The evaluation of suicide prevention activities: state of the art

Advancing suicide prevention in Germany, Austria and Switzerland: a qualitative study

Introduction

Suicide is a significant public health problem, impacting individuals, families and communities worldwide. Effective suicide prevention requires a comprehensive approach with diverse integrated interventions and collaboration across sectors, stakeholders and professions. This study aims to identify challenges, gaps and success factors in current suicide prevention efforts in Germany, Austria and Switzerland, providing specific recommendations for advancement.

Methods

We conducted online, semi-structured interviews with 36 suicide prevention experts from Germany, Austria and Switzerland, incorporating perspectives from policy, science and practice. Interviews were conducted between September 2022 and February 2023, audio-recorded, transcribed verbatim and analyzed using the Framework method.

Results

Despite progress in national strategies and coordinated efforts for suicide prevention, challenges such as resource scarcity, stigma and structural issues in psychiatric and psychotherapeutic care persist. The interviewees identified several areas for advancement, including developing targeted prevention measures for men and older people, strengthening collaboration across sectors, stakeholders and professions, and increasing the involvement of individuals with lived experience. While the COVID-19 pandemic has exacerbated challenges in psychiatric and psychotherapeutic care, it has concurrently strengthened interest in suicide prevention among policymakers and the media.

Discussion

National suicide prevention strategies play a crucial role in setting priorities, raising public awareness, and guiding action. However, since most suicide prevention efforts are still predominantly health sector-driven, a more comprehensive approach is needed to promote the involvement of all relevant actors and address suicidality as a collective societal responsibility. Tailoring prevention programs for risk groups like older people and men is important, as these populations show high suicide rates and face a lack of targeted interventions. Our study underscores the importance to continuously monitor, refine and strengthen collaborative and evidence-based suicide prevention efforts.

Utilisation and application of implementation science in complex suicide prevention interventions: A systematic review

OBJECTIVES

Little is known about how complex, multilevel, and multicomponent suicide prevention interventions work in real life settings. Understanding the methods used to systematically adopt, deliver, and sustain these interventions could ensure that they have the best chance of unfolding their full effect. This systematic review aimed to examine the application and extent of utilisation of implementation science in understanding and evaluating complex suicide prevention interventions.

METHODS

The review adhered to updated PRISMA guidelines and was prospectively registered with PROSPERO (CRD42021247950). PubMed, CINAHL, PsycINFO, ProQuest, SCOPUS and CENTRAL were searched. All English-language records (1990-2022) with suicide and/or self-harm as the primary aims or targets of intervention were eligible. A forward citation search and a reference search further bolstered the search strategy. Interventions were considered complex if they consisted of three or more components and were implemented across two or more levels of socio-ecology or levels of prevention.

RESULTS

One hundred thirty-nine records describing 19 complex interventions were identified. In 13 interventions, use of implementation science approaches, primarily process evaluations, was explicitly stated. However, extent of utilisation of implementation science approaches was found to be inconsistent and incomprehensive.

LIMITATIONS

The inclusion criteria, along with a narrow definition of complex interventions may have limited our findings.

CONCLUSION

Understanding the implementation of complex interventions is crucial for unlocking key questions about theory-practice knowledge translation. Inconsistent reporting and inadequate understanding of implementation processes can lead to loss of critical, experiential knowledge related to what works to prevent suicide in real world settings.

