This chapter covers the case study of VigilanS, a suicide reiteration prevention programme in France. The case study includes an assessment of VigilanS 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: VigilanS is a suicide reiteration prevention programme implemented at the national scale in France. It consists of post-hospital monitoring of individuals who have made a suicide attempt. The overall objective of VigilanS is to prevent suicide attempt repetition by maintaining contact with patients and improving care co‑ordination in outpatient healthcare services after hospital discharge, thereby reducing the risk of relapse. The initial duration of the programme is six months, but the patient can be reintegrated for a further six months if the need arises.
Best practice assessment:
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Criteria |
Assessment |
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Effectiveness |
VigilanS reduces the risk of suicide attempt repetition by 24% within a year. It has also shown to improve healthcare co‑ordination and raise awareness on suicide. By reducing the risk of suicide attempt repetition, an estimated 17 700 disability-adjusted life years (DALYs) will be gained from VigilanS by 2050 in France. Overall, self-harm cases are estimated to fall by about 13 100 between 2025 and 2050. Transferring VigilanS to OECD and EU27 countries is estimated to result in 1.42 and 1.37 DALYs gained per 100 000 people, respectively. |
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Efficiency |
When transferred to OECD and EU27 countries, VigilanS will result in no health expenditure savings in 26 countries and statistically significant savings in 17 countries. VigilanS would be cost-effective in nearly all countries. The reduction in self-harm resulting from VigilanS has, in turn, an impact on labour market participation and productivity, equivalent to a gain of 1.32 and 1.13 full-time equivalent workers per 100 000 working age people per year on average in OECD and EU27 countries. |
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Equity |
VigilanS focusses on a mentally vulnerable population, targeting all patients who are discharged from hospital after a suicide attempt and who are willing to participate in the programme. VigilanS is free of charge for the user. |
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Evidence‑base |
The quality of evidence used for this case study is “strong” in areas related to data collection methods and confounders, and moderate for study design and selection bias. |
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Extent of coverage |
Currently, VigilanS reaches approximately 46% of patients discharged from hospital following a suicide attempt, in France. |
Enhancement options: To enhance the effectiveness, patient outreach and support can be improved by enhancing follow-up, reducing delays, increasing availability and tailoring support to patient needs. Developing training for general practitioners and establishing healthcare networks to improve patient care co‑ordination would improve quality of care. To enhance equity and to enhance the evidence‑base, it is necessary to measure the impact of the programme on the vulnerable populations that are at higher risk of suicide behaviour. To enhance the extent of coverage, it is essential to tailor support for vulnerable groups and prioritise implementation in regions with highest rates of suicide attempts.
Transferability: VigilanS is broadly transferable to other settings within OECD and European countries. For example, it is likely that interventions to prevent suicide attempt repetition will receive political support due to existing policies and programmes on suicide prevention.
Conclusion: VigilanS is a best practice and transferable intervention with the potential to significantly reduce the number of suicide attempt repetitions.
VigilanS is a suicide reiteration prevention programme. It focusses on a mentally vulnerable population, targeting hospitalised patients who have attempted suicide. The programme aims to maintain contact with patients after hospital discharge and to ensure appropriate follow-up with outpatient health services (Box 6.1). Based in France, VigilanS was implemented in 2015 in one region, before being scaled up nationally. Today, VigilanS operates in 32 centres throughout the country. These centres have established partnerships with numerous hospitals, specifically hospital emergency, psychiatric and medicine‑surgery-obstetrics departments (Broussouloux S., 2019[1]).
Suicide represents a worldwide public health concern. Each year, more than 700 000 people die by suicide worldwide (World Health Organization, 2021[2]). With one in every 100 deaths being the result of suicide, it remains the fourth leading cause of death in the 15‑ to 29‑year‑olds. In 2020, the average suicide rate across OECD countries was 11.3 deaths per 100 000 population (OECD, 2023[3]). In France alone, nearly 10 000 deaths by suicide and 200 000 suicide attempts were reported in 2020, representing almost 28 deaths and 550 attempts per day (Direction générale de la santé, 2023[4]). Though numbers have been decreasing within the last decade in the European Union, the number of suicide attempts has slightly increased since the start of the COVID‑19 pandemic. Direct and indirect costs related to suicide in France were estimated to add up to nearly EUR 10 billion per year, of which 1.1 billion are directly related to medical costs (Direction générale de la santé, 2023[4]).
