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YOUTH SUICIDE PREVENTION

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Title: YOUTH SUICIDE PREVENTION


1
YOUTH SUICIDE PREVENTION
  • Dr Michael Dudley

2
EPIDEMIOLOGY OF YOUTH SUICIDE IN AUSTRALIA
3
  • For approx. last dozen years, expert reports and
    news stories made Australians aware that they had
    been experiencing rising male youth suicide rates
  • One 1998 report indicated that from 1990-1994,
    Australia had fourth highest recorded male youth
    rate and eighth highest female youth rate in the
    world

4
Male trends since the 1960s
  • Suicide rates for Australian males aged 15-24
    years rose from 9.6/100,000 in 1964-1968 to
    28.6/100,000 in 1994-1998
  • Suicide among young men was not notable 40 years
    ago, but today, suicides among males aged 25-44
    years comprise almost 50 of Australias total
    suicides.
  • They share the highest rates with males over 75
    years.

5
1989-1999 male rates
  • 25-34 year males 32.4/100,000
  • 35-44 year males 27.3/100,000
  • 75 year males 32.0/100,000
  • 15-24 year males fell from 29 to 19 per 100,000
    from 1999 to 2001
  • Suicide below age 15 is very rare, and almost
    unknown below age 12.

6
Female rates
  • Young female rates have stayed fairly steady.
  • The exception is young females in small rural
    towns, where rates rose significantly during the
    period from 1964-1998.

7
Method-specific suicide rates
  • 15-24 year male firearm suicide rates reduced
    from the late 1980s 7.7 (1989-1993) to 4.7
    (1993-1998
  • Male hanging suicides increased 9.3 (1989-1993)
    to 13.5 (1993-1998

8
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9
Suicide attempts
  • For every male suicide there are 30-50 attempts
    and for every female suicide there are 150-300
    attempts.
  • 10 of patients with DSH behaviour likely to
    reattempt within 3 months.

10
Suicidal ideation
  • Up to 25 of young people may have suicidal
    behaviour at any time
  • For most, this may be common and transient
  • For some it is persistent and associated with
    significant psychiatric morbidity

11
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12
Social risk factors
  • Poor educational achievement, low SES
  • Possible cohort effects
  • more parental separations repartnering
  • increasing psychological youth ill-health
  • decline of organised religious observance,
    decline of social bonds
  • consumerist culture that fails to generate hope

13
Social correlates of (non) well-being in the West
  • Emphasis on growth and productivity at all costs
  • Measurement of human worth in monetary terms
  • Pursuit of acquisitive self-interest rather than
    public good
  • Failure of rising income to correlate with
    increasing well-being
  • The erosion of civic time.
  • Individuals conceptualised as independent of
    social relations

14
Mental disorders and suicide the risks
  • Psychological autopsy studies show rates of
    mental disorder gt 90, especially
  • affective disorders
  • substance abuse disorders
  • conduct and antisocial disorders
  • bipolar disorder, (other) psychosis

15
Psychological traits
  • neuroticism (high trait anxiety)
  • hopelessness
  • impulsivity
  • personality disorders (antisocial, borderline)
  • negative cognitive style

16
Childhood adversity family factors
  • Family suicidal behaviour associated with suicide
    attempts and suicide, even after controlling for
    psychopathology
  • Parental discord assoc.with suicide attempt
  • Family violence poor parent care, over-control
    assoc.with suicide attempt suicide
  • Physical and sexual abuse assoc.with suicide
    attempt and ? suicide
  • Divorce only with other family risk factors

17
Odds ratios for mental health, family and social
risk factors (1)
  • Past attempt (18.6)
  • previous psychiatric care (14.3)
  • mood disorders (11.1)
  • substance abuse (6.6)
  • co-morbidity/multiple diagnoses (9.1)
  • low socio-economic status (2.3)
  • poor educational achievement (7.7)
  • childhood abuse (5.7)
  • family history of suicidal behaviour (2.5)

18
Odds ratios for mental health and social risk
factors (2)
  • Odds ratios and PARs for mental health risk
    factors associated with suicide and suicide
    attempts are significantly higher than those for
    a range of social and environmental risk factors,
    but social risk factors may affect a higher
    proportion of the population.