Engaging primary care professionals in suicide prevention: A qualitative study

In health systems with strongly developed primary care, such as in the Netherlands, effectively engaging primary care professionals (PCPs) in suicide prevention is a key strategy. As part of the national Suicide Prevention Action Network (SUPRANET), a program was offered to PCPs in six regions in the Netherlands in 2017–2018 to more effectively engage them in suicide prevention. This implementation study aimed to evaluate to what extent SUPRANET was helpful in supporting PCPs to apply suicide prevention practices. From March to May 2018, 21 semi-structured interviews have been carried out with PCPs and other non-clinical professionals from SUPRANET regions in the Netherlands. Verbatim transcripts were analysed using the grounded theory approach. Data was structured using the Consolidated Framework for Implementation Research, which enabled identifying facilitating and challenging factors for PCPs to carry out suicide prevention practices. An important challenge included difficulties in assessing suicide risk (intervention characteristics) due to PCPs’ self-perceived incompetence, burdensomeness of suicide and limited time and heavy workload of PCPs. Another important limitation was collaboration with mental health care (outer setting), whereas mental health nurses (inner setting) and SUPRANET (implementation process) were facilitating factors for applying suicide prevention practices. With regard to SUPRANET, especially the training was positively evaluated by PCPs. PCPs expressed a strong need for improving collaboration with specialized mental health care, which was not provided by SUPRANET. Educating PCPs on suicide prevention seems beneficial, but is not sufficient to improve care for suicidal patients. Effective suicide prevention also requires improved liaison between mental health services and primary care, and should therefore be the focus of future suicide prevention strategies aimed at primary care.

An effective suicide prevention program in the Israeli Defense Forces: A cohort study

Objective

To evaluate the effectiveness of the IDF Suicide Prevention Program, implemented since 2006.

Design

Quasi-experimental (before and after) cohort study.

Participants

Two cohorts of IDF mandatory service soldiers: the first inducted prior to (1992–2005, n = 766,107) and the second subsequent to (2006–2012, n = 405,252) the launching of the intervention program.

Exposure

The IDF Suicide Prevention Program is a population-based program, incorporating: reducing weapon availability, de-stigmatizing help-seeking behavior, integrating mental health officers into service units, and training commanders and soldiers to recognize suicide risk factors and warning signs.

Main outcome measure

Suicide rate and time to suicide in cohorts before and after exposure to the Suicide Prevention Program.

Results

Trend analysis showed lower suicide rates in the cohort after intervention. The hazard ratio for the intervention effect on time to suicide was 0.44 (95% CI = 0.34–0.56, P < .001) among males. Lower risk was associated with: male gender; born in Israel; higher socio-economic status; higher intelligence score; and serving in a combat unit (HR = 0.43: 95% CI = 0.33–0.55).

Conclusions

There was a 57% decrease in the suicide rate following the administration of the IDF Suicide Prevention Program. The effect of the intervention appears to be related to use of a weapon, and being able to benefit from improved help-seeking and de-stigmatization. Future efforts should seek to extend the program's prevention reach to other demographic groups of soldiers. The success of the IDF program may inform suicide prevention in other military organizations and in the civilian sector.

Suicide prevention gatekeeper training in the Netherlands improves gatekeepers' knowledge of suicide prevention and their confidence to discuss suicidality, an observational study

Background

The gatekeeper training is designed to help identify suicidal individuals, respond to suicidal ideation and refer to help. The internationally widely used training shows promising results. This is the first study presenting its effectiveness in the Netherlands and the first study investigating the effect in different employment sectors.

Methods

In an observational study, 113 Suicide Prevention – the Dutch suicide prevention expertise centre and lifeline - trained 526 professionals as gatekeepers. Changes in gatekeepers’ identifying and referral behaviour, knowledge of suicide prevention and skills-confidence were studied, using a pre-post (6 weeks after training) self-report questionnaire. Outcomes were analyzed with General Linear Model (GLM) repeated measures with four employment sectors (healthcare-, educational-, socioeconomic and other sectors) as a between-subjects factor.

Results

Pre-post self-reports of 174 respondents showed no change in the identification of suicidal people, referrals to the general practitioner (GP) or lifeline 113, but significant improvement in professionals’ knowledge and confidence (p < .001). Results did not differ between employment sectors.

Conclusions

The gatekeeper training significantly increases suicide prevention knowledge and skills confidence in abilities to address suicidality. Healthcare, education, socioeconomic and other professionals (e.g. security, justice, transport, church workers) benefit similarly from the training. Increasing the number of gatekeeper training programs in all sectors is recommended.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5512-8) contains supplementary material, which is available to authorized users.

Men and suicide prevention: a scoping review

BACKGROUND

Male suicide rates are higher than their female counterparts in almost every country around the world. Several developed countries have attempted to implement suicide prevention programmes, but few have specifically targeted men.