The likelihood of individuals who have previously attempted suicide, without resulting in death, and reiterating a suicide attempt is significant. A meta‑analysis found that one in five suicide attempt survivors go on to engage in a subsequent attempt (De la Torre-Luque et al., 2023[5]). The risk of suicide attempt repetition is particularly high within the first six months following the attempt – with three in four attempt repetitions happening within this timeframe (Direction générale de la santé, 2023[4]). In addition, limited access to care and inadequate care continuity are identified as problems in patients who made suicide attempts. Potential reasons include psychosocial barriers, such as low perception of the need for treatment and diverse attitudes towards seeking assistance (Bruffaerts et al., 2011[6]). This evidence highlights the importance of timely intervention and appropriate outpatient health services after hospital discharge.
VigilanS serves as a contact maintenance and reintegration system into mental health care, for a 6‑month duration (Broussouloux S., 2023[7]). The procedure for contact maintenance goes as follows:
On the first day – All patients released from the hospital emergency department or inpatient care following a suicide attempt and with up to three suicide attempts, receive a resource card with information relative to the programme, including dial information for support. Both the patient’s general practitioner (GP) and referring psychiatrist are then informed of their patient’s entry into the programme.
Between day 10 and day 20 – Recruited patients receive a first phone call from the VigilanS team during this period. If they are not reachable, the team sends a postcard to the patient’s postal address once a month for a duration of up to four months. The VigilanS team may also decide to reschedule one or multiple phone calls if deemed necessary. Should the patients experience a suicidal crisis, they are redirected towards an emergency consultation. Patients with first-time suicide attempt are not contacted in the first days after hospital discharge, but six months after discharge (see next section).
At six months – Both individuals with first-time suicide attempt and those with repeated suicide attempts receive a phone call by the VigilanS team, six months after inclusion. To optimise phone call attendance, patients receive appointment notifications via SMS or mail before the call. If the patient’s mental state has improved, they are discharged from the programme. However, if further support is considered necessary or if a patient makes another suicide attempt, they remain in the programme for an additional six months.
A VigilanS team consists of both a co‑ordination and an operational team. The co‑ordination team (typically including a medical co‑ordinator, an administrative assistant and a nurse) assures tasks of medical co‑ordination, secretarial duties and establishing partnerships with establishments to enroll patients. The operational team consists of Vigilansors.
The Vigilansors are health professionals (e.g. nurses or psychologists) who ensure that contact is maintained and care co‑ordination after hospital discharge is optimised. Vigilansors make phone calls to the patient, assess the patient’s well-being, suicidal tendencies and risks (see Box 6.2), and provide guidance and support as needed. Vigilansors also take care of emailing personalised postcards to patients who are difficult to contact, particularly after three unanswered calls. Postcards are usually sent after one to five months following hospital discharge, depending on the patient’s profile. Vigilansors may however take the initiative to send a postcard on top of the planned follow-up calls or at the end of a patient’s monitoring period – after six months. The Vigilansors also establish links between healthcare, social and educational networks to improve the patient’s healthcare pathway (Broussouloux S., 2019[1]).
The VigilanS programme uses two assessment tools to measure suicidal risk and ideation. These are the Columbia-Suicide Severity Rating Scale (C-SSRS) scale and the Mini International Neuropsychiatric Interview (MINI). These tools consist of short and simple questionnaires that can be administered to patients to evaluate suicidal ideation and behaviour. These tools pose questions on suicidal thoughts, preparation and intensity of suicidal ideation, as well as on clinical status and treatment history.
Both tools were used during the follow-up phone calls carried out by Vigilansors at 10 to 20 days and six months after the first suicide attempt, in both first-time suicide attempters and repeat attempters.
Regular communication is ensured between the VigilanS team and the patient’s healthcare professionals. After each phone call, a report is sent to the patient’s GP and referring psychiatrist. If there are concerns about the patient’s increased risk of suicide, Vigilansors can refer the patient back to their GP for further care and can reintegrate them into the monitoring system for another six months, to avoid any detrimental disruption of care. The monitoring process can be adapted to tailor the patient’s needs.
This section analyses VigilanS against the five criteria within OECD’s Best Practice Identification Framework – Effectiveness, Efficiency, Equity, Evidence‑base and Extent of coverage (see Box 6.3 for a high-level assessment). Further details on the OECD Framework can be found in Annex A.
Effectiveness
VigilanS has shown to reduce the number of suicide attempt repetitions by 24% within a year.
The intervention has also shown to improve healthcare co‑ordination and raise awareness on suicide.
By reducing the risk of suicide attempt repetition, an estimated 17 700 disability-adjusted life years (DALYs) will be gained from VigilanS by 2050 in France. Overall, self-harm cases are estimated to fall by about 13 100 between 2025 and 2050.
Transferring VigilanS to OECD and EU27 countries is estimated to result in 1.42 and 1.37 DALYs gained per 100 000 people, respectively.
