YOUTH SUICIDE PREVENTION

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YOUTH SUICIDE PREVENTION

• Dr Michael Dudley

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EPIDEMIOLOGY OF YOUTH SUICIDE IN AUSTRALIA
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• 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

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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.

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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.

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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.

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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

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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.

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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

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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

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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

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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

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Psychological traits

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

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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

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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)

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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.

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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

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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

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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

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SUICIDE PREVENTION
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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?)

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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.

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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

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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.

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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.

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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).

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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.

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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).

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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

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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.

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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.

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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.

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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.

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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

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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

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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.

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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

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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

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Media suicide portrayal

• Some evidence exists that media guidelines can
  improve community suicidal behaviour

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Postvention

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

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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.

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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.

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CLINICAL MANAGEMENT
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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

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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

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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)

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COMMUNITY CAPACITY BUILDING
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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

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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.

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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

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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.

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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

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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

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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.

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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.

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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.

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• 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

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

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Yarrabah

• A success story in community development

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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

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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

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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

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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.

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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

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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

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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

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• 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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