This chapter covers the case study of Suicide Prevention Austria (SUPRA), a national strategy for suicide prevention in Austria. The case study includes an assessment of SUPRA against the five best practice criteria, policy options to enhance performance and an assessment of its transferability to other OECD and EU27 countries.
Mental Health Promotion and Prevention
Best Practices in Public Health
Abstract
Description:
SUPRA is a national strategy for suicide prevention. SUPRA tackles multiple risk factors for suicide and introduces protective factors. This case study focusses on three key components of SUPRA: gatekeeper programmes (e.g. front-line workers trained to listen to people at risk of suicide and provide essential support), safeguarding hotspots for suicide attempts (e.g. bridges and railways), and reducing access to means of suicide (e.g. firearms and substances). SUPRA is a best practice transferred to countries within the EU-funded Joint Action ImpleMENTAL to improve mental health in Europe.
Best practice assessment:
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Criteria |
Assessment |
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Effectiveness |
Currently there are no available data on the global effectiveness of SUPRA or on the effectiveness of its components in the Austrian setting. Broader research backs up the effectiveness measures included in SUPRA:
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Efficiency |
Currently there are no data on the cost-effectiveness of SUPRA or of its components. Broader research signals positive economic effects of some suicide prevention actions included in SUPRA:
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Equity |
SUPRA has potential to improve health equity because it supports groups at higher risk of suicide which often encompass lower income, socially isolated, minority, and disadvantaged social groups. |
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Evidence‑base |
Data to assess the impacts and efficiency of SUPRA is not systematically collected. An analysis of other national suicide prevention strategies in Australia, Finland, Norway and Sweden, shows that they are effective at reducing overall suicide rates and suicide rates among specific age groups. |
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Extent of coverage |
SUPRA is tailored to cover the whole population, individuals with risk factors of increased likelihood of suicide, and people with suicidal behaviours which maximises the extent of population coverage. |
Enhancement options: To enhance its effectiveness, SUPRA should integrate broader social policy addressing structural causes of psychological distress (e.g. social safety nets). To enhance its evidence‑base, SUPRA should systematically collect data on the effectiveness, costs, and uptake of individual programme actions, and on intermediate outcomes, such as changes in awareness, attitude, stigma, and access to treatment. To enhance equity impacts, it is recommended to monitor the uptake of programme components by specific population groups (e.g. unemployed people, youth, and minority groups).
Transferability: A high-level transferability analysis using clustering suggests that 39 out of 42 EU/OECD countries considered would present many of the characteristics needed to ensure a successful transferability of SUPRA.
Conclusion: SUPRA presents a promising approach to articulate different dimensions of suicide prevention involving diverse stakeholders. Research suggests that most components of SUPRA are likely to be effective and efficient means to tackle suicide, yet SUPRA could benefit from a stronger monitoring and evaluation framework to measure its impacts with more accuracy.
Suicide Prevention Austria (SUPRA) -Suizidpräventionsprogramm- is a multilevel suicide prevention programme addressing several risk factors for suicide. SUPRA was first launched in 2012 as an initiative of the Austrian Ministry of Health to articulate existing suicide prevention actions at the national and sub-national levels, to introduce new actions, and to further improve their reach and effectiveness. SUPRA actions are multiple and can be independent from each other. They span across several areas, including co‑ordination schemes between Austrian national and sub-national governments, enhanced access to mental health support and treatment, restricted access to means of suicide, mental health and suicide prevention literacy, media guidelines for communication on suicide, and inclusion of suicide prevention in other health promotion actions.
SUPRA seeks to further decrease the suicide rate in Austria. The suicide rate in Austria had been following a downwards trend since 1986, which stabilised during the 2008 crisis. Since then, the suicide rate has stagnated around 13 suicides1 per 100 000 inhabitants in 2019, with a total of 1 113 people dying by suicide across the country in 2019 (Figure 8.1). Rates of suicide increase with age. Risk of suicide in the age groups 75 to 79, and 85 to 89, are twice and four times as high, respectively, as for the general population. More than a fourth of suicide victims in Austria are male, and suicide remains the most frequent cause of death for middle‑aged people, and the second most frequent in the age group 15 to 29 years old (BMSGPK, 2019[1]). Currently, there are no reliable data on suicide attempts given that many cases are not documented or do not result in contact with the healthcare services. Since 2022, Austria includes assisted suicide in its suicide statistics, which limits comparison over time (BMSGPK, 2023[2]).
Source: OECD Health Statistics, 2024, http://dx.doi.org/10.1787/health-data-en.