Efficiency
When transferred to OECD and EU27 countries, VigilanS will result in no health expenditure savings in 26 countries and statistically significant savings in 17 countries. VigilanS would be cost-effective in nearly all countries.
The reduction in self-harm resulting from VigilanS has, in turn, an impact on labour market participation and productivity, equivalent to a gain of 1.32 and 1.13 full-time equivalent workers per 100 000 working-age people per year on average in OECD and EU27 countries.
Equity
VigilanS focusses on a mentally vulnerable population, targeting all patients who are discharged from hospital after a suicide attempt and who are willing to participate in the programme. VigilanS is provided to the user free of cost.
Evidence‑base
VigilanS was evaluated using a non-randomised observational study, with a matched control group.
The study used to evaluate VigilanS had a strong assessment in the domain of “Data collection methods” and “Confounders”, moderate in “Study design” and “Selection bias”, and weak in “Blinding”. The overall quality assessment of the study was considered as moderate.
Extent of coverage
It is estimated that currently, VigilanS reaches approximately 46% of patients discharged from hospital following a suicide attempt, in France.
Effectiveness
VigilanS is a promising intervention for reducing the number of suicide attempt repetition and deaths by suicide
A study of the intervention’s effectiveness across six VigilanS centres from 2015 to 2017, has included a total of 23 146 patients, of which half received the intervention. This study shows a decrease in suicide attempt repetitions and deaths by suicide among patients in the intervention group compared to controls (patients who did not receive the intervention) (Broussouloux S., 2023[7]). Within the 12‑month follow-up, nearly 28% of participants in the intervention group had repeated a suicide attempt, compared to 43% in the control group (Table 6.1). In light of the interviews conducted with the study’s authors, the incidence risk ratio for suicide attempt reiteration has been reported as 0.76 [0.71‑0.81]. This means that patients receiving VigilanS have a 24% reduction in the number of suicidal attempt repetitions compared to those who did not receive the intervention. Regarding death by suicide, the event occurred in 0.53% of participants in the intervention group, compared to 0.67% in the control group during the 12‑month follow-up (Table 6.1).
Source: Adapted from Broussouloux et al. (2023[7]), “Évaluation d’efficacité de VigilanS de 2015 à 2017, dispositif de prévention de la réitération suicidaire“, https://www.santepubliquefrance.fr/maladies-et-traumatismes/sante-mentale/suicides-et-tentatives-de-suicide/documents/enquetes-etudes/evaluation-d-efficacite-de-vigilans-de-2015-a-2017-dispositif-de-prevention-de-la-reiteration-suicidaire.
VigilanS also improves care coordination after hospital discharge and raises awareness about mental health and suicide
The programme supports patients in redirecting them to further healthcare, as well as towards the associative and social sectors. Particular attention is paid to patients with a high number of suicide attempts, who are directed to more intensive healthcare pathways.
A qualitative study was conducted in five French regions between 2016 and 2018, based on surveys within VigilanS teams, as well as on-site visits, focus groups, and documentary analyses (Broussouloux S., 2019[1]). The VigilanS teams perceive the programme as effective in enhancing coordination and post-hospital outpatient care, as well as in improving the patients’ healthcare pathway. This includes helping patients schedule appointments with healthcare professionals, establishing care plans and reviewing conditions for discharge from VigilanS. Vigilansors reported that phone calls allow communication to take place in a more trusted environment, which gives patients a sense of security and improves communication about their health status and well-being. As a consequence, Vigilansors are better able to evaluate risks of suicidal ideation and provide the necessary support.
Overall, the programme was regarded as increasing awareness on suicide and mental health in the regions of its implementation, paving the way for further action on this matter (Broussouloux S., 2019[1]).
The OECD's Strategic Public Health Planning for non-communicable diseases (SPHeP-NCDs) microsimulation model was used to estimate the health and economic impact of expanding VigilanS across France, and across all OECD and non-OECD European countries, assuming that 60% of the target population receives the intervention. Details on the model are in Annex A, while the list of model assumptions are in Annex 6.A at the end of this Chapter.
The rest of this section presents results for France, followed by remaining OECD and non-OECD European countries.
France
The scale-up of VigilanS in France - assuming that 60% of the target population receives the intervention- is estimated to lead to a cumulative total gain of 17 700 disability-adjusted life years (DALYs) by 2050 (Figure 6.1) compared to prior the intervention.
Note: The black lines represent 95% confidence intervals. Figures are discounted at a rate of 3%.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
In gross terms, VigilanS is expected to have the greatest impact on self-harm1 (including suicide). Between 2025 and 2050, the number of self-harm cases is estimated to fall by nearly 13 100 cases. Over the years, the prevalence of certain diseases is expected to increase as suicide-related deaths are avoided.