AIMS

To identify what is currently known about suicide prevention strategies, programmes, and interventions of relevance to men.

METHOD

A scoping review guided by Arksey and O'Malley's five-stage framework.

RESULTS

Twenty-two studies were included. Thematic analysis identified three categories: (i) male suicide prevention interventions; (ii) factors or coping strategies that interrupt the suicidal process in men; (iii) men's perspectives on service provision. Interventions included awareness campaigns; training of community "gatekeepers"; psychological support; and educational initiatives targeted to either GPs or depressed or suicidal men. Men emphasised the need to receive support from a trusted and respected individual, preferably in an informal setting. Connecting with others, reframing help-seeking as masculine, and the use of emotional regulation techniques were all identified as factors with potential to interrupt the suicidal process.

CONCLUSIONS

This review demonstrates the need for further research examining the perspectives of suicidal middle-aged men and their close family and friends.

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.

AIMS

This study examined the effects of gatekeeper training on attitudes, knowledge and confidence of police officers in dealing with persons at risk of suicide.

METHODS

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 post-training.

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.

Review of suicide-prevention programs in Queensland: state- and community-level activities

OBJECTIVE

Information regarding the availability of suicide-prevention programs in Australia is sparse and rather difficult to obtain. This study aimed to report and describe suicide and/or self-harm-prevention programs in Queensland.

METHODS

Programs were classified by type of intervention, predominant type of program, setting of delivery and targeted population-at-risk.

RESULTS

Sixty-six organisations were identified, providing a total of 101 suicide-prevention programs. The majority of programs operated at the prevention or treatment level, with less than half providing continuing (long-term) care. The programs targeted 12 different risk groups and were most frequently delivered within community settings.

CONCLUSIONS

The findings show a diverse distribution of activities across the levels of prevention and different risk populations. This survey demonstrates the existence of remarkable gaps in coverage and provision of programs for specific high-risk groups.

How to decrease suicide rates in both genders? An effectiveness study of a community-based intervention (EAAD)

Background

The suicide rate in Hungary is high in international comparison. The two-year community-based four-level intervention programme of the European Alliance Against Depression (EAAD) is designed to improve the care of depression and to prevent suicidal behaviour. Our aim was to evaluate the effectiveness of a regional community-based four-level suicide prevention programme on suicide rates.

Method

The EAAD programme was implemented in Szolnok (population 76,311), a town in a region of Hungary with an exceptionally high suicide rate. Effectiveness was assessed by comparing changes in suicide rates in the intervention region after the intervention started with changes in national suicide rates and those in a control region (Szeged) in the corresponding period.

Results

For the duration of the programme and the follow-up year, suicide rates in Szolnok were significantly lower than the average of the previous three years (p = .0076). The suicide rate thus went down from 30.1 per 100,000 in 2004 to 13.2 in 2005 (−56.1 %), 14.6 in 2006 (−51.4 %) and 12.0 in 2007 (−60.1 %). This decrease of annual suicide rates in Szolnok after the onset of the intervention was significantly stronger than that observed in the whole country (p = .017) and in the control region (p = .0015). Men had the same decrease in suicide rates as women. As secondary outcome, an increase of emergency calls to the hotline service (200%) and outpatient visits at the local psychiatry clinic (76%) was found.

Conclusions

These results seem to provide further support for the effectiveness of the EAAD concept. Whilst the majority of suicide prevention programs mainly affect female suicidal behaviour, this programme seems to be beneficial for both sexes. The sustainability and the role of the mediating factors (social service and health care utilization, community attitudes about suicide) should be key points in future research.

Developing social capital in implementing a complex intervention: a process evaluation of the early implementation of a suicide prevention intervention in four European countries

BACKGROUND

Variation in the implementation of complex multilevel interventions can impact on their delivery and outcomes. Few suicide prevention interventions, especially multilevel interventions, have included evaluation of both the process of implementation as well as outcomes. Such evaluation is essential for the replication of interventions, for interpreting and understanding outcomes, and for improving implementation science. This paper reports on a process evaluation of the early implementation stage of an optimised suicide prevention programme (OSPI-Europe) implemented in four European countries.