SUPRA’s most noteworthy innovation is its co‑ordination strategy, integrating evidence‑based suicide prevention actions under a detailed implementation framework. SUPRA first outlined a “starting package” of priority actions for suicide prevention that were already in place or that could be implemented easily in the short term (e.g. over the next two years). These included, among others, setting up a national co‑ordination centre for suicide prevention, integrating a network of phone‑based and online‑based support and information services such as websites and hotlines. In 2019, a full starting package and longer-term implementation concept linking 70 actions to 18 operative goals and 6 strategic goals for suicide prevention was presented to further support the implementation of SUPRA across the entire country (Grabenhofer-Eggerth et al., 2022[3]). Between 20% to 30% of the actions foreseen in SUPRA’s starting package have been implemented in Austria by June 2023.
SUPRA has six strategic goals, including multiple actions (Table 8.1). The strategic goals serve as the overarching framework guiding targeted operational goals and specific actions. For example, the strategic goal of “Coordination and organisation” is supported by the operational goal of “embedding suicide prevention into national and sub-national structures”, exemplified by the establishment of the SUPRA federal co‑ordination centre. Similarly, the strategic goal of “Support and treatment” is operationalised through the implementation of a “Train-the‑trainer” gatekeeper program, expanding the availability of frontline support. Each operational goal is directly tied to actionable measures, such as safeguarding suicide hotspots to restrict access to means, awarding the Papageno media prize to raise awareness, and integrating suicide prevention into school-based programmes to align with broader health promotion efforts. Together, these interconnected goals and actions ensure a cohesive and evidence‑based approach to reducing suicidality.
Note: This table does not comprise all the operative goals and actions included within SUPRA. SUPRA’s handbooks offers a full account.
Source: Grabenhofer-Eggerth et al., (2022[3]), SUPRA Handbook; an experience‑based document for implementing a national suicide prevention programme.
SUPRA measures are classified as universal, selective, and indicated prevention, depending on the public they are addressed to. Universal health promotion targets the whole population or community; selective prevention is focussed on groups at higher risk of suicide, such as youth, LGBTQI+ individuals, and people in precarious living situations; and indicated prevention is tailored to those having shown suicidal behaviours. Table 8.2 describes them in detail.
Source: WHO, (2021[4]) LIVE LIFE: an implementation guide for suicide prevention in countries. https://www.who.int/publications/i/item/9789240026629
How SUPRA contributes to suicide prevention
Suicide occurs in a complex social and psychological context. No single factor can be signaled as a main determinant of suicidal behaviour, but it is acknowledged that people undergoing major personal crises such as loosing close relationships or jobs, enduring long-lasting suffering, abuse, or pain, and in general being subject to high levels of deprivation, disadvantage, and negative life events are at increased risk of suicide (Kabir, Wayland and Maple, 2023[5]). This entails that suicide prevention strategies and programmes should encompass the wide contexts in which people live – including workplace, education and leisure – rather than focussing exclusively on the clinical aspects of mental health (O’Connor et al., 2023[6]).
This case study focusses on three components of SUPRA: gatekeeper programmes, restricting access to means of suicide and safeguarding of hotspots for suicide attempts, which are evidence‑based suicide prevention programmes. The following sections briefly describe these interventions and explain how they have been implemented within the framework of SUPRA.
Gatekeeper programmes for suicide prevention
Gatekeepers for suicide prevention are individuals who provide front-line support to individuals at risk of suicide, delivering or arranging essential suicide prevention interventions. The Gatekeepers are often front-line workers more likely to interact with individuals at risk of suicide due to their professional or social activities, such as labour market service employees, teachers, police, doctors, or volunteers. Gatekeepers are trained to show willingness to listen to people at risk of suicide, demonstrate that they understand their distress, and offer support around suicidality. Didactic methods include role‑play, case‑discussion, group-reflection and discussion, and presentation of slides (Plöderl et al., 2023[7]). SUPRA’s working group seeks to train as many Gatekeepers as possible. Gatekeepers must be trained by a certified Gatekeeper instructor, who received specialised education through a tailored “train-the-trainer” educational programme. The training concept was developed by a working group of the Austrian Society for Suicide Prevention (Österreichischen Gesellschaft für Suizidprävention) in co‑operation with SUPRA under the leadership of qualified health professionals (BMSGPK, 2019[1]).
Restricting access to means of suicide (e.g. firearms, lethal substances)
SUPRA proposes a variety of approaches to reduce access to objects and substances that might be used to attempt and commit suicide. The most frequent means of suicide in Austria in 2023 were hanging (42%), firearms (18%) and poisoning (13%). Changes in weapons legislation and standards for accessing potentially lethal substances (such as pesticides) can reduce the availability of suicide means and reduce the overall opportunities for committing or attempting suicide. For instance, the Austrian weapons law of 2018 introduces a mandatory psychological assessment for people intending to buy firearms (BMSGPK, 2019[1]; ÖGS, 2018[8]).
