Title: YOUTH SUICIDE PREVENTION
1YOUTH SUICIDE PREVENTION
2EPIDEMIOLOGY 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
4Male 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.
51989-1999 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.
6Female 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.
7Method-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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9Suicide 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.
10Suicidal 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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12Social 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
13Social 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
14Mental 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
15Psychological traits
- neuroticism (high trait anxiety)
- hopelessness
- impulsivity
- personality disorders (antisocial, borderline)
- negative cognitive style
16Childhood 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
17Odds 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)
18Odds 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.
19Life 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
20Aboriginal 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
21Rural-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
22SUICIDE PREVENTION
23What 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?)
24What 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.
25What 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
26Does 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.
27Does 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.
28Does 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).
29Does 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.
30Health 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).
31What 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
32Improving 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.
33Green card
- It is probably helpful for enhancing adherence
- There may be a trend towards reducing likelihood
of repeat DSH, esp. in first time attempters.
34Psychological 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.
35Pharmacotherapy
- 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.
36Clinical 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
37Clinical 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
38Hotlines
- 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.
39Suicide 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
40Targetting 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
41Media suicide portrayal
- Some evidence exists that media guidelines can
improve community suicidal behaviour
42Postvention
- Slender evidence that postvention is effective in
suicide prevention, though much need for
development of groups and standards in this area
43Government 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.
44Principles 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
45It 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.
46LIFE 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
47LIFE 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
48LIFE 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
49LIFE 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
50LIFE 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
51LIFE 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
52Finland 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
53Finland 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
54Reasons?
- 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)
55AUSTRALIAS 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.
56CLINICAL MANAGEMENT
57General 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
58Mental 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
59Principles 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)
60COMMUNITY CAPACITY BUILDING
61Community 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
62Community 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.
63Community 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
64Community 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.
65Dominant 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
66Example 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
67Social 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.
68CommunityLIFE 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.
69CommunityLIFE 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
72Yarrabah
- A success story in community development
73Yarrabah 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
74Yarrabah 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
75Yarrabah 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
76Practice 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.
77Spirituality
- 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
78Spirituality - 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
79Spirituality 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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