethal means to commit suicide and general physical health status. Help-seeking behaviour, access to psychiatric treatment and public attitudes towards suicide are also relevant associated aspects (Mann 2002; Buck 2004; Gunnell et al. 2004; Jacobi et al. 2004; Bouch and Marshall 2005; Bernal et al. 2007). Many suicide prevention interventions only address one or two of these aspects. The effects of such interventions might be limited, and not strong enough to be detectable in the outcome evaluation (Althaus and Hegerl 2003). The implementation of multilevel and multifaceted suicide prevention interventions appears to be promising. Targeting many of the factors associated with suicidality simultaneously may not only have additive suicide preventive effects, but the effect may also be stronger due to synergy between the different interventions (Figure 66.1). Awareness and education campaigns are an important element of such multilevel intervention programmes.

In the following chapter, awareness and education campaigns, as well as multilevel intervention programmes from different countries and continents, and their effects on suicidality, will be presented and discussed. Some of these campaigns address suicidality directly, e.g. the United States Air Force Suicide Prevention Programme, whereas others are targeting depressive disorders, e.g. beyondblue in Australia; Defeat Depression Campaign in Great Britain; European Alliance Against Depression (EAAD) and the German Alliance Against Depression.

In 1988, the National Institute of Mental Health (NIMH) launched the first major federally funded multiphase public and professional health information and education programme in the US: Depression/Awareness, Recognition, Treatment (D/ART) to improve the availability and quality of care for individuals suffering from affective disorders (Regier et al. 1988). A strong focus was put on raising awareness of depressive disorders among the general population and experts to educate both the public and professionals that depressive disorders are common, serious and treatable, and also to spotlight obstacles to improving depression recognition and treatment in primary care.

In close cooperation with regional partners, training materials, brochures and leaflets were produced and disseminated, advertisements were placed in newspapers and TV and training was offered in different languages, and used in the US to account for the heterogeneity of the population. Regional adaptations of the programme have been evaluated in several individual studies (e.g. O'Hara et al. 1996). O'Hara and colleagues evaluated 18 2-day clinical training programmes for professionals in Iowa, which were attended by 1221 participants (physicians, psychologists, social workers, and nurses) over a 3-year period. Evidence shows that participants’ level of knowledge of depression significantly increased and a 6-month follow-up evaluation indicated a continued positive evaluation of the programme (O'Hara et al. 1996). The D/ART programme is not explicitly targeted at lowering suicidality, and to date, no systematic nationwide evaluation concerning this aspect has been conducted.

An anti-stigma programme named Defeat Depression Campaign was implemented in the United Kingdom from 1992–1996, by the Royal College of Psychiatrists. It aimed to improve attitudes towards, and recognizing, depression on a national basis, supplemented by separate local and regional activities. The campaign addressed the problem on two levels: GPs were trained and offered support in diagnosis and treatment of depression. In addition, the general public was educated about depression through videos, flyers and brochures. Beside distributing information materials and delivering comprehensive training, a broad media campaign accompanied this programme. Due to a strong focus on primary care, the Defeat Depression Campaign also included the development of treatment guidelines, organization of case and consensus conferences, and the dissemination of training material, mainly for the field of primary care. During the programme, a noticeable improvement in awareness for depressive disorders, and knowledge about neurobiological factors involved, could be observed (Paykel et al. 1997); however, it did not lead to a considerable and sustainable improvement in delivering care to affected patients (Rix et al. 1999).

Changes in prescribing rates of antidepressants were noted, the total number of prescriptions increased markedly from seven million in 1987 to about fifteen million in 1996 (Paykel 2001). National suicide rates were a key evaluating indicator during the Defeat Depression Campaign. Over the years of the campaign, suicide rates had fallen from 7.71/100,000 (1992) to 6.89/100,000 (1995) (Paykel 2001). However, the reduction in suicide rates cannot solely be attributed to the campaign (Rix et al. 1999; Paykel 2001). There are several other events that might have contributed to this effect. First, the introduction of the green paper ‘The health of the nation: a strategy for health in England’ in 1992, which also called for a 15 per cent reduction in the overall suicide rate, and a 33 per cent reduction in the suicide rate in the severely mentally ill (Hawton 1998), as an aim for the mental health services. Other factors that might have played a role are well-known fluctuations in suicide rates, and the introduction of new antidepressant drugs, with associated intensive marketing activity from the drug industry (Rix et al. 1999; Paykel 2001).