Safeguarding hotspots for suicide
Bridges, highways, railway lines, metro platforms and other physical places are often used to commit suicide and suicidal attempts. These places are secured by installing physical barriers that eliminate or reduce the likelihood of people accessing climbing over, therefore reducing the opportunities to commit or attempt suicide. Since 2016, the Institute for Suicide Prevention Graz, in collaboration with the Austrian Motorway and Expressway Financing Corporation (ASFINAG), has initiated a project to enhance the safety of hotspot bridges. All bridges within the ASFINAG network, identified by the Austrian Federal Ministry of the Interior (BMI), have been evaluated by the respective motorway authorities. Six of these bridges have been classified as hotspots according to the Swiss model (Bundesamt für Strassen-ASTRA), accounting for factors such as frequency of suicidal events and the accessibility and visibility of the place. Two of these hotspots have already undergone structural modifications such as the elevation of railings and the safeguarding of bridgeheads. Additionally, some bridges have been equipped with information boards displaying a telephone counselling number. ASFINAG employees have also received suicide prevention training. The long-term plan is to implement this programme across Austria (BMSGPK, 2019[1]).
This section analyses SUPRA against the five criteria within OECD’s Best Practice Identification Framework – Effectiveness, Efficiency, Equity, Evidence‑base and Extent of coverage (see Box 8.1 for a high-level assessment). Further details on the OECD Framework can be found in Annex A.
Effectiveness
Currently there are no available data on the global effectiveness of SUPRA or on the effectiveness of its components in the Austrian setting. Broader research backs up the effectiveness measures included in SUPRA:
Gatekeeper programmes for suicide prevention have shown positive effects overall, but the quality of evidence is relatively low.
Safeguarding hotspots for suicide attempts is a highly effective measure for suicide prevention, reducing suicides by about 93% compared to before the introduction of the intervention.
Interventions requiring safe storage for firearms and restricting access to lethal doses of medication are associated with a 13% and 22% reduction in suicides.
Efficiency
Currently there are no data on the cost-effectiveness of SUPRA or of its individual components. Broader research signals positive economic effects of specific suicide prevention measures:
Gatekeeper programmes are cost-saving in the United States.
Interventions to make suicide hotspots safer show a return-on-investment of EUR 2.40 for every EUR 1 invested.
Interventions banning dangerous pesticides can prevent up to 28 000 suicides at a cost of EUR 0.006 capita.
Equity
SUPRA has potential to improve health equity because it supports groups at higher risk of suicide which often encompass lower income, socially isolated, and unfairly disadvantaged social groups.
Evidence‑base
Data to assess the impacts and efficiency of SUPRA is not systematically gathered. An analysis of other national suicide prevention strategies in Australia, Finland, Norway and Sweden, show that they are effective at reducing overall suicide rates and suicide rates among specific age groups.
Extent of coverage
The multilevel nature of SUPRA encompassing universal, selective, and indicated prevention makes it particularly suitable to tackle health and social inequalities around suicide.
Effectiveness
Three SUPRA components are examined herein, based on their promising effectiveness. This section presents a summary of the research around the effectiveness of gatekeeper programmes, programmes to secure hotspots for suicide, and programmes restricting access to means of suicide. As evidence of effectiveness is not available in Austria, the evidence is collected from other settings.
Gatekeeper programme
Gatekeeper programmes improve people’s knowledge, skills, and confidence in helping individuals at risk of suicide, although there is no evidence for a causal link with reduced suicide rate. Gatekeeper programmes offer training to identify people at risk of suicide and refer them to appropriate services (Hawgood et al., 2022[9]). Evidence of the causal link between gatekeeper programmes and reduced suicide rates is modest. Some systematic reviews have found overall positive effect on relevant suicidal behaviours. However, the quality of evidence is either low or unclear and demands careful interpretation. A quantitative summary was not calculated given the heterogeneity between the measured outcomes (Yonemoto et al., 2019[10]).
Safeguarding hotspots for suicide attempts
Safeguarding hotspots is very effective at reducing suicide rates. Safeguarding hotspots for suicide attempts includes installing fences and safety nets, among others. These measures are implemented in places that have been previously used to commit suicide, such as highways, buildings, and bridges. The interventions either prevent people from climbing over or protect them from falls. A systematic review on interventions to reduce suicides at hotspots suggests that physically safeguarding hotspots is associated with a reduction in the incidence rate of suicides by approximately 93% (incidence rate ratio 0.07, 95% CI 0.02‑0.19; p<0.0 001) – 14 times lower than the incidence rate before the intervention- (Pirkis et al., 2015[11]). A national survey in Switzerland compared the effectiveness of suicide prevention measures implemented on bridges and other high structures. Comparing scenarios before and after the intervention, the study found that both barriers and safety nets were effective, with a mean suicide reduction of 68.7% for barriers and 77.1% for safety nets (Hemmer, Meier and Reisch, 2017[12]). There is relatively strong evidence that safeguarding hotspots averts suicide without substitution effects (Pirkis et al., 2015[11]; Cox et al., 2013[13]).