METHODS

The process analysis was conducted within the framework of a realist evaluation methodology, and involved case studies of the process of implementation in four European countries. Datasets include: repeated questionnaires to track progress of implementation including delivery of individual activities and their intensity; serial interviews and focus groups with stakeholder groups; and detailed observations at OSPI implementation team meetings.

RESULTS

Analysis of local contexts in each of the four countries revealed that the advisory group was a key mechanism that had a substantial impact on the ease of implementation of OSPI interventions, particularly on their ability to recruit to training interventions. However, simply recruiting representatives of key organisations into an advisory group is not sufficient to achieve impact on the delivery of interventions. In order to maximise the potential of high level 'gatekeepers', it is necessary to first transform them into OSPI stakeholders. Motivations for OSPI participation as a stakeholder included: personal affinity with the shared goals and target groups within OSPI; the complementary and participatory nature of OSPI that adds value to pre-existing suicide prevention initiatives; and reciprocal reward for participants through access to the extended network capacity that organisations could accrue for themselves and their organisations from participation in OSPI.

CONCLUSIONS

Exploring the role of advisory groups and the meaning of participation for these participants revealed some key areas for best practice in implementation: careful planning of the composition of the advisory group to access target groups; the importance of establishing common goals; the importance of acknowledging and complementing existing experience and activity; and facilitating an equivalence of benefit from network participation.

Best practice elements of multilevel suicide prevention strategies: a review of systematic reviews

Background: Evidence-based best practices for incorporation into an optimal multilevel intervention for suicide prevention should be identifiable in the literature. Aims: To identify effective interventions for the prevention of suicidal behavior. Methods: Review of systematic reviews found in the Pubmed, Cochrane, and DARE databases. Steps include risk-of-bias assessment, data extraction, summarization of best practices, and identification of synergistic potentials of such practices in multilevel approaches. Results: Six relevant systematic reviews were found. Best practices identified as effective were as follows: training general practitioners (GPs) to recognize and treat depression and suicidality, improving accessibility of care for at-risk people, and restricting access to means of suicide. Although no outcomes were reported for multilevel interventions or for synergistic effects of multiple interventions applied together, indirect support was found for possible synergies in particular combinations of interventions within multilevel strategies. Conclusions: A number of evidence-based best practices for the prevention of suicide and suicide attempts were identified. Research is needed on the nature and extent of potential synergistic effects of various preventive activities within multilevel interventions.

Community and health professionals' attitude toward depression: a pilot study in nine EAAD countries

BACKGROUND

Community facilitators (CFs), such as pharmacists, policemen, teachers and clergy, may be an important community resource for patients with depression in addition to (mental) health professionals. However, they are ill prepared for such a role and little is known about their attitudes toward depression, which may affect practice.

AIM

To investigate CFs' attitudes toward depression and compare them to those of (mental) health professionals and nurses.

METHOD

Attitudes were assessed in participants (n = 2,670) of training programmes about depression in nine countries of the European Alliance Against Depression (EAAD). The EAAD questionnaire included attitudes toward depression and its treatment, perceived causes, preferred treatment options, and knowledge of depression symptoms.

RESULTS

CFs and nurses had a more negative attitude toward patients with depression and toward antidepressants, and more limited knowledge of depression symptoms than (mental) health professionals. CFs more frequently supported non-standard treatment for depression. Nurse assistants clearly differed from registered nurses with their attitudes being among the least favourable and their knowledge the most limited of all groups.

CONCLUSIONS

CFs and nurses had less favourable attitudes and more limited knowledge regarding depression when compared to mental health professionals and doctors. This may negatively affect professional collaboration, challenge optimal treatment and stigmatize patients. CFs' and nurses' knowledge and attitudes may be similar to those of the general population and be related to a lack of training in mental health issues.

Reducing suicides through an alliance against depression?

BACKGROUND

Since 2003, the Regensburg Alliance Against Depression, the regional partner of the German Alliance Against Depression, has been conducting a four-level intervention program to improve early detection and treatment of patients with depression, which was successfully piloted in the framework of the German Research Network on Depression and Suicidality.