In 2000, the Australian government started a five-year initiative to prevent depression and respond effectively to it. The beyondblue initiative has five priority areas: community awareness and de-stigmatization, consumer and carer support, prevention and early intervention, primary care training and support, and applied research (Jorm et al. 2005). According to a first evaluation of this programme, an increase of public awareness and general recognition of the programme could be observed after three years of intervention (Hickie 2004; Jorm et al. 2005). A pre-existing national mental health policy and implementation plan, a substantial funding base and participation by key political, media and community leaders have probably contributed considerably to these short-term effects (Hickie 2004).

A major limitation in the evaluation of national strategies like beyondblue or the Defeat Depression Campaign is the absence of a control group, making it difficult to separate the effects of the intervention strategy from other influences, thus, making it impossible to know whether the observed changes would have occurred without the intervention. Jorm et al. (2005), for instance, attempted to overcome this by using the states that did not fund Beyondblue as a control group. They found that the ‘high-exposure states’ had a greater increase in belief in the helpfulness of several interventions than the control group. The ‘high-exposure’ states also showed a greater decrease in the belief that it is helpful to deal with depression alone. Jorm and colleagues concluded that beyondblue had a positive effect on some beliefs about depression treatment, most notably on counselling and medication, including the value of help-seeking in general.

In 2001, a National Strategy for Suicide Prevention (NSSP) was published in the US. Its aims were to promote awareness of suicide as a public health problem, to prevent premature deaths due to suicide across the lifespan, to reduce the rates of other suicidal behaviours, to reduce the harmful after-effects associated with suicidal behaviours and the traumatic impact of suicide on family and friends, to promote opportunities and settings to enhance resiliency, resourcefulness, respect, and interconnectedness for individuals, families, and communities. The aim of the strategy is to develop and implement community-based suicide prevention programmes, including training programmes for recognition of at-risk behaviour and delivery of effective treatment. Results of this initiative remain to be evaluated.

This approach to reducing the risk of suicide was first implemented in the United States Air Force in 1996, in response to the rise in the numbers of suicides between 1990 and 1995. Eleven initiatives were implemented, with the aim of strengthening social support, promoting development of effective social and coping skills, promoting awareness of the various risk factors related to suicide, reducing modifiable risk factors, enhancing factors considered protective, changing policies and norms to encourage effective help-seeking behaviours, and reducing the stigma related to help-seeking behaviour. The evaluation of AFSPP showed that the Air Force personnel exposed to the programme experienced a 33 per cent reduction of suicide risk compared with personnel prior to the implementation (Registry of Evidence-Based Suicide Prevention Programs 2005; Pflanz 2007). When the project began, suicides constituted the second leading cause of death in the Air Force, with an annual rate of 15.8/100,000. Since then, the suicide rate has declined (statistically significantly) to 5.6/100,000 in 1999. The suicide rates increased in 2000 and early 2001, but have declined again since April 2001, and have remained lower than rates prior to 1995. It must be noted that the suicide rates in the US also declined in the second half of the 1990s. This decline, however, is extremely small compared to that measured in the Air Force (The United States Air Force Medical Service 2002). As the Air Force community represents a select population, the generalizeability of these findings have been discussed (Knox et al. 2003).

Suicide prevention strategies, including public awareness campaigns, need to be shaped differently in Asia compared to Western countries, due to different cultural and social backgrounds. Compared to the West, self-poisoning with pesticides plays a far more important role in these regions than in Europe or Australia (Eddleston and Phillips 2004; Vijayakumar 2005), see also Chapter 17 in this book. In addition, compared to Western countries, higher suicide rates are found in rural, rather than urban areas, and more women than men die by their own hand in China for instance (Ji and Kleinman 2001).