Restricting access to means of suicide
Restricting access to firearms and potentially lethal substances prevents suicide. Making the means of suicide less deadly or less available, reduce fatal attempts and help reduce suicide rates (Barber and Miller, 2014[14]). A study from the United States, where gun ownership is highly prevalent, shows that policies requiring safe storage of firearms are associated with a 13.1% (95% Confidence interval: 2.7%‑22.3%) reduction in adolescent firearm suicide (Kivisto et al., 2021[15]). Similarly, restricting access to lethal doses of medication (e.g. analgesics) was associated with a 22% reduction in suicides compared to rates before restriction policies were introduced (Hawton et al., 2004[16]). Decreasing the lethality of means available is of special relevance, considering that 90% of people who attempt suicide do not die in the attempt (Owens, Horrocks and House, 2002[17]). Restricting access to means of suicide works by delaying attempts – increasing the likelihood that the triggering events will pass – and substituting means for less lethal ones allows people to receive help and support (Barber and Miller, 2014[14]).
Efficiency
Data on the global costs of SUPRA are not readily available. SUPRA components are delivered by different national and sub-national stakeholders, and there are no readily available data on the global costs of SUPRA. However, there is some evidence on the cost-effectiveness of selected components of SUPRA. Evaluations of interventions containing a gatekeeper programme demonstrated to be cost-saving in the United States (Le et al., 2021[18]). Interventions to install barriers at multiple bridge sites across Australia were cost-saving with a return of USD 2.40 for every USD 1 (EUR 2.40 for every EUR 1) invested over 10 years (Bandara et al., 2022[19]). A modelling study estimated that banning highly hazardous pesticides across 14 studied countries could result in about 28 000 fewer suicide deaths each year at an annual cost of USD 0.007 (EUR 0.006) per capita (Lee et al., 2021[20]). The cost-effectiveness of multicomponent suicide prevention strategies such as SUPRA have been evaluated in other settings. In a Canadian study, the incremental cost-effectiveness rate associated with the implementation of suicide prevention programmes reached on average CAD 3 979 (EUR 2 806) per life year saved (Vasiliadis, Lesage and Seguin, 2015[21]).
Equity
To date, there are no data on the equity impacts of SUPRA. Suicidality impacts men and women in noticeably different ways. While women are more likely to attempt suicide than men, death by suicide is more frequent among men, probably because of their likelihood to choose more deadly means (Sher, 2021[22]). Additional sources also signal that suicide is more likely among ethnic and racial minorities, and lower socio-economic groups (World Health Organization, 2014[23]). SUPRA is tailored to cover both the whole population, individuals with risk factors of increased likelihood of suicide behaviour, or people with suicidal behaviour. Its actions focus on universal, selective, and indicated prevention according to the risk of suicidality of individuals. Tailored prevention is likely to reduce health inequalities among social groups.
Evidence‑base
SUPRA relies on evidence‑based interventions but it does not systematically assess their effectiveness in the Austrian context. National programmes for suicide prevention were evaluated in other settings. A research article investigating the effectiveness of national suicide prevention programmes in Australia, Finland, Norway and Sweden, shows a reduction in suicide rates post-implementation, particularly among men aged 25‑64 and women aged 45‑64. However, the authors highlight important limitations of the study, including not being able to isolate the effects of individual components of the programmes and the lack of control for confounding variables such as access to healthcare, economic conditions, or social change which might affect suicide rates (Lewitzka et al., 2019[24]).
Extent of coverage
SUPRA actions are rolled out at the national and sub-national level. They intend to cover the whole Austrian population, while more tailored actions target individuals with risk factors of increased likelihood of suicide, and people with suicidal behaviour. However, to date there are no specific data on the level of implementation of the different measures and thus the share of the population effectively covered by SUPRA actions is unclear.
Recommendations to improve SUPRA’s performance across OECD’s Best Practice Assessment Framework would demand a sounder monitoring and evaluation framework for SUPRA, encompassing data on the effectiveness, costs, coverage, and uptake of individual components of the programme. Additionally, data about intermediate outcomes relevant to suicide prevention, such as changes in awareness, attitude, stigma, broader mental health and well-being, and access to treatment could provide a more nuanced picture of the impacts of SUPRA. This considered, the following recommendations broadly apply to national suicide prevention strategies, and some dimensions relate specifically to SUPRA.
