A cross-national study on gender differences in suicide intent

BACKGROUND: Suicide accounts for over 58,000 deaths in Europe per annum, where suicide attempts are estimated to be 20 times higher. Males have been found to have a disproportionately lower rate of suicide attempts and an excessively higher rate of suicides compared to females. The gender difference in suicide intent is postulated to contribute towards this gender imbalance. The aim of this study is to explore gender differences in suicide intent in a cross-national study of suicide attempts. The secondary aims are to investigate the gender differences in suicide attempt across age and country. METHODS: Data on suicide attempts (acquired from the EU-funded OSPI-Europe project) was obtained from eight regions in Germany, Hungary, Ireland and Portugal. Suicide intent data was categorized into 'Non-habitual Deliberate Self-Harm' (DSH), 'Parasuicidal Pause' (SP), 'Parasuicidal Gesture' (SG), and 'Serious Suicide Attempt' (SSA), applying the Feuerlein scale. Gender differences in intent were explored for significance by using X2)-tests, odds ratios, and regression analyses. RESULTS: Suicide intent data from 5212 participants was included in the analysis. A significant association between suicide intent and gender was found, where 'Serious Suicide Attempts' (SSA) were rated significantly more frequently in males than females (p < .001). There was a statistically significant gender difference in intent and age groups (p < .001) and between countries (p < .001). Furthermore, within the most utilised method, intentional drug overdose, 'Serious Suicide Attempt' (SSA) was rated significantly more often for males than females (p < .005). CONCLUSIONS: Considering the differences in suicidal intent between males and females highlighted by the current study, gender targeted prevention and intervention strategies would be recommended

Effectiveness of Depression–Suicidal Behaviour Gatekeeper Training among police officers in three European regions: Outcomes of the Optimising Suicide Prevention Programmes and Their Implementation in Europe (OSPI-Europe) study

Background: Gatekeeper training for community facilitators, to identify and respond to those at risk of suicide, forms an important part of multi-level community-based suicide prevention programmes.&nbsp; &nbsp; Aims:&nbsp; This study examined the effects of gatekeeper training on attitudes, knowledge and confidence of police officers in dealing with persons at risk of suicide.&nbsp; &nbsp; Methods:&nbsp; A total of 828 police officers across three European regions participated in a 4-hour training programme which addressed the epidemiology of depression and suicidal behaviour, symptoms of depression, warning signs and risk factors associated with suicidal behaviour, motivating help-seeking behaviour, dealing with acute suicidal crisis and informing bereaved relatives. Participants completed internationally validated questionnaires assessing stigmatising attitudes, knowledge about depression and confidence in dealing with suicidal persons pre- and posttraining. Results: There were significant differences among countries in terms of previous exposure to suicidal persons and extent of previous training. Post-training evaluation demonstrated significant improvements in stigmatising attitudes, knowledge and confidence in all three countries. Conclusion: The consistently positive effects of gatekeeper training of police officers across different regions support inclusion of this type of training as a fundamental part of multi-level community-based suicide prevention programmes and roll-out, nationally and internationally

Exploring synergistic interactions and catalysts in complex interventions: longitudinal, mixed methods case studies of an optimised multi-level suicide prevention intervention in four european countries (Ospi-Europe)

Background: The Medical Research Council (MRC) Framework for complex interventions highlights the need to explore interactions between components of complex interventions, but this has not yet been fully explored within complex, non-pharmacological interventions. This paper draws on the process evaluation data of a suicide prevention programme implemented in four European countries to illustrate the synergistic interactions between intervention levels in a complex programme, and to present our method for exploring these. Methods: A realist evaluation approach informed the process evaluation, which drew on mixed methods, longitudinal case studies. Data collection consisted of 47 semi-structured interviews, 12 focus groups, one workshop, fieldnoted observations of six programme meetings and 20 questionnaires (delivered at six month intervals to each of the four intervention sites). Analysis drew on the framework approach, facilitated by the use of QSR NVivo (v10). Our qualitative approach to exploring synergistic interactions (QuaSIC) also developed a matrix of hypothesised synergies that were explored within one workshop and two waves of data collection. Results: All four implementation countries provided examples of synergistic interactions that added value beyond the sum of individual intervention levels or components in isolation. For instance, the launch ceremony of the public health campaign (a level 3 intervention) in Ireland had an impact on the community-based professional training, increasing uptake and visibility of training for journalists in particular. In turn, this led to increased media reporting of OSPI activities (monitored as part of the public health campaign) and also led to wider dissemination of editorial guidelines for responsible reporting of suicidal acts. Analysis of the total process evaluation dataset also revealed the new phenomenon of the OSPI programme acting as a catalyst for externally generated (and funded) activity that shared the goals of suicide prevention. Conclusions: The QuaSIC approach enabled us to develop and refine our definition of synergistic interactions and add the innovative concept of catalytic effects. This represents a novel approach to the evaluation of complex interventions. By exploring synergies and catalytic interactions related to a complex intervention or programme, we reveal the added value to planned activities and how they might be maximised

