Professor Graham Martin OAM MD, MBBS, FRANZCP, DPM

Nearly 1 million people in 2007

10 0 30 20 60 50 40

(a) Males

No. of years pre-strategy

(b) Females

60 50 40 30 20 10 No. of years post-strategy All ages 0 15-24 years No. of years pre-strategy No. of years post-strategy

10 0 30 20 60 50 40

(a) Males

No. of years pre-strategy

(b) Females

60 50 40 30 20 10 No. of years post-strategy All ages 0 15-24 years No. of years pre-strategy No. of years post-strategy

60 50 20 10 40 30 0

(a) Males

No. of years pre-strategy

(b) Females

60 50 40 30 20 10 No. of years post-strategy All ages 0 15-24 years No. of years pre-strategy No. of years post-strategy

60 50 20 10 40 30 0

(a) Males

No. of years pre-strategy

(b) Females

60 50 40 30 20 10 No. of years post-strategy All ages 0 15-24 years No. of years pre-strategy No. of years post-strategy

60 50 20 10 40 30 0

(a) Males

No. of years pre-strategy

(b) Females

60 50 40 30 20 10 No. of years post-strategy All ages 0 15-24 years No. of years pre-strategy No. of years post-strategy

SUICIDES AS A PROPORTION OF ALL DEATHS

ABS, 2007 3303.0

20 15 10 5 0 45 40 35 30 25 Recorded rates Scenario 1 Scenario 2 Revised suicide rates under both scenarios did not significantly differ from recorded suicide rates based on 95% confidence intervals.

Australian Suicide Rates 15-24 yrs, per 100,000 (ABS) 25 20 35 30 15 10 5 0 1968 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 2000 2002 2004 2006

    Big changes have occurred over 12 years The changes in youth suicide could be described as dramatic (55% reduction) They appear to be real, despite any possible misclassifications It is tempting to suggest that the National Strategy ± state strategies may have had some impact

“The recent sudden turnaround in Australian young male suicide trends and its extent appears to preclude explanations centering on slow-moving social indices traditionally associated with suicide, or on possible cohort effects.

This sudden decrease has occurred mainly in non-impulsive means, and at the same time has broken a long-standing secular link between 20-24 yr male suicide and unemployment, lending plausibility to the case for the NYSPS having had an impact on young male suicide in Australia.”

There are 2 issues within the rates which need to be addressed:

•

Rural and Remote Status, and

•

Socio-economic Status

Australian suicide rates by urban-rural residence, 1979-2003 (rate per 100,000)

Page A, Morrell S, Taylor R, Dudley M, Carter G. Further increases in rural suicide in young Australian adults: Secular trends 1979-2003. Soc Sci Med. 65(3): 442-53.

Australian suicide rates by low, middle & high SES, 1979-2003 (rate per 100,000)

Page A, Morrell S, Taylor R, Carter G, Dudley M. Divergent trends in suicide by socio-economic status in Australia. Soc Psychiatry Psychiatr Epidemiol 2006;41(11):911-7.

Harding et al., 2006. NATSEM

Male

Suicide (X60-X84) Accidental Poison.

Indig Aust Non-indig

(X40-X49)

Indig Aust Non-indig

Assault (X85-Y09)

Indig Aust Non-indig 74 1,588 24 408 22 100 Female Total 29 444 13 156 15 62 103 2,032 37 564 37 162 Rank % All deaths OR 5 14 14 39 14 51

4.2

1.5

1.5

0.4

1.5

0.1

2.8

3.75

15

   This brings us to the crucial issue of the origins of suicide.

On the one hand we know that suicide is a behaviour related to mental illness and occurring at the end point of despair On the other hand, there are social and cultural conditions which contribute to the development of mental health problems and despair

        

Support high risk through Suicide Prevention Centre (I) Post-discharge contact with psychiatric inpatients (I) (3%) Education for GPs (II) Drug treatments and ECT (II) Improved Prescribing (eg SSRIs) (III) (4%) Suicide Prevention Centres (III) Group treatment for depressed and suicidal (III) Media restrictions on reporting (III) Legislation of Drugs (eg Barbiturates) (III)

 

“National suicide prevention strategies have been proposed despite knowledge deficits about the effectiveness of some common key components the most promising interventions are physician education, means restriction, and gatekeeper education. Many universal or targeted educational interventions are multifaceted, and it is not known which components produce the desired outcome”

National Strategies are successful if they provide…  communication program to the whole population   education for relevant groups (‘gatekeepers’) reduced access to means (bridges, firearms, etc)      a strategy on drugs and alcohol a critical mass of clinical services with relevant and sufficient highly trained professionals improved services managing suicidal people, as well as improved linkages with the community proper evaluation with a formative approach a strategy for Indigenous peoples

A large number of people at small risk may give rise to more cases of disease than a small number of cases at high risk A population strategy of prevention is necessary where risk is widely diffused through the whole population.