Enhancing effectiveness
SUPRA can enhance its effectiveness by tackling the social determinants of psychological distress and improving individual coping and social-emotional skills. Social and economic crises often lead to increased suicide rates (Chang et al., 2013[25]). To prevent suicide, it is important to have sound social security systems in place that can mitigate the impact of negative life events on people’s psychological distress (e.g. social safety nets). Moreover, providing education and social-emotional skills to help individuals cope with life’s challenges in a positive and constructive manner is shown to improve overall mental health and is likely to have a positive impact on reducing suicide rates.
Enhancing equity
SUPRA can enhance equity impacts by disaggregating data by different population groups. SUPRA’s structure is well-suited to tackle health inequalities around suicide. To enhance SUPRA’s equity impacts, it would be essential to monitor the SUPRA actions by breaking down the data by different population groups. Groups of interest are those at higher risk of suicidal ideation, including individuals undergoing life crises (such as losing a family member, their job, or becoming displaced), youth, minority groups such as LGBTQI+, and indigenous communities, individuals in precarious living situations and lower income groups.
Enhancing the evidence‑base
SUPRA can enhance its evidence‑base by systematically collecting and monitoring key outcome measures. Currently SUPRA does not systematically collect data on its individual components, such as cost, effectiveness, uptake and coverage. Collecting these data, within the framework of an appropriate monitoring and evaluation framework, would contribute to consolidate the evidence for the effectiveness of SUPRA and pin-point areas for potential improvement. Monitoring intermediate outcomes would also be relevant. Some research suggests that including intermediate outcomes such as changes in awareness, attitude, stigma, and access to treatment, might provide a more nuanced picture of the impacts of suicide prevention programmes (Arensman et al., 2010[26]).
Enhancing extent of coverage
SUPRA intends to be an encompassing strategy for suicide prevention covering the entire population with actions targeting individuals, families, communities, and sub-groups with different risk profiles. Carefully monitoring the levels of uptake of SUPRA actions at the national and sub-national level can provide a clearer picture of its current reach and serve to enhance its extent of coverage.
This section explores the transferability of SUPRA. It is divided into three sub-sections: 1) notes on current efforts for transferring SUPRA to other settings; 2) transferability assessment using publicly available data, and; 3) considerations for policymakers interested in introducing a national suicide prevention strategy similar to the one presented in this case study.
Previous transfers
SUPRA has been identified as a best practice model for suicide prevention in Europe. SUPRA is being disseminated to other countries as part of the European Union Joint Action ImpleMENTAL, aimed at implementing mental health best practices across member countries. Austria has produced a Handbook (Grabenhofer-Eggerth et al., 2022[3]) to guide countries interested in integrating components of SUPRA in their own national suicide prevention strategies. By March 2024, 17 European countries initiated pilots of SUPRA in their national setting, as part of collaborative work of Joint Action ImpleMENTAL for Suicide Prevention (JA-ImpleMENTAL, 2023[27]). Measures chosen under the six strategic areas have been prioritised based on the country needs. A total of over 140 measures were implemented across the countries participating in the project.
Transferability assessment
This section outlines the methodological framework to assess transferability followed by an analysis of the results.
Methodological framework
Table 8.3 presents a selection of high-level indicators to assess the transferability of SUPRA to other OECD and non-OECD European countries. Variables were selected considering data availability and content relevance. Jurisdictions considering the transfer of SUPRA should carefully consider their local context, needs, and resources.
Results
Main results from the transferability assessment are summarised below:
a) In Austria, a higher share of adults reported having consulted a mental health or rehabilitative professional, compared to potential transfer countries – 7% compared to 5.9% in the median in OECD and EU countries.
b) A higher healthcare access and quality index is correlated with higher accessibility of mental health services. The index for Austria is higher than the median across OECD and EU countries (88.2 versus 85.8), suggesting that countries with a higher index have a more favourable sector-specific context to implement SUPRA.
c) As in Austria, a vast majority (90%) of countries have strategy or action plan that guide implementation of the mental health policy. This result suggests that SUPRA would likely receive political support among most potential transfer countries.
d) Mental health awareness and literacy policies are in place in 88% of countries, including Austria. Increasing awareness around mental health issues and suicide are goals of SUPRA actions, therefore policy supporting these objectives enhances the transferability of SUPRA.
e) As in Austria, a large proportion (90%) of countries reported having policies to support mental health in educational settings. As SUPRA integrates suicide prevention into existing school-based health promotion programmes, this result suggests that SUPRA would likely receive political support among most potential transfer countries.
f) As in Austria, a vast majority (93%) of countries have suicide prevention policies in place. This provides further evidence of SUPRA’s transferability, given it aligns with national strategy in most countries.
g) Austria spends a higher proportion of current health expenditure on preventive care, compared to other countries (10% vs. 4.42% for the median in OECD and EU countries). Countries with higher spending would likely have economic support for the transfer of SUPRA.