OECD and EU countries
Transferring VigilanS to OECD and EU27 countries is estimated to result in 1.42 and 1.37 DALYs gained per 100 000 people, on average per year between 2025 and 2050, respectively (ranging from 0.37 in Cyprus to 3.51 in Lithuania) (Figure 6.2). In gross terms, the intervention is estimated to reduce the number of cases of self-harm by nearly 232 540 cases across all countries, between 2025 and 2050. This represents about 1.1% of all cases of self-harm across OECD and EU27 countries.
Note: NS = non-significant. The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
Efficiency
Similar to “Effectiveness”, this section presents results for France followed by remaining OECD and EU27 countries. It presents the potential impact of the intervention on healthcare expenditure and a cost-effectiveness analysis assuming programme costs as reported in Annex 6.A at the end of this Chapter.
France
By reducing the risk of suicide attempt repetition in persons having attempted suicide, VigilanS can reduce healthcare costs (e.g. hospitalisations after a suicide attempt). VigilanS would lead to cumulative health expenditure savings of EUR 0.35 per person by 2044 (Figure 6.3). However, on the long term, as people who received the intervention are less likely to die from suicide, they may develop chronic diseases and consume healthcare, as it is captured by the dynamics of the model (Box 6.4). Therefore, health expenditure savings are offset by the cost of treating future chronic diseases.
Note: The black lines represent 95% confidence intervals. Figures are discounted at a rate of 3%.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
Estimates derived from the OECD SPHeP-NCD model are calculated for the period 2025-2050. In the model, an individual has a certain risk of developing a disease each year. Individuals can develop different categories of diseases such as diabetes, stroke, ischaemic heart disease, cancer, depression, anxiety, dementia, musculo-skeletal disorders (e.g. low back pain, rheumatoid arthritis), chronic obstructive pulmonary diseases, cirrhosis, alcohol dependence, self-harm (e.g. suicide attempts) and injuries.
The model uses a competing event framework. This means that diseases and causes of death compete one against the others to determine the death of an individual. For this reason, people who do not die by suicide due to the intervention may continue to develop other chronic diseases, which represent a cost for the health system.
An analysis reveals that the savings related to self-harm alone are higher than the cost of the intervention. When considering only the costs of self-harm, it is expected that VigilanS will save up to EUR 0.46 per capita per year by 2050. By 2030, more than EUR 0.10 per capita will be saved in France (Figure 6.4). On average, this amounts EUR 0.07 per capita per year over the period 2025-2030, which is higher than the intervention cost (estimated at EUR 0.05 per capita).
Note: The black lines represent 95% confidence intervals. Figures are discounted at a rate of 3%.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
OECD and EU countries
It is estimated that transferring VigilanS to the 43 OECD and EU27 countries would result in no health expenditure savings in 26 countries since health expenditure savings are offset by the cost of treating future chronic diseases. Yet, health expenditure savings would be statistically significant in 17 countries.
Table 6.2 provides information on intervention costs, total health expenditure savings and the cost per DALY gained in local currency for OECD and EU27 countries. VigilanS is not cost saving in any country, as the reduction in health expenditure related to self-harm is outweighed by increased spending on other diseases (Box 6.4). However, in all countries with the exception of Romania, VigilanS is considered cost-effective with the cost per DALY gained below a cost-effectiveness threshold often applied in European countries (i.e. around EUR 50 000 per DALY based on (Vallejo-Torres et al., 2016[8])).
Note: * Cost per DALY gained is measured using total intervention costs less total health expenditure savings divided by total DALYs gained over the period 2025‑2050. **The impact on health is non-significant. For countries presenting negative values in total health expenditure savings between 2025‑2050, VigilanS leads to an increase in healthcare costs but still remains cost effective. “ns” means non significant.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
The reduction in cases of self-harm resulting from VigilanS has, in turn, an impact on labour market participation and productivity. By reducing self-harm incidence, VigilanS is expected to lead to increases in employment and reductions in absenteeism, presenteeism, and early retirement. Converting these labour market outputs into full-time equivalent (FTE) workers, it is estimated that OECD and EU27 countries will gain 1.32 and 1.13 FTE per 100 000 working age people per year between 2025 and 2050 respectively (Figure 6.5). Country variations are mainly explained by the prevalence rates of self-harm across countries and projections of working-age population. In monetary terms, this translates into average per capita increase in labour market production of EUR 0.64 for OECD countries and EUR 0.44 for EU27 countries (Figure 6.5).
Note: The black lines represent 95% confidence intervals.
Source: OECD analyses based on the OECD SPHeP-NCDs model, 2025.
