Barriers and Facilitators to Implementing the Community-Based 4-Level Approach for Depression and Suicide Prevention in the Bundeswehr: A Qualitative Study with Military General Practitioners

BackgroundDepression remains a critical mental health issue in military contexts, where timely recognition and appropriate treatment are essential. Military general practitioners (GPs) in the Bundeswehr (German Armed Forces) serve as primary gatekeepers for mental health concerns. To strengthen depression management and suicide prevention, the community-based 4-level approach was adapted to the Bundeswehr context and implemented at eight military garrisons. This study explores military GPs’ perspectives on barriers and facilitators influencing the implementation of the 4-level approach.MethodsSemistructured interviews were conducted with 17 military GPs across eight intervention garrisons, following a 4-hour training on depression recognition, treatment, and the use of digital tools. The interviews were based on the theoretical domains framework (TDF), combining deductive coding and inductive belief statement synthesis. Intercoder reliability was high (Cohen’s kappa = 0.96).ResultsEleven of fourteen TDF domains were relevant for implementation. The most significant domain was social influence, particularly concerning the stigma surrounding mental illness. Other key domains included environmental context and resources and professional identity. The key facilitators were a perceived reduction in stigma, active involvement of commanding officers, high clinical relevance of depression and a strong intention to apply the intervention content. The key barriers included persistent stigmatization, time constraints, work-related causes of depression and the variability in perceived relevance of depression across units. ConclusionImplementation of the 4-level approach within the Bundeswehr is shaped by organizational, cultural, and contextual factors. Persistent stigma, high workload, and military-specific stressors impede effective implementation, whereas leadership engagement and the perceived clinical relevance of depression facilitate it. Despite training, some GPs appeared to hold a simplified view of the development of depression, which highlights the need for more tailored training to address misconceptions about depression and to improve diagnostic accuracy. Digital tools are seen as very useful but require better integration into routine clinical practice.