A darker shade indicates SUPRA is more suitable for transferral in that particular country.
Note: n/a = no available data. The shades of blue represent the distance each country is from the country in which the intervention currently operates, with a darker shade indicating greater transfer potential based on that particular indicator (see Annex A for further methodological details). The full names and details of the indicators can be found in Table 8.3.
Source: IHME (2017[29]), Global Burden of Disease Study 2015 (GBD 2015) Healthcare Access and Quality Index Based on Amenable Mortality 1990–2015, https://ghdx.healthdata.org/record/ihme-data/gbd-2015-healthcare-access-and-quality-index-1990-2015 (accessed on 7 April 2024); Eurostat (2022[28]), Self-reported consultations of mental healthcare or rehabilitative care professionals by sex, age and educational attainment level, https://doi.org/10.2908/HLTH_EHIS_AM6E (accessed on 7 April 2024); OECD/WHO Regional Office for Europe (2023[30]), Mental Health Systems Capacity Questionnaire 2023 - Strategy or action plan that guide implementation of the mental health policy; Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes to improve mental health awareness and literacy; OECD/WHO Regional Office for Europe (2023[32]), Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes to support mental health in educational settings; OECD/WHO Regional Office for Europe (2023[31]), OECD/WHO Regional Office for Europe (2023[33]), Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes that support suicide prevention; OECD (2022[34]), OECD Data Explorer - Prevention spending as a percentage of current health expenditure, http://data-explorer.oecd.org/s/1nl (accessed on 11 April 2025).
To consolidate findings from the transferability assessment above, countries have been clustered into three groups, based on indicators reported in Table 8.4. Countries in clusters with more positive values have the greatest transfer potential. While this analysis provides a high-level overview assuming some simplifications, it is important to note that countries in lower-scoring clusters may also have the capacity to adopt the intervention successfully. For further details on the methodological approach used, please refer to Annex A.
Key findings from each of the cluster are below with further details in Figure 8.2 and Table 8.5:
Countries in cluster one have population, sector-specific, political, and economic conditions in place that would support the introduction of a suicide prevention programme. This cluster comprises 30 countries, including Austria.
Countries in cluster two have some degree of political support for the introduction of suicide prevention programmes akin to SUPRA. Ensuring that the population is favourable to take part in these initiatives and that the resources allocated to prevention policies are sufficient might favour the transferring SUPRA. The existence of other suicide prevention policies might also improve transferability for this cluster. This group includes 10 countries.
Countries in cluster three meet economic conditions supportive of SUPRA. Considering the circumstances pertaining the rest of the dimensions would be necessary to ensure that SUPRA is transferrable for this cluster. This group includes three countries.
For further details on the methodological approach used, please refer to Annex A. Figure 8.2 presents a graphical representation of clusters, and Table 8.5 a list of countries per cluster.
Note: Bar charts show percentage difference between cluster mean and dataset mean, for each indicator.
Source: OECD analysis.
New indicators to assess transferability
Data from publicly available datasets alone is not ideal to assess the transferability of SUPRA. Box 8.2 outlines several new indicators policymakers could consider before transferring SUPRA.
In addition to the indicators within the transferability assessment, policymakers are encouraged to collect and consider information for the following indicators:
Population context
What is the level of mental health literacy within the population (e.g. awareness and attitudes) especially about suicidality?
What are the main barriers to access to mental health care services?
Sector specific context
Which actions for suicide prevention are already in place?
Is a gatekeeper programme in place to train front-line workers to listen to people at risk of suicide and provide essential assistance?
Is there a programme for social-emotional skills training in education?
Political context
Is there regulation on access to means of suicide, including safeguarding hotspots, and restricting access to firearms and potentially lethal medications?
Have these interventions received political support from key decision makers?
Have these interventions received financial commitment from key decision makers?
Economic context
Are there dedicated funding packages or budget for suicide prevention?
SUPRA is a national strategy for suicide prevention. It is composed by 70 actions to tackle risk factors for suicide and introduce protective factors. This case study highlights gatekeeper programmes, safeguarding hotspots for suicide attempts, and reducing access to means of suicide as promising components of SUPRA that can be integrated in other national suicide prevention strategies.
The components of SUPRA are highly effective to reduce suicide rates. Safeguarding suicide hotspots and reducing access to means of suicide are two components of SUPRA having the largest impact on suicide prevention. A systematic review on interventions to reduce suicides at hotspots suggests that physically safeguarding hotspots is associated with a reduction in the incidence rate of suicide by approximately 93%. Restricting access to lethal doses of medication was associated with a 22% reduction in suicides compared to rates before restriction policies were introduced. Safeguarding hotspots has been associated positive returns on investment. SUPRA does not yet have cost-effectiveness assessments of the programme altogether or of its components.