19
Life events
  • Stressful life events in 75 of those dying by
    suicide or making suicide attempts
  • Explanations ?effort after meaning ?confounding
    effects (social disadvantage, psychiatric
    morbidity, family and childhood adversity)
  • Event types interpersonal problems, legal
    problems most common

20
Aboriginal and Torres Strait Islanders
  • Gaps and inconsistencies in reporting
    (significant proportion of indigenous suicides is
    not registered as indigenous)
  • historically very low rates
  • now young male rates double non-Aboriginal,
    community waves esp. in small rural and remote
    areas
  • younger ages, alcohol, clusters, communal grief

21
Rural-metropolitan differences
  • 1964-1968 male 15-24 year rates, metro. 9.8,
    rural towns lt 4,000 4.9/100,000
  • 1994-1998 male 15-24 year rates, metro. 24.9,
    rural towns lt 4,000 53.7/100,000
  • Small towns rates metro areas x 2
  • Reasons 1) resource loss, youth migration
  • 2) more health problems, less services
  • 3) male identity problems? (lack of valued social
    roles, disrupted personal histories)
  • 4) access to firearms

22
SUICIDE PREVENTION
23
What is suicide prevention?
  • Clinical (or related) interventions
  • Population interventions
  • Scientific or social scientific body of research,
    practice and theory
  • Social movement or affirmation of life (cf.
    rational suicide debate - is suicide prevention
    always desirable?)

24
What is suicide prevention?
  • This question is not just about scientific
    evidence, but concerns conviction regarding the
    worth of human life. Suicide prevention involves
    philosophical and existential questions regarding
    what we do.

25
What is suicide prevention?
  • Programs and initiatives range from prevention,
    through early intervention intervention to
    postvention
  • They work directly with target populations, or
    indirectly at a community or system level
  • Outcome measures may be suicidal behaviour or
    mental health other risk factors for suicide

26
Does suicide prevention work?
  • Wilkinson (1994) stated that the reality is that
    there is no convincing evidence that education,
    improved social conditions and support, or better
    training, play a substantive part in preventing
    suicide.
  • Gunnell and Frankel (1994) also concluded that
    no single intervention has been shown in a well
    conducted randomised trial to reduce suicide.

27
Does suicide prevention work?
  • It is hard to demonstrate that it works, since
  • suicide has a very low base rate
  • the absence of a suicide generates no data
  • the sample sizes needed to demonstrate efficacy
    for interventions are dauntingly large.

28
Does suicide prevention work?
  • E.g. 1) to reduce suicide in England and Wales by
    15, one needs to sample 13 million subjects
  • 2) to demonstrate 15 reduction in subsequent
    suicide over 8 years for those attempting, one
    needs to examine 45,000 subjects
  • 3) to demonstrate a 15 reduction in suicide in
    patients 1 year after psychiatric
    hospitalisation, one needs to examine 142,000
    subjects (Gunnell Frankel,1994).

29
Does suicide prevention work?
  • Some suicide prevention programs may not be
    easily amenable to evaluation by traditional
    scientific methods e.g. those that deal with
    community capacity-building or organisational
    change and suicide prevention, and ethical
    questions regarding the place of rational suicide.

30
Health personnel attitudes to suicide prevention
(Morgan, 94)
  • 1/5 did not believe in suicide prevention. They
    thought suicide was
  • a social problem too big for clinical
    intervention, or
  • a private matter, or
  • undetectable because suicidal people often did
    not ask directly for help.
  • Cf also malignant alienation (Morgan and
    Priest, 1991).

31
What treatments work for youth suicidal
behaviour? RCT and other evidence
  • Still considerable uncertainty regarding
    successful interventions for people engaging in
    DSH presenting to ED
  • Research tends to be based on those who attend,
    but fewer than 50 of patients may be referred
    for follow up treatment and of those receiving an
    appointment, up to 75 may not attend.
  • Males dont attend appointments

32
Improving follow-up
  • Extra motivational efforts, continuity of care,
    intensive follow up and domiciliary care have
    been used to improve follow-up
  • Result Adherence improves, but none
    significantly reduce deliberate self harm.