Equity
VigilanS focusses on a mentally vulnerable population, targeting all patients who are discharged from hospital after a suicide attempt and who are willing to participate in the programme. VigilanS has created partnerships with public hospitals nationwide (32 hospitals, to date). The programme is accessible to the entire population without any cost, ensuring fair and equitable access. Inclusion in the programme requires patient’s consent. Patients with more than three suicide attempts are, however, excluded from the programme, as their specific needs require a higher level of care. The effectiveness study found equal effectiveness of the intervention for men and women (Broussouloux S., 2023[7]). The same study found no statistical differences between the effect on individuals who received a first phone call six months after hospital discharge (those with a first suicide attempt) and those who received a first call within three weeks (those with a history of suicide attempts).
Communication with patients is conducted by telephone and postcards, which may present limitations for patients who are difficult to reach by phone, speak a foreign language, or do not have a permanent postal address.
Evidence‑based
The evidence on VigilanS effectiveness and efficiency is collected from an observational and retrospective study, including 11 573 participants who have received the intervention, matched with 11 573 patients who did not received the intervention (for a total of 23 146 observations) (Broussouloux S., 2023[7]). This study uses medical records from VigilanS and hospital medical-administrative databases for patient data.
The Quality Assessment Tool for Quantitative Studies assesses the quality of evidence as strong in the domain of “Data collection methods” and “Confounders”, moderate in “Study design” and “Selection bias”, and weak in “Blinding” (see the table below) (Effective Public Health Practice Project, 1998[9]). The overall quality assessment of the study was considered as moderate.
Source: Effective Public Health Practice Project (1998), “Quality assessment tool for quantitative studies”, https://www.nccmt.ca/knowledge-repositories/search/14; Broussouloux et al. (2023[7]), “Évaluation d’efficacité de VigilanS de 2015 à 2017, dispositif de prévention de la réitération suicidaire”.
Extent of coverage
In 2023, about 35 200 patients received the VigilanS programme, which was implemented across all regions of continental France and in certain overseas territories. As a matter of comparison, it is estimated in 2023 that there was a total of 200 000 suicide attempts in France (Direction Générale de la Santé, 2023[10]).
However, the size of the target group for the intervention (individuals who are hospitalised after a suicide attempt) is unclear. An analysis of hospital data showed that about 76 000 people were admitted to medical, surgical and emergency departments after a suicide attempt in 2022 (Infosuicide, n.d.[11]). However, this estimate does not take into account patients who went to the emergency department after a suicide attempt but were not admitted, or those who were admitted to a psychiatric ward, who would be eligible for VigilanS and enrolled in the programme. This estimate also does not take into account for the possibility that individuals may have been hospitalised several times following suicide attempts within a year. Despite these limitations, and assuming the target group comprises 76 000 people in France, the programme is estimated to cover 46% of the target population.
All individuals discharged from a hospital after a suicide attempt were included in the programme, regardless of age, gender or other socio-economic factors. However, the patient’s consent is required to be included in the programme. In addition, the programme does not include patients with more than three suicide attempts, as their specific needs require a higher level of care (Broussouloux S., 2019[1]).
Enhancing effectiveness
Increasing the frequency of phone calls and shortening the delay between hospital discharge and the initial follow-up call for patients with first-time suicide attempt are likely to improve the effectiveness of VigilanS. Allowing for more frequent phone calls with patients would permit to increase surveillance and improve the support to patients. Additionally, minimising the delay between hospital discharge and the initial follow-up may improve results in terms of suicide attempt repetition. In the VigilanS programme, patients with first-time suicide attempt receive their first phone call six months after hospital discharge. However, this timeframe may be too lengthy, particularly if the patient does not actively seek care on their own (Broussouloux S., 2019[1]). As the risk of suicide attempt repetition is particularly high in the first six months after an initial attempt, research suggests that effective outpatient follow-up care during this period is crucial to reduce the risk of a repeated suicide attempt (Inagaki et al., 2019[12]). Further research is needed to evaluate the call frequency and timeframe to optimise the effectiveness (and the efficiency) of preventive suicide monitoring.
Increasing the availability of services by extending operating hours of the Vigilansors team may increase patient reach and support. The existing operating hours for VigilanS telephone support are limited to a restricted timeframe on weekdays (Broussouloux S., 2019[1]). This constraint imposes limitations on the accessibility of the programme’s support services. Extending operational hours or alternatively, complementing the programme with dedicated suicide hotlines, could significantly increase the availability and reach of assistance for patients with suicidal behaviour.
Adapting support to patient’s needs can enhance the programme’s effectiveness across diverse populations. Some patients have greater needs in terms of support and guidance. This concerns patients with a history of repeated suicide attempts or with personality disorders, minors or individuals lacking social support (Broussouloux S., 2019[1]). These patient groups may be at higher risk of repeating a suicide attempt and may require tailored support. Individuals with higher risk of suicide during hospitalisation require follow-up care that are intensive and prompt after hospital discharge (Che, Gwon and Kim, 2023[13]).