Suicide disproportionately affects disadvantaged social groups; the multilevel structure of SUPRA addresses inequalities. SUPRA actions target both the general public, minorities (such as the unemployed and other people at disadvantage), people showing suicidal behaviours, and those directly in contact with them. This structure is likely to have a positive effect in reaching the groups most affected by suicidality and reducing inequalities.
SUPRA would benefit from a stronger monitoring and evaluation framework. Specifically, to enhance its evidence‑base, SUPRA should systematically collect data on the effectiveness, costs, and uptake of individual programme actions, and on intermediate outcomes, such as changes in awareness, attitude, stigma, and access to treatment. To enhance equity impacts, monitoring the programme uptake by specific population groups would be essential.
SUPRA is highly transferable to 30 OECD and EU countries and intermediately transferable to 10 other countries. The transferability analysis using clustering suggests that SUPRA can be readily transferred to 70% of countries, which were included in the cluster of highest transferability. Besides, 23% of countries were included in the cluster of intermediate transferability. However, all countries can engage in suicide prevention adapting actions and strategies to their specific needs, resources, and contexts. Box 8.3 outlines next steps for policymakers and funding agencies.
Next steps for policymakers and funding agencies to enhance the impact of SUPRA:
Develop and implement a comprehensive monitoring and evaluation framework for SUPRA.
Carry out cost-effectiveness assessments of individual actions within SUPRA.
Disseminate results of impact and cost-effectiveness assessment among the broader public, funders, decision makers and other key stakeholders.
References
[26] Arensman, E. et al. (2010), “Intermediate outcome criteria and evaluation of suicide prevention programmes: a review”, Injury Prevention, Vol. 16/Suppl 1, p. A234, https://doi.org/10.1136/ip.2010.029215.835.
[19] Bandara, P. et al. (2022), “Cost-effectiveness of Installing Barriers at Bridge and Cliff Sites for Suicide Prevention in Australia”, JAMA Network Open, Vol. 5/4, p. e226019, https://doi.org/10.1001/jamanetworkopen.2022.6019.
[14] Barber, C. and M. Miller (2014), “Reducing a Suicidal Person’s Access to Lethal Means of Suicide”, American Journal of Preventive Medicine, Vol. 47/3, pp. S264-S272, https://doi.org/10.1016/j.amepre.2014.05.028.
[2] BMSGPK (2023), Suizid und Suizidprävention in Österreich Bericht 2023, https://www.sozialministerium.at/dam/jcr:802889bf-4033-4280-ac4e-6ad2ef02eda5/Suizidbericht_2023.pdf (accessed on 17 January 2024).
[1] BMSGPK (2019), Suizid und Suizidprävention in Österreich Berich 2019.
[25] Chang, S. et al. (2013), “Impact of 2008 global economic crisis on suicide: time trend study in 54 countries”, BMJ, Vol. 347/sep17 1, pp. f5239-f5239, https://doi.org/10.1136/bmj.f5239.
[13] Cox, G. et al. (2013), “Interventions to reduce suicides at suicide hotspots: a systematic review”, BMC Public Health, Vol. 13/1, p. 214, https://doi.org/10.1186/1471-2458-13-214.
[28] Eurostat (2022), Self-reported consultations of mental healthcare or rehabilitative care professionals by sex, age and educational attainment level, https://doi.org/10.2908/HLTH_EHIS_AM6E (accessed on 7 April 2024).
[3] Grabenhofer-Eggerth, A. et al. (2022), SUPRA Handbook: an experience-based document for implementing a national suicide prevention program.
[9] Hawgood, J. et al. (2022), “Gatekeeper Training and Minimum Standards of Competency”, Crisis, Vol. 43/6, pp. 516-522, https://doi.org/10.1027/0227-5910/a000794.
[16] Hawton, K. et al. (2004), “UK legislation on analgesic packs: before and after study of long term effect on poisonings”, BMJ, Vol. 329/7474, p. 1076, https://doi.org/10.1136/bmj.38253.572581.7c.
[29] IHME (2017), Global Burden of Disease Study 2015 (GBD 2015) Healthcare Access and Quality Index Based on Amenable Mortality 1990–2015, https://ghdx.healthdata.org/record/ihme-data/gbd-2015-healthcare-access-and-quality-index-1990-2015 (accessed on 7 April 2024).
[27] JA-ImpleMENTAL (2023), Country Profiles: Suicide Prevention, https://web.archive.org/web/20240228132005/https://ja-implemental.eu/country-profiles/ (accessed on 18 March 2024).