Public attitudes toward depression and help-seeking

Background: Public attitudes toward depression and help-seeking behaviour are important factors influencing depressed people to obtain professional help and adequate treatment. OSPI-Europe is a multi-level suicide prevention programme including a public awareness campaign. It was implemented in four regions of four European countries (Germany, Hungary, Ireland and Portugal). This paper reports the results of the evaluation of the campaign, including its visibility and effects of the campaign on stigma associated with depression and help-seeking behaviour. Methods: A representative general population survey (N = 4004) including measures on personal stigma, perceived stigma, openness to help, perceived value of help, and socio-demographic variables was conducted in the four intervention and four control regions in a cross-sectional pre-post design. Results: The public awareness campaign was considerably more visible in Germany and Portugal compared to Ireland and Hungary. Visibility was further affected by age and years of schooling. Personal stigma, perceived stigma and openness toward professional help varied significantly across the four countries. Respondents in the intervention regions showed significantly less personal depression stigma than respondents in the control regions after the campaign. Respondents of the intervention region who were aware of the campaign reported more openness toward seeking professional help than respondents who were unaware of it. Conclusion: The OSPI-Europe awareness campaign was visible and produced some positive results. At the same time, it proved to be difficult to show strong, measurable and unambiguous effects, which is in line with previous studies. Public awareness campaigns as conducted within OSPI-Europe can contribute to improved attitudes and knowledge about depression in the general public and produce synergistic effects, in particular when the dissemination of awareness campaign materials is simultaneously reinforced by other intervention levels of a multi-level intervention programme. Limitations: The survey was cross-sectional and based on self-report, so no causal inferences could be drawn

What Are Reasons for the Large Gender Differences in the Lethality of Suicidal Acts? An Epidemiological Analysis in Four European Countries

BackgroundIn 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 FindingsMethods. 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 (www.ospi-europe.com). 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 chi(2)-test for two-by-two tables. We assessed the effect sizes with phi coefficients (phi). 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 ResultsSuicidal 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 &lt;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) (chi(2) = 35.74; p &lt;0.000001).Main limitations of the studyDue 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.ConclusionsMen 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.</p

Prevention of suicidal behaviour: Results of a controlled community-based intervention study in four European countries

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 (2 = 0.13; p = 0.72) from the decrease in the control regions (-18 cases, -1.40%). However, intervention effects differed between countries (2 = 8.59; p = 0.04), with significant effects on suicidal acts in Portugal (2 = 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.Additional co-authors: Armin Schmidtke, György Purebl, James C Coyne, Ricardo Gusmão, on behalf of The OSPI-Europe Consortiu

Long-Term Efficacy of Internet-Based Cognitive Behavioral Therapy Self-Help Programs for Adults With Depression: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BackgroundDepression is a worldwide mental disorder and a leading cause of disability. Many people with depression do not want to take medication or have the motivation to seek psychotherapy treatment for many reasons. Guided internet-based self-help programs may be a promising solution for addressing these issues. This kind of intervention has proven to be effective in reducing depression symptoms on a short-term scale. However, as treatment often is a long-term rehabilitation process, it is important to examine not only the short-term effects of internet-based cognitive behavioral therapy (iCBT) self-help treatment but also the follow-up or long-term efficacy of this kind of intervention. ObjectiveThis systematic review and meta-analysis aimed to identify studies that examined follow-up data ≥8 weeks after posttreatment measurements and thereby examined the long-term efficacy of iCBT self-help programs with minimal weekly guidance for people with depression. It aimed to analyze the long-term efficacy of iCBT treatments compared to control conditions as well as long-term efficacy within the iCBT treatment conditions. Additionally, it aimed to conduct subgroup analyses according to the follow-up time points for each outcome. Finally, it examined long-term improvements in quality of life. MethodsThe Cochrane Collaboration Depression, Anxiety, and Neurosis Controlled Trials Register (CCDANCTR), grey literature, reference lists, and correspondence were used to search for published and unpublished randomized controlled trials (RCTs) that reported the long-term or follow-up efficacy of computer-based or iCBT self-help treatments for depression with minimal guidance of up to 10 min/wk. The search took place between 2015 and 2022 (October). ResultsThe search resulted in a total of 2809 study abstracts, of which 15 studies (with 17 samples) met all inclusion criteria and were included in the long-term analysis. The results showed that the depression outcomes of all follow-up time points together in the treatment conditions were favored over the control conditions with a medium effect size of 0.43 (n=1689 participants; 9 RCTs; standardized mean difference [SMD] –0.43, 95% CI –0.67 to –0.20; P<.001). The analysis of long-term efficacy within the iCBT treatment conditions showed that the follow-up outcomes of the treatment groups were favored over the posttreatment outcomes with a small effect size of 0.20 (n=2196 participants; 17 RCTs; SMD 0.20, 95% CI 0.07-0.49; P=.003). Findings for improving quality of life also showed that the iCBT conditions were favored over the control conditions with a small effect size of 0.19 (n=1345 participants; 3 RCTs; SMD 0.19, 95% CI 0.08-0.30; P<.001). ConclusionsThis systematic review and meta-analysis found that iCBT self-help interventions had a superior long-term efficacy for individuals with depressive symptoms compared to control groups. The within-group analysis of iCBT treatment conditions also showed statistically significant improvements in reducing depressive symptoms at follow-up compared to posttreatment measurements