33
Green card
  • It is probably helpful for enhancing adherence
  • There may be a trend towards reducing likelihood
    of repeat DSH, esp. in first time attempters.

34
Psychological therapies
  • Dialectical behaviour therapy useful for multiple
    episodes in Borderline PD
  • Trend to efficacy for problem-solving therapy
  • Recent RCTs on Manual Assisted Cognitive
    Behavioural Therapy, Brief Interpersonal
    Psychodynamic Therapy group therapy are
    promising
  • Cognitive behavioural family therapy also proved
    efficacious in quasi-experimental trial.

35
Pharmacotherapy
  • No firm evidence apart from a small study by
    Montgomery et al (1979) concerning flupenthixol.
  • Patient numbers were too small and side effect
    burden too great for this to be a useful
    intervention.

36
Clinical Treatments for Depression
  • Many depressed adolescents do not get to
    treatment
  • Many GPs do not feel equipped to deal with
    mental health problems presenting in the young
  • CBT brings quicker relief of major depressive
    symptoms, but little evidence that this persists
    beyond 6 months

37
Clinical Treatments for Depression (2)
  • Antidepressants effective short-term, but little
    data on medium to long term effects
  • Suicidal youth negate the need for help, not just
    related to hopelessness and prior help-seeking
  • We need to understand help-negation better to
    enhance treatment seeking by depressed youth

38
Hotlines
  • Slender evidence that these have an impact on
    suicidal behaviour, since they may not reach the
    target population
  • A higher density of suicide prevention centres
    may result in relative improvement in overall
    suicide rates.

39
Suicide Education in Schools?
  • little evidence that these programs are
    successful in identifying high risk students or
    in changing attitudes
  • a move has occurred towards more universal mental
    health, whole-of-school programs, which aim at
    school cultures, case-find in this context

40
Targetting underlying psychiatric risk factors
  • Strong commitment to doing this, but little
    evidence at this stage that targetting alcohol
    and drug abuse, antisocial behaviours or family
    dysfunction has an effect on suicidal behaviour

41
Media suicide portrayal
  • Some evidence exists that media guidelines can
    improve community suicidal behaviour

42
Postvention
  • Slender evidence that postvention is effective in
    suicide prevention, though much need for
    development of groups and standards in this area

43
Government responses
  • Commonwealths National Youth Suicide Prevention
    Strategy (NYSPS) (1995-1999)
  • Response to broad-based community concern
  • The Commonwealths new LIFE program (2000-)
    superseded NYSPS, reflects these findings, and is
    oriented for all age groups.

44
Principles of NYSPS
  • Biopsychosocial model
  • evidence-based practice (or vice versa)
  • universal, selected and indicated programs
  • national, state and local interventions
  • population-based prevention and early
    intervention
  • shared responsibility consumers, professionals,
    govt (all levels and programs), NGOs, indigenous
    peoples etc
  • sensitivity to cultural diversity

45
It is crucial that activities do no harm.
  • Some well-meaning activities that aim to prevent
    suicide can increase risk of suicide among
    vulnerable groups.
  • It is particularly important to keep this in mind
    in programs involving schools, the media or
    raising awareness of suicide.
  • All approaches need to be pilot tested and
    carefully evaluated for negative as well as
    positive outcomes.

46
LIFE I Promoting well-being, resilience
community capacity
  • Supporting community initiatives
  • Implementing effective parenting skills and
    support programs
  • Implementation and evaluation of Mind Matters
    resources in schools
  • Addressing social structural issues (e.g.
    intersectoral collaboration, community
    environments and resources)
  • Using materials to address stigma
  • Media strategies

47
LIFE II. Enhancing protective and reducing risk
factors
  • Enhancing protective factors
  • Reduce known risk factors
  • Increase awareness of early signs and symptoms
  • Increase acceptability of help-seeking
  • Media strategies re portrayal of youth, high-risk
    groups, suicide, mental disorders
  • Reduce access to lethal methods of suicide

48
LIFE III. Services and support within communities
for those with increased risk
  • Enhancing service responses to community groups
    at risk
  • Increasing response in rural and remote
    communities