Operational adaptations, such as face‑to-face visits, may also need to be considered when approaching population groups for which phone calls may not be optimal, such as minors and elderly patients.
Improving quality of care by developing training and establishing guidelines for GPs in suicide prevention. The VigilanS programme allows GPs to be aware about their patients’ mental status by receiving health reports and communicating with the monitoring team for further insights. These interactions play a crucial role in improving the support and quality of care offered to patients and could be strengthened by providing training and establishing guidelines for GPs on suicide prevention (Carrigan et al., 2003[14]), (Broussouloux S., 2019[1]).
Establishing healthcare networks to facilitate co‑ordination among healthcare professionals and ensure time‑efficient care for patients. Establishing timely and effective co‑ordination between the suicide monitoring team, social services and health and mental health professionals, to co‑ordinate on patient care and follow-up, would contribute to enhancing the quality of care of patients. This has the potential to increase the effectiveness of the programme, particularly when the monitoring team and the co‑ordinating professionals operate from the same premises (Broussouloux S., 2019[1]).
Ensuring sufficient human resources depending on regional needs. To improve co‑ordination and quality of care, programmes like VigilanS must ensure sufficient human resources to overcome time and resource constraints. To ensure this, conducting regular territorial assessments of suicidal attempts is essential to better estimate local needs and allocate sufficient human resources accordingly.
Enhancing efficiency
Policies that boost effectiveness will have a positive impact on efficiency (see Enhancing effectiveness). In addition, VigilanS could enhance its efficiency with the following recommendations:
Improving coverage in increasing patient uptake of the programme in regions where patient uptake is low and through the co‑ordination with primary healthcare services.
Providing patients with the choice of a digital follow-up, as an alternative to postcards.
Adapt the frequency of follow-up based on identified risk markers (e.g. psychiatric comorbidity, recurrence, age).
Enhancing equity
Stratifying patient data to measure the impact of VigilanS on vulnerable populations and priority groups can improve equity impact. Although VigilanS is accessible to all populations without distinction, the programme effectiveness has not been evaluated on different population groups. To enhance VigilanS equity impacts, it would be essential to monitor the programme uptake and outcomes by breaking down the data by different population groups, to the extent permitted by national regulations and authorisations for demographic data collection. Groups of interest are those at higher risk of suicidal ideation, including youth, women, LGBTQ+ individuals, Indigenous communities, individuals with substance abuse disorders, individuals with a history of self-harm, or experiencing financial hardship (e.g. unemployment and housing insecurity) (Mao et al., 2025[15]).
Providing support in multiple languages can improve equity. Language barriers often impede access to healthcare. Addressing this barrier by offering support in the most commonly used languages, can improve inclusivity and coverage of non-native speakers that represent a particularly vulnerable group.
Enhancing the evidence‑base
Improving the programme’s evaluation quality by controlling for variables related to socio-economic factors and outside care. Controlling for a range of confounding factors allows to obtain more robust results and draw less biased conclusions. The study has controlled for a variety of confounders, including year and region of inclusion, sex, age group, date of suicide attempt, hospitalisation motive, and history of suicide attempts. Accounting for further variables such as minority group, socio-economic status and external mental health interventions, would allow to better measure the impact of the programme on different subgroups and would mitigate treatment bias.
Enhancing extent of coverage
A comprehensive and adaptive approach is needed to boost the uptake of VigilanS among individuals with suicidal ideation. VigilanS has expanded its coverage to the national level in France. The programme is available to all patients having been to the hospital after a suicide attempt, without any distinction. Some vulnerable groups may however need adjustments in the support offered by the programme, this concerns, for example, minors, older people, those from minority groups, persons with personality disorders and individuals with history of recurrent suicide attempts (Broussouloux S., 2019[1]). Furthermore, a dedicated support system for patients who have attempted suicide more than three times could provide more frequent check-ins and additional assistance to help access appropriate psychological or psychiatric care.
Efforts to implement post-hospital monitoring and support programmes such as VigilanS, should prioritise regions with the highest rates of suicide attempts. This approach would require making regional assessments of suicidal tendencies and identifying areas with the greatest needs.
This section explores the transferability of VigilanS and is broken into three components: 1) an examination of previous transfers; 2) a transferability assessment using publicly available data; and 3) additional considerations for policymakers interested in transferring VigilanS.