[5] Kabir, H., S. Wayland and M. Maple (2023), “Qualitative research in suicidology: a systematic review of the literature of low-and middle-income countries”, BMC public health, Vol. 23/1, p. 918, https://doi.org/10.1186/S12889-023-15767-9.
[15] Kivisto, A. et al. (2021), “Adolescent Suicide, Household Firearm Ownership, and the Effects of Child Access Prevention Laws”, Journal of the American Academy of Child & Adolescent Psychiatry, Vol. 60/9, pp. 1096-1104, https://doi.org/10.1016/j.jaac.2020.08.442.
[20] Lee, Y. et al. (2021), “The cost-effectiveness of banning highly hazardous pesticides to prevent suicides due to pesticide self-ingestion across 14 countries: an economic modelling study”, The Lancet Global Health, Vol. 9/3, pp. e291-e300, https://doi.org/10.1016/s2214-109x(20)30493-9.
[24] Lewitzka, U. et al. (2019), “Are national suicide prevention programs effective? A comparison of 4 verum and 4 control countries over 30 years”, BMC Psychiatry, Vol. 19/1, https://doi.org/10.1186/s12888-019-2147-y.
[6] O’Connor, R. et al. (2023), “Gone Too Soon: priorities for action to prevent premature mortality associated with mental illness and mental distress”, The lancet. Psychiatry, Vol. 10/6, pp. 452-464, https://doi.org/10.1016/S2215-0366(23)00058-5.
[34] OECD (2022), OECD Data Explorer - Prevention spending as a percentage of current health expenditure, http://data-explorer.oecd.org/s/1nl (accessed on 11 April 2025).
[33] OECD/WHO Regional Office for Europe (2023), Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes that support suicide prevention.
[31] OECD/WHO Regional Office for Europe (2023), Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes to improve mental health awareness and literacy.
[32] OECD/WHO Regional Office for Europe (2023), Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes to support mental health in educational settings.
[30] OECD/WHO Regional Office for Europe (2023), Mental Health Systems Capacity Questionnaire 2023 - Strategy or action plan that guide implementation of the mental health policy.
[8] ÖGS (2018), Stellungnahme der “Österreichischen Gesellschaft für Suizid prävention” (ÖGS) ad Novelle Waffengesetz, https://web.archive.org/web/20240117100526/https://www.parlament.gv.at/dokument/XXVI/SNME/3127/imfname_717742.pdf (accessed on 17 January 2024).
[17] Owens, D., J. Horrocks and A. House (2002), “Fatal and non-fatal repetition of self-harm”, British Journal of Psychiatry, Vol. 181/3, pp. 193-199, https://doi.org/10.1192/bjp.181.3.193.
[18] Patel, V. (ed.) (2021), “Cost-effectiveness evidence of mental health prevention and promotion interventions: A systematic review of economic evaluations”, PLOS Medicine, Vol. 18/5, p. e1003606, https://doi.org/10.1371/journal.pmed.1003606.
[11] Pirkis, J. et al. (2015), “Interventions to reduce suicides at suicide hotspots: a systematic review and meta-analysis”, The Lancet Psychiatry, Vol. 2/11, pp. 994-1001, https://doi.org/10.1016/S2215-0366(15)00266-7.
[7] Plöderl, M. et al. (2023), “Effects of gatekeeper trainings from the Austrian national suicide prevention program.”, Frontiers in psychiatry, Vol. 14, p. 1118319, https://doi.org/10.3389/fpsyt.2023.1118319.
[12] Seedat, S. (ed.) (2017), “Comparing Different Suicide Prevention Measures at Bridges and Buildings: Lessons We Have Learned from a National Survey in Switzerland”, PLOS ONE, Vol. 12/1, p. e0169625, https://doi.org/10.1371/journal.pone.0169625.
[22] Sher, L. (2021), “Gender differences in suicidal behavior”, QJM: An International Journal of Medicine, Vol. 115/1, pp. 59-60, https://doi.org/10.1093/qjmed/hcab131.
[21] Vasiliadis, H., A. Lesage and M. Seguin (2015), “Implementing Suicide Prevention Programs: Costs and Potential Life Years Saved in Canada”, The journal of mental health policy and economics, Vol. 28/3, pp. 147-155.
[4] WHO (2021), LIVE LIFE: An implementation guide for suicide prevention in countries., https://www.who.int/publications/i/item/9789240026629 (accessed on 19 January 2024).
[23] World Health Organization (2014), Preventing suicide: A global imperative, World Health Organization, https://www.who.int/publications/i/item/9789241564779 (accessed on 16 May 2023).
[10] Yonemoto, N. et al. (2019), “Gatekeeper training for suicidal behaviors: A systematic review”, Journal of Affective Disorders, Vol. 246, pp. 506-514, https://doi.org/10.1016/j.jad.2018.12.052.
← 1. Age‑ and sex-standardised rate.