49
LIFE IV. Services for individuals at high risk
  • Better identification and service response for
    incidents of DSH
  • Reduce risk of suicide and DSH among people with
    mental disorder
  • Support for those involved with the criminal
    justice or juvenile justice system
  • Reduce risk of suicide and DSH associated with
    DA use
  • Prompt and effective support for people bereaved
    by suicide

50
LIFE V Partnerships with Aboriginal and Torres
Strait Islander peoples
  • Share information about and implement
    life-affirming suicide-prevention programs that
    are community based and grounded in the culture
    of ATSI peoples
  • Increase the relevance of services and programs
    to needs, culture and strengths of Aboriginal and
    Torres Strait Islander peoples

51
LIFE VI Progressing the evidence base
  • Support strategic research and evaluation of
    programs, research and knowledge relating to good
    practice
  • Provide timely access to accurate and up-to-date
    data on suicide, DSH, risk and good practice
    initiatives
  • Increase training and educational levels
  • Implement guidelines and protocols

52
Finland a national program that worked?
  • A nationwide target and action strategy
    identifying ways of preventing suicide to suit
    local conditions
  • Research phase 1986-1988 (continuing)
  • program planning 1989-1991
  • implementation 1992-1996
  • evaluation 1997-1998

53
Finland a national program that worked?
  • 1986 target was to reduce suicide by 20.
  • Suicide rate rose to 1990 in parallel with
    rapidly growing economy, then fell with recession
    1991-1995, associated with increase in depressive
    feelings and suicidal ideation in population.
  • Despite exceptionally strong recovery, suicide
    has continued to decline
  • 1998 rate was 21 lower than 1990

54
Reasons?
  • Growing use of antidepressants (1998 rates of
    usage 4X that of 1990).
  • Volume of psychiatric open care, and locally
    organised treatments
  • Marked decrease in alcohol consumption during
    recession (tho rising since 1995, unemployment
    has decreased)

55
AUSTRALIAS NYSPS/LIFE
  • Significant gains despite short time since
    initiation and methodological problems in
    evaluation.
  • Improvements in service activity and intermediate
    outcomes
  • 1997-2001, suicide rates among 15-24 year males
    fell from 31 to 20 per 100,000, and among 25-34
    year males from 41 to 33 per 100,000
  • Cant prove due to NYSPS/LIFE, but such trends
    support effectiveness.

56
CLINICAL MANAGEMENT
57
General principles
  • All services should have accessible policies and
    procedures, governing the acute phase, ongoing
    treatment and rehabilitation and discharge
  • Pathways need to be accepted and endorsed by
    local clinical community
  • Key aims are continuity of care and positive
    staff attitudes to DSH

58
Mental health assessment
  • Assessment of immediate danger of repetition
  • Access to lethal means
  • Diagnostic assessment
  • Social assessment
  • Plan of action, including further inpatient
    observation, transfer to psych unit, discharge
    with follow-up

59
Principles of m/health assessment
  • Assessment of immediate risk of repetition or
    suicide completion
  • Recog.and treatment of psychopathology
  • Psychosocial assessment
  • Engaging and establishing rapport
  • Management of effects of injury or poisoning
    (coordinated, multidisciplinary)
  • Assessment and resolution of crises
  • Assessment and mobilization of supports
  • Initiating treatment (for resilience, coping)

60
COMMUNITY CAPACITY BUILDING
61
Community and its breakdown
  • A key part of the social conversation, affecting
    domains such as family, law and order, authority,
    trust
  • The remedy, according to much contemporary
    government and health services discourse, is to
    have more community, via social capital,
    community capacity-building etc

62
Community as ambiguous territory
  • At its simplest, the term community refers to
    groups of people living in reciprocal
    relationships. This includes communities of
    friendship and shared interests.

63
Community as ambiguous territory (2)
  • A fashionable term, perhaps because of nostalgia
    over its loss, or because it is a motherhood
    word, so imprecise that it allows for slippage.
  • Earlier use referred to community action relating
    to issues of access, equity and rights of
    disadvantaged groups, but
  • In the 1990s there was a shift in Australian
    social policy from issues of social justice to
    questions of social order

64
Community as ambiguous territory (3)
  • Those who are primarily concerned with social
    disadvantage and unequal power relations
    typically use community as a term which includes
    the state.

