About the Community-Based 4-Level Intervention

• Developed as part of the “Nuremberg Alliance against Depression” in 2002 

• It was shown that suicidal acts can be significantly reduced through the intervention (Hegerl et al., 2008).  

• Continuously refined, culturally adapted, and rolled out all over the world 

• A systematic review by an independent research group (Linskens et al., 2022) identified it as the most promising community-based suicide preventive intervention worldwide 

• Its implementation involves simultaneous activities at 4 levels: 

  • Level 1: Training of general practitioners and other health professionals concerning diagnosis and treatment of depression and suicidality.

  • Level 2: Addressing the general public via a depression awareness campaign with posters, cinema spots, information leaflets, brochures, public events and online offers. Key messages are: Depression is a real disease; Depression can affect anyone; Depression has many faces; Depression can be treated.

  • Level 3: Training of community facilitators and stakeholders, including educational workshops concerning recognition and handling of depression and suicide risk. Trainings are tailored to various target groups, including: carers, teachers, priests, pharmacists, police and journalists.

  • Level 4: Information, psychoeducation and support of self-help for patients with depression, high-risk groups and their relatives.

How to start?

Implementation of the Community-Based 4-Level Intervention is supported by the EAAD's coordination centre, offering a step-by-step implementation guide (“cook book”) and a catalogue of intervention and evaluation materials. Many materials have already been translated into various languages. For information on starting a regional alliance, please contact the coordination center.

Awards & Recognitions

• Voted “Best Practice” by EU Member States at a European Commission Joint Research Centre event (2019) 

• Identified as European good practice in mental health by the EU-Compass for Action on Mental Health and Wellbeing (European Commission, 2016) 

• Selected as a best practice example by the WHO (WHO, 2014) 

• First winner of the European Health Forum Award (2007) for the 4-Level Intervention 

• Selected as a best practice example by the EU (European Commission, 2005)

Publications

Below is a collection of research and publications related to the Community-Based 4-Level Intervention. These resources provide valuable insights into the approach’s effectiveness in improving depression care and preventing suicidal behavior across various European regions. Explore the listed publications for further information and evidence:

1. Hegerl, U. (2020). Practical lessons learnt from the worldwide implementation of 115 community-based interventions for suicidal prevention. European Journal of Public Health, 30(Supplement_5), ckaa165.1219. https://doi.org/10.1093/eurpub/ckaa165.1219

2. Hegerl, U., Heinz, I., O’Connor, A., & Reich, H. (2021). The 4-level approach: Prevention of suicidal behaviour through community-based intervention. Frontiers in Psychiatry, 12, 760491. https://doi.org/10.3389/fpsyt.2021.760491

3. Hegerl, U., Maxwell, M., Harris, F., Koburger, N., Mergl, R., Székely, A., Arensman, E., Van Audenhove, C., Larkin, C., Toth, M. D., Quintão, S., Värnik, A., Genz, A., Sarchiapone, M., McDaid, D., Schmidtke, A., Purebl, G., Coyne, J. C., & Gusmão, R. (2019). Prevention of suicidal behaviour: Results of a controlled community-based intervention study in four European countries. PLOS ONE, 14(11), e0224602. https://doi.org/10.1371/journal.pone.0224602

4. Hegerl, U., Rummel-Kluge, C., Värnik, A., Arensman, E., & Koburger, N. (2013). Alliances against depression: A community-based approach to target depression and to prevent suicidal behaviour. Neuroscience & Biobehavioral Reviews, 37(10 Pt 1), 2404–2409. https://doi.org/10.1016/j.neubiorev.2013.02.009

5. Linskens, E. J., Venables, N. C., Gustavson, A. M., Sayer, N. A., Murdoch, M., MacDonald, R., Ullman, K. E., McKenzie, L. G., Wilt, T. J., & Sultan, S. (2023). Population- and community-based interventions to prevent suicide. Crisis, 44(4), 330–340. https://doi.org/10.1027/0227-5910/a000873

6. Schnitzspahn, K. M., & Hegerl, U. (2024). The 4-level approach: A community-based intervention targeting depression and suicidal behaviour. Mental Health and Prevention, 34, 1–4. https://doi.org/10.1016/j.mhp.2024.200329

7. Schnitzspahn, K., Abdulla, K., Arensman, E., Van Audenhove, C., Mere, R., Pérez Sola, V., Sisask, M., Székely, A., Toczyski, P., & Hegerl, U. (2025). Community-based 4-level intervention targeting depression and suicidal behavior in Europe: Protocol for an implementation project. JMIR Research Protocols, 14, e64218. https://doi.org/10.2196/64218