Previous transfers
VigilanS has not yet been transferred to other countries. However, some OECD countries, such as Australia and Spain (Catalonia), have adopted suicide prevention programmes similar to VigilanS, that provide follow-up support after a suicide attempt (Martin et al., 2023[16]; CoDiRISC[17]). Other countries, such as Denmark, Finland and Norway have implemented specialised outpatient programmes for individuals having attempted suicide (e.g. psychosocial therapy) (Nordic Council of Ministers[18]).
Transferability assessment
This section outlines the methodological framework to assess transferability followed by analysis results.
Methodological framework
A few indicators to assess the transferability of VigilanS were identified (see Table 6.4). Indicators were drawn from international databases and surveys to maximise coverage across OECD and non-OECD European countries. Please note, the assessment is intentionally high level given the availability of public data covering OECD and non-OECD European countries.
Results
Results from the transferability assessment using publicly available data are summarised below (see Table 6.5 for results at the country level):
The analysis shows that the number of psychologists in France is similar or lower than in many OECD countries. On average, there are 0.53 and 0.49 psychologists per 1 000 population in OECD and EU countries respectively, while France matches the EU average with 0.49 psychologists per 1 000 population. France however presents a high rate of mental health nurses – nearly 1 per 1 000 population. In comparison, OECD and EU countries have 0.52 and 0.42 mental health nurses for 1 000 inhabitants, respectively.
In terms of access to mental health care, over 7% of the French population reported consulting mental health care or rehabilitative care professionals, compared to around 6% on average across OECD countries. The Healthcare Access and Quality Index demonstrates high results in most countries, ranging over 80 for more than 70% of OECD countries.
The vast majority of countries have national strategies and programmes for suicide prevention (90%) and for guidance in implementing mental health policies (81%), indicating that VigilanS would likely receive political support among potential transfer countries. Most countries also have mental health prevention policies within primary healthcare settings.
Spending on prevention across OECD countries is typically lower than in France (i.e. only 7 of the 43 countries analysed spent more on prevention than France). Given that VigilanS is a preventive intervention, these results may indicate a potential affordability issue in many countries.
A darker shade indicates VigilanS is more suitable for transferral in that particular country
Note: n/a = data was not available. 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 can be found in Table 6.4.
Source: Eurostat (2022[19]), 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); IHME (2017[20]), 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); OECD (2021[21]), A New Benchmark for Mental Health Systems: Tackling the Social and Economic Costs of Mental Ill-Health, https://doi.org/10.1787/4ed890f6-en; OECD/WHO Regional Office for Europe (OECD/WHO Regional Office for Europe, 2023[22]), Mental Health Systems Capacity Questionnaire 2023 - Strategy or action plan that guide implementation of the mental health policy; OECD/WHO Regional Office for Europe (2023[23]), Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes to enable mental health promotion, prevention and treatment of mental health conditions in primary health care; OECD/WHO Regional Office for Europe (2023[25]), Mental Health Systems Capacity Questionnaire 2023 - Policies and programmes that support suicide prevention.
To help consolidate findings from the transferability assessment above, countries have been clustered into one of three groups, based on indicators reported in Table 6.4. 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 clusters are below with further details in Figure 6.6 and Table 6.6:
Countries in cluster one, including France, have populational, sector specific and economic arrangements in place to transfer VigilanS. These countries however may wish to ensure that the intervention aligns with political priorities. Overall, they are less likely to experience issues associated with implementing and operating the programme in their local context. This group includes nine countries.
Countries in cluster two have populational and political arrangements to support VigilanS. Prior to transferring the intervention, however, these countries may wish to consider ensuring that the sector is ready to implement the programme and ensure long-term affordability by increasing spending on prevention. This group includes 21 countries.
Countries in cluster three have political and economic arrangements to transfer VigilanS. These countries may wish to undertake further analysis to ensure the programme can be implemented within the existing healthcare infrastructures. This group includes 12 countries.
Note: Bar charts show percentage difference between cluster mean and dataset mean, for each indicator.
Source: OECD analysis.
Note: Due to high levels of missing data, the following country was omitted from the analysis: Croatia.
Source: OECD analysis.
New indicators to assess transferability
Data from publicly available datasets alone is not ideal to assess the transferability of public health interventions. Box 6.5 outlines several new indicators policymakers could consider before transferring VigilanS.
In addition to the indicators within the transferability assessment, policymakers are encouraged to collect 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 mental health care?
Sector specific context
Do patients already receive psychological support or guidance at hospital discharge following a suicide attempt?
Political context
Are there existing programmes for the prevention of suicide attempt repetition?
Have these interventions received political support from key decision makers?
Have these interventions received financial commitment from key decision makers?
Economic context
Are there any financial schemes in place to support vulnerable population groups in accessing mental health care?
What is the share of healthcare expenditure allocated to mental health prevention programmes?
Is there a dedicated funding budget for suicide prevention?