METHODS

After 5 years of campaign, the suicide rates before and after the intervention were evaluated in comparison with two control regions and with the German overall rate.

FINDINGS

The results show that only the suicide rate in Regensburg fell significantly during the intervention period. The drop in the suicide rate was due to a significant decrease in male suicides.

INTERPRETATION

An intensive community-based campaign could be effective in lowering suicide rates. Especially, the combination of continuing medical educations (CMEs) for general practitioners focusing on 'male depression' and low-threshold campaigns for the general public seems to reach male depressive patients.

Sustainable effects on suicidality were found for the Nuremberg alliance against depression

During an intense four-level community-based intervention program conducted in Nuremberg (490,000 inhabitants) in 2001 and 2002 [Nuremberg Alliance Against Depression (NAD)], the number of suicidal acts (main outcome completed + attempted suicides) had dropped significantly (-21.7%), a significant effect compared with the baseline year and the control region (Wuerzburg, about 290,000 inhabitants). To assess the sustainability of the intervention effects the number of suicidal acts was assessed in the follow-up year (2003), after the termination of the 2-year intervention. Also, in the follow-up year (2003), the reduction in suicidal acts compared with the baseline year in Nuremberg (2000 vs. 2003: -32.4%) was significantly larger than that in the control region (P = 0.0065). The reduction was even numerically larger than that of the intervention years (2001, 2002). Thus, 1 year after the end of the main intervention, preventive effects on suicidality of the NAD remain at least stable. The four-level intervention concept appears to be cost-effective and is presently implemented in many European regions.

Optimizing suicide prevention programs and their implementation in Europe (OSPI Europe): an evidence-based multi-level approach

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.

Case-control study of suicide attempts in the elderly

BACKGROUND

Prior studies have inadequately explored the relationship between late-life suicidal behavior and subclinical/clinical symptoms. This study aimed to assess the risk associated with subclinical symptoms, mild cognitive impairment and clinical factors among late-life suicide attempters.

METHOD

Forty-three elderly patients aged 60 years and older who sought emergency services in a university-affiliated general hospital for attempting suicide and 43 comparison subjects participated in this study between March 2005 and December 2006. The comparison group was recruited by advertising in the community around the hospital. DSM-IV based diagnostic interview and screening instruments including the GDS, MMSE, BSRS-5 and APGAR were applied. Adjusted odds ratios were measured in the final multiple logistic regression model.

RESULTS

Suicide attempters were more likely to meet a diagnosis of depressive disorder, after adjustments for BSRS-5 score and drinking habit. The adjusted odds of suicide among people with a BSRS-5 score of more than 5 points was 17.8 times higher than those with the BSRS score less than or equal to 5 points.

CONCLUSIONS

Our findings support the significant impact on late-life suicidal behavior from the assessment of subclinical symptoms, including anxiety, depression, hostility, sleep condition and interpersonal symptoms. The assessment of subclinical symptoms by the BSRS-5 may help in the future prevention of late-life suicidal behavior in primary care settings.

Toward a New Prevention of Suicide in Schizophrenia

Suicide is the primary cause of death among schizophrenic patients; follow-up studies suggested that 10-13% of schizophrenic patients die by suicide. Preventive measures based on early recognition of risk factors and the establishment of drug treatment protocols are no doubt of great help but have not resulted in a significant reduction of the number of suicides among these patients. Schizophrenia is a chronic disorder affecting all aspects of the individual's life. Prevention should therefore be addressed to various areas. This paper overviews studies dealing with major fields of interest in the prevention of suicide among patients with schizophrenia. The authors focus on the role of pharmacological treatment, psychosocial interventions and psychotherapy, the struggle against stigmatization and the role of GPs. Prevention of suicide among inpatients with schizophrenia is also analysed. It is concluded that those integrated strategies already in use and the implementation of less known interventions should constitute a more effective prevention of self-inflicted deaths among these patients.