65
Dominant rhetoric from the stateabout community
  • The state is just another player, but also the
    funder and manager
  • Declining personal morality
  • Self-help, self-reliance, and independence
  • Mutual obligation (for welfare recipients)
  • Community (national, local) of like-minded
    (masculine) selves
  • we in community is a dangerous pronoun

66
Example self-harm in immigration detention
  • Male and female rates between ten and 100 times
    the national average
  • Reflects convergence of (child) health,
    protection and human rights concerns, driven by
    the extremity of detention and detention
    environment
  • self harm regarded as manipulation by DIMIA
  • continuation without review, in the face of
    evidence regarding the harmful effects amounts to
    state-sponsored trauma and child neglect and/or
    abuse

67
Social capital
  • Defined as the fabric of networks, trust and
    reciprocity that binds society together
  • Can be positioned in either of these conceptions
    of community.
  • Made to do the massive work of overcoming the
    social effects of globalisation.

68
CommunityLIFE Project
  • Funded by the Federal Department of Health and
    Ageing
  • Aims to build community capacity for suicide
    prevention
  • Based on the LIFE Framework, the national
    framework for suicide prevention in Australia.
  • Has a mainstream and an Indigenous component.

69
CommunityLIFE Project
  • Project managed by a consortium.
  • Current members are the Centre for Developmental
    Health (CDH) based in Perth, Auseinet based in
    Adelaide, Suicide Prevention Australia (SPA)
    based in Sydney.

70
  • Specific CommunityLIFE project objectives
    include
  • Help meet community need for suicide prevention
    programs consistent with LIFE
  • Build partnerships with key non Indigenous and
    Indigenous groups
  • Enhance community participation, capacity
    building and skills in planning, implementing and
    evaluating safe, effective and sustainable
    community suicide prevention programs
  • Support knowledge development

71
  • Website and resources
  • Guidelines for community capacity-building
  • Advisory or Consultation Service
  • Evaluation

72
Yarrabah
  • A success story in community development

73
Yarrabah historical issues
  • Community identified violence, racism, cultural
    dislocation, permanent unemployment, poverty
    lack of basic amenities, alcohol and drug misuse
  • Suicide did not become a common occurrence till
    mid 1980s, after which there were 3 waves

74
Yarrabah what ensured community engagement?
  • Community ownership of problem response is
    crucial
  • Democratic, community controlled decision-making
  • Social-historical understanding of health
  • Primary health care approach
  • Focus on community rather than indiv. risk
  • Devt of knowledge skills over time

75
Yarrabah what enabled the achievements?
  • Community ownership
  • Holistic intervention and empowerment
  • Appropriate resources and support
  • Program structure, protocols, ongoing needs
    assessment planning (not just crises)
  • A range of culturally appropriate interventions
  • Comprehensive, community controlled primary
    health care services

76
Practice change in clinical organisations
  • This requires education, management support
    local drivers, policy and procedure,
    culture/attitudinal changes and partnerships
  • The best sustainability was for enhancements
    developed by services themselves.

77
Spirituality
  • A sense of connection with a higher being or
    reality and with all things, or as ultimate value
    and meaning.
  • About deepest longings of human beings for
    wholeness, connection and transformation, for
    providing a sense of purpose and agency, for the
    sense of sacred presence that often anchors
    these.
  • Mental health professionals history of mistrust
    (limits of modern psychiatry), but rising again,
    after heyday of secularism

78
Spirituality - negative aspects
  • Associations of some religion with
    authoritarianism, self-righteousness, prejudice,
    anxiety, dependency, depression and abuse
  • Limits to religious tolerance is arguably a
    failure to recognise their social capital, which
    could benefit community.
  • Therefore bridging capital (Putnam) is reduced

79
Spirituality positive aspects
  • Generally major positive mental health effects
    (Koenig, 2001) (100s of randomised controlled
    studies).
  • It is the foundation of ethics, justice and
    resistance to social forces that marginalise
    people, and of creative imagination.
  • Antidote to consumerism
  • It is the meeting point of many paths, affording
    people the chance to bring together different
    traditions

80
  • Spirituality cant be privatised, commodified or
    packaged
  • It is not a prescription or a Medicare Benefit
    item cannot be imposed from outside as a remedy

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