For China, suicide is a major public health problem and it is gradually being recognized. Based on the results of a national case–control psychological post mortem study, Phillips and colleagues have drawn the conclusion that risk factors for suicide do not differ greatly between China and the West (Phillips et al. 2002). Furthermore, they suggest that suicide preventive programmes in China should also use a multilevel and multifaceted approach. This is supported by Motohashi and colleagues who conducted a community-based, multi-level intervention for suicide prevention in Japan, with the result of a decrease in suicide rates from 70.8/100,000 in 1999 to 34.1/100,000 in 2004 (Motohashi et al. 2007).

A 10-year National Strategy to reduce suicide in Scotland by 20 per cent by 2013 was launched in 2002. It is embedded into a complex national strategy to improve mental health and well-being in Scotland (http://www.wellontheweb.org). This two-phase plan (implementation phase 2003–2006, and evaluation, review and assessment phase 2006–2012) aims to improve early prevention and crisis response, engagement with the media, and adoption of an evidence-based approach (Mackenzie et al. 2007). The main aim is to set out a framework to achieve seven multifaceted objectives: early prevention and intervention, responding to immediate crisis, longer-term work to provide hope and support recovery, coping with suicidal behaviour and completed suicide, promoting greater public awareness and encouraging people to seek help early, supporting the media and knowing ‘what works’ to prevent suicide. The strategy addresses several levels by a variety of means, and among other things, includes a telephone advice line. Local actors such as the health service, councils and voluntary organizations are asked to jointly develop and implement local plans for suicide prevention. The outcome evaluation of this first phase mainly aims at evaluating the implementation process itself, rather than a possible impact on suicide rates, which is planned for later phases of the campaign.

The reduction in male suicide and undetermined deaths between 2002 (N = 673, rate = 34.1/100,000) and 2003 (N = 577, rate = 29.1/100,000) occurred when Choose Life had only been partially implemented, and perhaps may also be due to the influence of other factors, e.g. legislation restricting sales of paracetamol. In addition, in the absence of control data, there is a significant challenge in interpreting trends over time (Mackenzie et al. 2007). At the time of writing, the evaluation was still in progress.

The Nuremberg Alliance Against Depression, an intervention for suicide prevention, was implemented in the city of Nuremberg, Germany (population 500,000) in 2001 and 2002, with Würzburg (population 270,000) as the control region. The intervention approached the prevention of suicidality on four levels (see Figure 66.2).

Twelve training sessions were carried out in Nuremberg over the two-year period. The course curriculum included diagnosis and treatment of depression, managing suicidality, guiding patients from screening to diagnosis to treatment, and using the WHO 5 Well-being Questionnaire as a screening tool.

GPs were also provided with two professionally produced videotapes. The first videotape informed GPs about the diagnosis and treatment of depression, the second video was intended to support the GPs in informing the individual patients about their disorder and its treatment.

A professional public relations campaign was established, including posters at public places, leaflets, information brochures and several public events. Additionally, a cinema spot was developed, a website was established and two prominent patrons supported the campaign (German Federal Minister for Family Affairs, Senior Citizens, Women and Youth and the Bavarian Minister of the Interior Affairs). Forty-three lectures and events for the general public were organized, 25,000 brochures and more than 100,000 leaflets were produced and distributed.

In addition, close cooperation with the media was established in order to avoid imitation suicides. A 14-item media guide was handed out to local media in Nuremberg, providing information how to report and how not to report suicide (Schäfer et al. 2006).

Eighty-four educational workshops were provided to important community facilitators, such as teachers, counsellors, priests, geriatric nurses, policemen, pharmacists and others. In the course of these workshops, more than 2000 individuals were trained how to recognize people with depression, and to influence depressed people to seek appropriate treatment.

An emergency card was handed out to patients after a suicide attempt, containing a telephone number, which allowed easy access to professional help offered by a specialist 24 hours a day seven days a week (24/7). Several initiatives were started to establish new self-help activities and support existing self-help activities.