The unreported morbidity of suicidal poisonings during an insurgency: a 16-year Kashmir experience

Around a million people commit suicide, and at least 10 times this number attempt suicide, worldwide every year. No nationwide epidemiological studies have been undertaken in India but a significant rise in suicides has been observed in Kashmir in recent years. This study was carried out on patients reporting to the Government SMHS Hospital in Srinagar with a history of suicidal poisoning.

The 'European Alliance Against Depression (EAAD)': a multifaceted, community-based action programme against depression and suicidality

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).

Might the decrease in the suicide rates in France be due to regional prevention programmes?

Suicide mortality rates decreased in France from 1996 to 1999, and a difference was observed between the 11 regions which have implemented suicide prevention programmes (Programmes régionaux de santé (PRS)) and the 11 others which have not launched PRS of this kind. The former regions showed a sharper decrease in their suicide mortality rates than the latter. In the present study, the explanatory factors underlying these differential regional trends were examined using an ecological model. Principal component analysis (PCA) and multiple regression procedures provided consistent findings in terms of the main factors associated with the male and female mortality rates, which were found to be unemployment problems and economic inequalities, respectively. However, these factors do not explain the differential regional trends. The suicide mortality rates were negatively correlated with regional lithium prescription rates in the case of males, whereas alcohol withdrawal drug prescription rates were positively correlated in the case of females. It is still difficult to conclude whether the PRS definitely had positive effects. However, no single variable alone can account for all the trends in the suicide rates.

Problematizing special observation in psychiatry: Foucault, archaeology, genealogy, discourse and power/knowledge

Special observation by mental health professionals is the recommended approach for those people deemed as at risk or risky. Recent research and academic writing have challenged the benefits of observing people/patients who are defined as 'at risk', and a more human engagement process is being recommended. Despite this assault, practice has not changed substantively, suggesting a need for a thorough exploration and questioning of the practices and process. The paper outlines three Foucaultian approaches to historical analysis. It applies aspects of Foucault's archaeology/genealogy, discourse and power/knowledge to explore the practices of special observation as a means of controlling risk, especially suicide risk. We identify the regulatory function of the 'gaze', professional codes and government policy in relation to restricting professional practices. We argue that observation can be related to moral therapy, wherein the person relinquishes madness for responsibility through a disciplinary process and, in governing risk, a 'professional industry' is created. The regulation of statements about people with mental health issues are exposed and related to what can be said and done by professionals. Finally, we look at productive power in relation to observation, and how it is intimately related to resistance. We conclude with 'soft' recommendations for practice discursively produced through the writing of the paper.

Newer prophylactic agents for bipolar disorder and their influence on suicidality

Different from lithium, there is little known so far on the effect of (newer) anticonvulsants on suicidality in bipolar patients. We evaluated data of 128 patients with bipolar disorders for suicidal ideation. These patients were treated with various mood-stabilizing medications for at least 3 months. No suicide attempt or completed suicide occurred in this cohort during prospective follow up for an average of 13.3 +/- 12.1 years. Compared to lithium, the relative risk of suicidal ideation was numerically slightly higher for valproate, carbamazepine and a small group treated with either levetiracetam, oxcarbazepine or topiramate, but lower in patients treated with lamotrigine, without reaching statistical significance. Confounding variables in more intensive care of these patients participating in a naturalistic study may blur small differences and contribute to a generally favorable outcome.

Increased mortality in depressive disorders: a review

Several factors have been proposed to explain the relationship between excess mortality and depressive disorders. These include mechanisms such as increased suicide rates, hazardous health behavior (smoking, alcohol use, unhealthy eating), psychologic reactions to developing a medical illness, biological dysregulations (hyperactivity of the hypothalamic pituitary adrenal, neuro-immune dysregulation, sympathoadrenergic dysregulation), and noncompliance with medical treatment. The evidence supporting the role of each of these mechanisms in excess mortality varies considerably. The causal direction in most of the mechanisms is not clear. It is possible that the explanatory factors, such as smoking, compliance, or biological mechanisms, cause depression, or that depression causes these factors, or that both are explained by a third, underlying factor. We will summarize the evidence supporting these mechanisms, and propose options for possible interventions aimed at reducing the increased risk of dying.