Multilevel approaches in adult suicide prevention

Abstract

The next steps forward in suicide prevention are to learn (i) how to best combine single measures into a multilevel intervention in order to create additive and synergistic effects and (ii) how to implement them in the communities in different cultures and healthcare systems. A narrative review based on findings and experiences from existing community-based multilevel interventions which have provided some evidence for preventive effects on suicidal behaviour is presented. Most multilevel interventions combine training for primary care providers and gatekeepers, public awareness activities, restricting access to lethal means, engaging with the media, and support for high risk groups. However, effects on completed suicides and/or suicide attempts have only been reported for a few interventions. The best evaluated community-based intervention is the four-level programme offered by the European Alliance Against Depression (EAAD; implemented in over 115 regions in 15 countries by 2019).

Munich Alliance Against Depression

“…One strength of the Munich Alliance Against Depression is the fact that it refers to a well-established multilevel intervention model ( Hegerl et al, 2021 ) and enabled the evaluation of a complex community-based suicide prevention program with a 6-year intervention period. The intervention and control region consisting of two large German cities was a further strength of our study.…”

“…Improving the treatment of depressive disorders should therefore be an important element in suicide prevention programs. In this context, community-based interventions are of special interest because they are promising tools for both prevention of suicidal behavior and improvements regarding the care of patients with depression ( Hegerl et al, 2013 , 2021 ; World Health Organization, 2012 ; Zalsman et al, 2016 ). So far, many suicide prevention studies focus on changes of knowledge and awareness of depression, and far fewer studies examine with sufficient statistical power whether corresponding campaigns have significant effects on the number of suicides ( Pirkis et al, 2019 ).…”

“…Multifaceted community-based interventions have been shown to be the most promising approach to reduce suicidal acts (suicides and suicide attempts); in this context, the most broadly implemented and evaluated concept is the four-level intervention approach of the European and the German Alliance Against Depression (GAAD; Hegerl et al, 2021 ). Intervention effects of such programs were studied using suicidal acts (suicides and suicide attempts) as the primary outcome.…”

The 4-Level Approach: Prevention of Suicidal Behaviour Through Community-Based Intervention

“…Given the variety of contributing factors and the complexity of suicidal behaviour, multifaceted community-based interventions combining different suicide preventive measures [e.g., ( 1 – 3 )] are amongst the most promising approaches to prevent suicidal behaviour (attempted and completed suicides) ( 4 , 5 ), as no single intervention for suicide prevention is at a clear advantage ( 6 ). The EAAD (European Alliance Against Depression e.V.)…”