Evaluation of the intervention included data from a 1-year baseline study and from a control region. The only a priori defined primary outcome was the number of suicidal acts (fatal + non-fatal). This allowed a confirmatory statistical approach. Fatal and non-fatal suicidal acts were combined as a primary outcome, because a power analysis revealed that even a population of 500,000 inhabitants is not sufficient to statistically detect a reduction in suicide rates of 20%.

During the two intervention years, the number of suicidal acts decreased by 24% in the intervention region, which was significantly more than the control region, where rates remained stable (Althaus et al. 2007). During the first intervention year, the lowest suicide rate ever measured was observed in Nuremberg, however, this number is still not outside of the 95% confidence interval of the preceding 12 years (95% −CI: 72.2–96.7) (Hegerl et al. 2006; Althaus et al. 2007). Interestingly, the reduction of suicidal acts was not a short-term effect, because an additional decrease was observed in the follow-up year after the 2-year intervention (−32% compared to the baseline year).

Furthermore, when analysing suicidal acts in terms of methods used, the strongest reduction (−47%) was observed for the five high-risk suicide methods (jumping from an extended height, hanging, suicide by firearms, drowning, being run over) (Hegerl et al. 2006; Althaus et al. 2007). This suggests that the reduction in suicidal acts observed in Nuremberg might be underestimated, because more attempted suicides, especially intoxications, may have been recognized after the awareness campaign.

Other evaluations have investigated the effects of the different interventions on the four levels, such as the effects of the media guide on news reporting about suicides, prescription rates of antidepressants or the effects of the public relations campaign in general.

Following the implementation of the 14-item media guide containing recommendations for appropriate, accurate and potentially helpful media coverage of suicide, suicide reports (N = 761, frequency, distribution and qualitative aspects) in three regional dailies (daily newspapers) in Nuremberg were compared (Schäfer et al. 2006). While there was a noticeable reduction in the number of articles on suicide (−26%) in two dailies, an increase in the number of suicide reports was found in the third newspaper, a famous German tabloid (+22%). Evaluation showed that more help-seeking information (telephone numbers, websites, self-help measures, etc.) was provided. One of the conclusions drawn from the evaluation was that the successful implementation of media guides on suicide reporting depends on the willingness of the main editors in charge to be engaged and willing to cooperate (Schäfer et al. 2006). Follow-up will show the long-term impact of the media guide on suicide reporting.

Changes in the prescription of antidepressants by practice-based doctors have also been analysed (Pfeiffer-Gerschel 2007). He compared the prescribed defined daily doses (DDD) in the intervention region and the rest of Bavaria (German federal state). After the first intervention year (2001), the prescribed DDD of all antidepressants increased by 15% in Nuremberg in comparison to the baseline year 2000; about 11,800 persons were treated with antidepressants in 2000 during the entire year, this number increased to 13,500 in 2001. This finding is statistically significant in comparison to the rest of Bavaria (increased by 8%). After the second intervention year, however, about 15% more antidepressants were prescribed, both in Nuremberg and the rest of Bavaria, as compared to 2000. It is noteworthy that prescriptions by neurologists increased significantly (+25% in 2001, +41% in 2002) as compared to the rest of Bavaria (+13% in 2001, +24% in 2002). Thus, with regard to prescription of antidepressants, the Nuremberg Alliance Against Depression mainly had an effect on practice-based neurologists.

The professional public relations campaign was evaluated based on the results of telephone surveys in 2000 and 2001, which assessed public beliefs and attitudes toward depression and suicidality (Hegerl et al. 2003). The evaluation revealed no major effects, e.g. the opinion that antidepressants are addictive was observed in 80% of the population before and, also, after the intervention (Althaus et al. 2002). This finding corresponds to experiences from other health campaigns: it is not too difficult to achieve awareness, but it is hard to change attitudes (Hegerl et al. 2003). There have been several spontaneous reports from depressed persons in Nuremberg stating that the campaign was very helpful, because they felt less stigmatized and able to speak more openly about their disorder. Finally, as Pfeiffer-Gerschel states, the interventions at the public relations level, self-help and cooperation with multipliers (see Figure 66.2), also encouraged more people with depression to seek professional help (Pfeiffer-Gerschel 2007). Therefore, we believe that the public relations campaign is still one of the most effective elements of the multilevel suicide prevention intervention. It seems to work by giving hope to those affected by psychiatric disorders, it motivates help-seeking behaviour and helps to overcome social isolation.