VigilanS is a national suicide prevention programme based in France targeting individuals having attempted suicide. The purpose of VigilanS is to prevent suicide attempt repetition in individuals discharged from the hospital following a suicide attempt. The programme offers support in maintaining contact with patients and providing guidance for further care.
The support provided by VigilanS has led to reductions in suicidal behaviour. VigilanS has shown to significantly improve patient mental health, in decreasing the number of suicide attempt repetitions by 24%. The intervention is estimated to be cost effective in nearly all countries.
The programme would benefit from enhancing strategies to effectively reach and support vulnerable groups. An assessment of VigilanS’ performance against the best practice criteria highlighted potential areas for improvement. These include, but are not limited to, enhancing outreach efforts and availability for patients, adapting contact maintenance strategies to better support vulnerable and hard-to-reach groups, and addressing barriers in access that exacerbate inequalities.
VigilanS is highly transferable in nine out of 42 EU and OECD countries, and intermediately transferable to an additional 21 of them. The transferability analysis using clustering suggests that this programme can be readily transferred to 21% of countries, which were included in the cluster of highest transferability. However, all countries have the opportunity to implement suicide prevention strategies according to their specific needs, resources and contexts.
Box 6.6 outlines next steps for policymakers and funding agencies.
Next steps for policymakers and funding agencies to enhance VigilanS are listed below:
To improve the overall effectiveness of the programme, consider strategies that aim to improve outreach to vulnerable populations, reduce delay between outreach efforts, provide long-term support and establish healthcare networks to facilitate co‑ordination among healthcare professionals.
To support further data collection such as patient health outcomes associated with VigilanS, along with data monitoring on suicidal behaviour, and assessment of regional needs for suicide prevention. And encourage analyses stratified by population groups (e.g. minors; older people, minority groups, those with history of suicidal behaviour) in order to tailor the programme to vulnerable groups.
References
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VigilanS is expected to reduce the number of suicidal reiterations by 24% in patients receiving the programme, compared to a business-as-usual scenario (IRR (suicidal reiteration) = 0.76 [0.71;0.81], p-value<0.00 001) (Broussouloux S., 2023[7]). To obtain effectiveness results on self-harm across countries, IHME data was used (IHME, 2024[29]). It is assumed that 38% of self-harm cases correspond to suicide attempts (Duarte et al., 2020[27]).
To estimate the impact of the programme on labour market participation, it is assumed that a suicide attempt leads to approximately six months of absenteeism, based on data from Segar et al. (2024) on the average cost of suicide attempt and death by suicide in France, combined with the average annual gross salary in France (Segar et al., 2024[28]).
The costs of self-harm and death included in the model are based on previous analyses (OECD, 2019[30]).
Results from the study show, that the maximum impact on suicide reiteration reduction is observed at six months, with a maintained effect up to 12 months. Based on similar studies, the effect of the intervention is estimated to last up to three years, and then decrease linearly to reach baseline levels at five years (Lahoz, Hvid and Wang, 2016[31]).
For VigilanS, the inclusion criteria are:
Individuals who have been hospitalised following a suicide attempt.
Individuals who have sought emergency services within a hospital following a suicide attempt.
Individuals with over three suicide attempts are excluded from the programme.
The model assumption relies on IHME self-harm data. Not all people will self-harm have a suicide attempts. According to the literature, 38% of people with self-harm have a suicide attempt (Duarte et al., 2020[27]). Also, it is estimated that 61% (100%‑39%) of them have one suicide attempt (Léon, Roscoät and Beck, 2023[32]). Finally, all suicide attempts do not lead to hospitalisation. 58% of suicide attempts lead to hospital of which 89% were hospitalised at least one night (Léon, Roscoät and Beck, 2023[32]). Therefore, in the model, 12% of people with self-harm were estimated to be eligible (target) to the programme (38%*(1‑39%)*58%*89%=12%).
As described in the main text, the programme is estimated to cover 46% of the target population. In the model, it is estimated that the coverage is boosted by a third to reach 60% of the target (national coverage target for VigilanS).
Funding of the VigilanS programme is mainly provided by the regional health agencies (Agences Régionales de Santé) and ranged from EUR 165 000 to EUR 486 000 per region in 2018 (Broussouloux S., 2019[1]). On average, over the six study regions, it is estimated that VigilanS costs EUR 235 per participant per year (Broussouloux S., 2023[7]). Costs related to possible additional consultations with mental health professionals -beyond the support provided within the programme‑ are not included in the programme cost and assumed to be covered by the health system.
← 1. Self-harm is defined as deliberate bodily damage inflicted on oneself resulting in death or injury (Institute for Health Metrics and Evaluation (IHME), 2021[33]).