International and Hungarian studies show that depression is underdiagnosed and undertreated and that this is particularly true for depressed suicide victims. It is reported that more than 50 percent of suicide victims contact their general practitioners (GPs) four weeks before their death, but unfortunately GPs have difficulties in diagnosing depression and initiating adequate treatment.

The main focus of the Kiskunhalas Suicide Prevention Project is training of the region's GPs on the diagnosis and appropriate treatment of depression and the management of suicidal patients. Kiskunhalas is located in southeast Hungary. We selected this region because the suicide rate is almost twice the Hungarian rate, which was 58/100,000 in 2000.

Our hypothesis was, that after the intensive (two-day) training, the number of recognized (and appropriately treated) depressed patients will increase substantially and this will be reflected in the increasing use of antidepressants and in the decreasing suicide mortality in the region served by trained GPs. The results of a comparable study in Gotland (Sweden) suggest that this suicide preventive effect is more pronounced among females.

The first training courses were conducted in October and November of 2000. Comparing the number of completed suicides 2.5 years before and 2.5 years after the training (using January 1, 2001 as the starting date for comparisons), the number of victims in Kiskunhalas region (population approx. 73.000) were 115 (88 males and 27 females) and 94 (78 males and 16 females). This represents a 18.3 percent reduction in the total suicide mortality (minus 11.4 percent for males and minus 40.7 percent for females).

The number of suicide victims in the control region (Kiskunfélegyháza) 2.5 years before and 2.5 year after January 1, 2001 were 68 (52 males and 16 females) and 60 (43 males and 17 females). This means an 11.1 percent decline in the total suicide mortality (17.4 percent decrease in males and 6.2 percent increase among females).

Comparing the number of suicide victims in the whole territory of Hungary (population approx. 10 million) 2 years before and 2 years after January 1, 2000 (1999 plus 2000 versus 2001 plus 2002) the figures are 6,597 (5,013 males and 1,584 females) and 5,822 (4,477 males and 1,345 females). The reduction of total suicide mortality is 11.8 percent (10.7 percent for males and 13.1 percent for females).

In summary the decrease of total suicide mortality after the training was somewhat greater in the Kiskunhalas region (18.3 percent) than in the control region (11.1 percent) and than in the whole territory of Hungary (11.8 percent). In accordance with our hypothesis, female suicide mortality decreased markedly in Kiskunhalas region (40.7 percent), while the decline of the same figure in the whole territory of Hungary was 13,1 percent. Unexpectedly there was a slight increase among female suicide victims in the control region (6.2 percent).

Analyzing the utilization of antidepressants (and the number of drug-treated depressives) showed a 12 percent increase in the whole territory of Hungary from 2000 to 2001, while the same figure was more than double in the region of Kiskunhalas.

The substantially higher decrease in female suicides in region Kiskunhalas than in the whole territory of Hungary (41 percent versus 13 percent) is in accordance with our hypothesis based on the results of the Gotland Study. That study as well as others showed that female depressives more often seek treatment for depression than males.

On the other hand, male depression is frequently masked by alcoholism and aggressive behavior, leading to lower rates of recognition of depression. Since our program focused primarily on recognition and treatment of depression, it is not surprising that the suicide-preventive effect was less obvious in males, whose depression is frequently comorbid with alcohol abuse or dependence.

Namely, in our sample 64.5 percent of the suicide victims (46 patients) had lifetime alcohol dependency/abuse. Most notably 46.5 percent of the whole sample (33 patients) had alcohol dependency. Further, the rate of alcohol- induced mood disorders was 10 percent and alcohol-induced delusional disorders was 8.5 percent in the whole sample.

Analyzing the association of the last physician contact and the demographic characteristics and diagnoses of the suicide victims, we found that men in general and alcoholics were less likely to be seen in their last year of life. Patients with alcohol abuse/dependence and elderly were less likely to be diagnosed and treated with depression.

This region lacks the basic treatment facilities for alcohol-related disorders. Therefore in view of our findings in the following years we will focus more intensively on the problem of alcoholism. We also realized that to maintain the motivation of GPs as well as to further increase their knowledge in the treatment of depression and substance abuse we need follow up training sessions. In addition to the yearly half-a-day meetings, which focus primarily on case discussions, we conduct three-monthly two-hour discussions on selected topics (e.g. treatment of depressed elderly, dual diagnosis patients, etc.).

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