Efficacy of an internet-based self-management intervention for depression or dysthymia – a study protocol of an RCT using an active control condition

Abstract Background The treatment of major depressive disorder, a highly prevalent disorder associated with pronounced burden, is a large challenge to healthcare systems worldwide. Internet based self-management interventions seem to be a cost effective way to complement the treatment of depressed patients, but the accumulating evidence is mainly based on the comparison to waitlist controls and treatment as usual, which might lead to an overestimation of effects. Furthermore, studies assessing long-term effects and possible negative outcomes are still rare. Methods/Design The proposed study evaluates the efficacy of the German version of the iFightDepression® tool in comparison to an active control condition. A total of 360 patients with mild to moderate depressive symptoms are included into a two-armed randomized controlled trial. They receive one of two six week interventions; either the iFightDepression® tool or progressive muscle relaxation serving as the control condition. Both intervention groups receive information material, weekly tasks via the internet and regular phone calls as part of the intervention. The primary outcome is change in depressive symptoms after the intervention period, as measured with the Inventory of Depressive Symptomatology. Satisfaction with the program, usability, changes in perceived quality of life, and possible negative effects are assessed as secondary outcomes. Discussion This study represents the first randomized controlled trial on the iFightDepression® self-management tool in its German version, aiming at efficacy, but also at providing new insights into so far understudied aspects of E-mental health programs, namely the specificity of the treatment effect compared to an active control condition, it’s continuity over a time course of 12 months, and possible negative effects of these internet based interventions. Trial registration International trial-registration took place through the “international clinical trials registry platform” (WHO) with the secondary ID 080–15-09032015. German Clinical Trial Registration: DRKS00009323 (DRKS.de, registered on 25 February 2016)

Public attitudes toward depression and help-seeking

Background: Public attitudes toward depression and help-seeking behaviour are important factors influencing depressed people to obtain professional help and adequate treatment. OSPI-Europe is a multi-level suicide prevention programme including a public awareness campaign. It was implemented in four regions of four European countries (Germany, Hungary, Ireland and Portugal). This paper reports the results of the evaluation of the campaign, including its visibility and effects of the campaign on stigma associated with depression and help-seeking behaviour. Methods: A representative general population survey (N = 4004) including measures on personal stigma, perceived stigma, openness to help, perceived value of help, and socio-demographic variables was conducted in the four intervention and four control regions in a cross-sectional pre-post design. Results: The public awareness campaign was considerably more visible in Germany and Portugal compared to Ireland and Hungary. Visibility was further affected by age and years of schooling. Personal stigma, perceived stigma and openness toward professional help varied significantly across the four countries. Respondents in the intervention regions showed significantly less personal depression stigma than respondents in the control regions after the campaign. Respondents of the intervention region who were aware of the campaign reported more openness toward seeking professional help than respondents who were unaware of it. Conclusion: The OSPI-Europe awareness campaign was visible and produced some positive results. At the same time, it proved to be difficult to show strong, measurable and unambiguous effects, which is in line with previous studies. Public awareness campaigns as conducted within OSPI-Europe can contribute to improved attitudes and knowledge about depression in the general public and produce synergistic effects, in particular when the dissemination of awareness campaign materials is simultaneously reinforced by other intervention levels of a multi-level intervention programme. Limitations: The survey was cross-sectional and based on self-report, so no causal inferences could be drawn