In conclusion, evaluation of the Nuremberg Alliance Against Depression has provided evidence that its four-level intervention concept and its materials are effective in the prevention of suicidality. The success of this multilevel intervention is most likely not only based on the effectiveness of the single intervention on all levels, but more on synergistic effects between them. This is in line with evidence derived from other fields of prevention, such as HIV prevention (UNAIDS 2006) and tobacco control (The World Bank 1999), which showed that tackling a public health problem on multiple levels and by multiple strategies is more effective than using one strategy on its own. Also, the WHO clearly advocates choosing a multifaceted approach in the prevention of mental disorders and suicidality (World Health Organization 2004).

Since 2002, the concept of the Nuremberg Alliance Against Depression has spread throughout Germany: 40 German regions and communities have initiated their own intervention programmes, and several more are planning to do so in the future (Hegerl and Schäfer 2007). Under the conceptual umbrella of the non-profit organization named German Alliance Against Depression, these regions share their knowledge and cooperate to improve the care of depressed and suicidal patients (http://www.buendnis-depression.de/). Results of this initiative remain to be evaluated.

Based on the Nuremberg intervention, the European Alliance Against Depression (EAAD) was formed in 2004 to disseminate this intervention method across Europe (http://www.eead.net/). The project combines the materials and methods of the Nuremberg Alliance Against Depression with the knowledge, experience, materials and networks of the partners in 17 European regions (Hegerl et al. 2004; Pfeiffer-Gerschel et al. 2007).

The European Commission presented the EAAD project as one of the most promising strategies in the area of mental health at the WHO European Ministerial Conference on Mental Health in Helsinki in 2005, and named it as a best practice example for improving mental health in Europe through community-based intervention (Hegerl et al. 2007). EAAD uses a bottom-up approach, i.e. starting from a regional model project and moving toward a national expansion of activities. Results of this initiative remain to be evaluated. Based on the EAAD concept, the European research project ‘Optimised suicide prevention programmes and their implementation in Europe’ (OSPI Europe, http://www.ospi-europe.com/) has been started in 2008 with the aim to optimize and evaluate community-based suicide prevention programmes in different European Countries.

As outlined above, several regional and national awareness campaigns targeting suicidality directly or indirectly via depression, have been implemented and evaluated (Paykel et al. 1998; Regier et al. 1988; Paykel et al. 1997; Rix et al. 1999; Appleby et al. 2000; Hegerl et al. 2003; Hickie 2004; Green and Gask 2005; Morriss et al. 2005; Hegerl et al. 2006; Hegerl et al. 2007; Mackenzie et al. 2007; Pflanz 2007). Most of the awareness campaigns did not allow conclusions to be derived about the effectiveness of the interventions in preventing suicidality due to, for instance, the lack of a control region, or the lack of prospective studies of completed as well as attempted suicides. In addition, suicidality is linked to many other factors, such as socio-economic aspects, which are difficult to control in the evaluation.

However, there are good reasons to assume that awareness and education campaigns develop the strongest effect when integrated into a multilevel and multifaceted intervention programme. The goal should be to combine the awareness campaign with other measures in such a manner as to create synergistic effects. The experience from the Nuremberg Alliance Against Depression showed that a public awareness and education campaign makes it easier to get the attention and interest of primary care providers concerning Continuing Medical Education (CME) activities, which focus on depression and suicidality, and to get support from other community facilitators. Furthermore, a professional public campaign makes it easier for primary care providers to confront patients with psychiatric diagnoses and to motivate them concerning treatment, not least because awareness campaigns can contribute to improving community mental health knowledge. Finally, for those affected by depression or other mental disorders, the public campaign reduces the perceived stigma, thus lessening the isolation which contributes to despair and suicide risk.