Rose, Geoffrey, The strategy of preventive medicine. Oxford University Press, 1992

Mortality threshold Move population risk Low High Suicide risk

Mental Health Promotion

  

70+ Projects funded, covering:

    

Primary prevention and cultural change Early Intervention Crisis Intervention Treatment, support and postvention Access to Means/Injury prevention $31m+ (over 4 years) National Advisory Council

Valuing Young Lives, Penny Mitchell, Australian Institute of Family Studies, 2000



Process Indicators are available for:

  

Professional training (eg in parenting programs) Gatekeeper training (eg KYA & GPs - 7% or 3500) Curricula for schools

   

Media Resource Kit Training for Telephone Counsellors Crisis/Hospital Emergency Departments Community Development projects

Valuing Young Lives, Penny Mitchell, Australian Institute of Family Studies, 2000

 

Impact Indicators

 

Clinical programs (“some evidence”) Population level impacts (“no evidence exists”) Outcome Indicators (only a few available)

   

Clinical programs



3 programs in mental health services



1 program in Accident & Emergency Parenting programs Telephone counselling services Programs for marginalised youth

Valuing Young Lives, Penny Mitchell, Australian Institute of Family Studies, 2000 The Evaluation Experience, Jonine Penrose-Wall et al., NYSPS Evaluation Working Group, 2000

  

Many, if not most, of the smaller programs simply completed their course, were not refunded, and their long term impact at a local level is unknown A few programs acted as springboards for larger, better programs Some of the larger programs have lasted to the present day and continue to have impact at a national level

  

Achieving the Balance (Suicide Prevention Australia, 1998) negotiated widely with Media to provide clear, relevant advice.

Then, a new National Media & Mental Health Committee commissioned:



major literature review

  

1-year prospective research revised guidelines www.MindFrame-Media.info

In the 18 years before the 1996 gun law reforms, there were 13 mass shootings in Australia, and none in the 10.5 years afterwards.

Declines in firearm-related deaths before the law reforms accelerated after the reforms for total firearm deaths (p 0.04), firearm suicides (p 0.007) and firearm homicides (p = 0.15), but not for unintentional firearm deaths, which increased.

No evidence of substitution effect for suicides or homicides was observed.

S Chapman, P Alpers, K Agho, M Jones, Injury Prevention 2006;12:365–372

Amitryptiline Dothiepin Doxepin Fluoxetine Other

Total

ABS, 1999 MALE 0-14 15-24 FEMALE 0-14 199 27,292

27,491

2198 852 4083

7,134 Total: 47,086

41 63 4940

5044

15-24 1727 724 178 2134 2845

7417

704,200

    

young people used psychotropics 41,548 (5.9%) Citalopram 25,351 (3.6%) Paroxetine 51,407 (7.3%) Sertraline 11,972 (1.7%) Other SSRI 20,422 (2.9%) Venlafaxine = 18.5% 130,277 Total SSRI prescriptions

   

12,676 (1.8%) Tricyclics 12,676 (1.8%) Other Antidepressant 10.1% Anxiolytics 83.5% other including 69.2% Vitamins and Minerals Table 15, page 36 Ausstats 2005

   

No change in rates of depression between 1995 and 2005 (ABS: Mental & Behavioural Problems, 2005) More children <17 years were homeless and sought help through Supported Accommodation Assistance Program (SAAP) (AIHW) Reported cases of child abuse rose from 91,734 to 115,471 during the period 1995/6-2000/1 Number of children placed in out of home care rose from 14,078 to 18,241 during the period 1997 2001

129/12,006 1.1%

• Of those who self-injured in the month prior to survey, 48.4% also experienced suicidal ideation in the month compared to only 7.7% of those who did not self-injure (OR 11.25, 95% CI 7.88-16.06). • However, only 14 of 133 one-month self injurers (10.5%) also reported a suicide attempt in the previous 12 months. Despite the small number, the rate is high compared to non-self injurers (33 of 11,873, 0.28%) (OR 41.60, 95% CI 21.32 – 81.18).

Meta-analysis of 331 Coronial Studies  65 studies met criteria;    Subject N = 19,347; Alcohol discovered in 81.7% suicides; 22.7% intoxicated at time of death (Blood Alcohol Concentration ≥ 100mg/dL Smith, Branas and Miller, 1999

    DENMARK (1916-17) prices up, suicide down Skog, 1993 RUSSIA (1984-88) restrictions on Vodka sales following Perestroika led to reduced suicide Wasserman et al., 1994 UNITED STATES (1970-89) states with lower spirit consumption have reduced suicide Gruenewald et al., 1995 ICELAND (1989) legalization of strong beer / reduced spirits / decrease in suicide rate Lester 1999

  Strong association between drinking and attempts in 13 year olds (Time 1) (chi-square 220.5, p<0.0001) 15.9% of those drinking >1/week claimed an attempt, compared to 0.9% for those claiming never (Odds ratio 17.3).

   357 deaths attributed to opioids in 2004, ages 15 to 54 years.

Males comprised 78% of the deaths Ten-year breakdown of deaths attributed to opioids in 2004 showed:  43% were among the 25-34 year age group,    28% in the 35-44 age group, 18% in the 45-54 age group, 10% 15-24 age group.

Degenhardt et al.,2006.

National Drug and Alcohol Research Centre.

 Non-suicidal patients can all defend notions of continuity of the self  80% of suicidal patients can mount no argument about continuity (self or other)  Failures in ‘self’ continuity ‘predict’ suicide risk (Ball & Chandler, 1989; Lalonde & Ferris, 2001)

 Euro-American culture & Essentialism  Self & knowledge are individualistic  Aboriginal culture & Narrative    Self is relational Knowledge is communal/cultural product Identity is defined by Place (on the land), and is fashioned out of materials made available by culture Lalonde 2006

Courtesy: Michael Chandler University of British Columbia

Courtesy: Michael Chandler University of British Columbia

    In a very recent study (Patrao, Page, Martin unpublished paper ex a masters thesis) Postcodes with access to 6 NYSPS programs or more had a significantly lower young male suicide rate (34.5 per 100,000) compared to areas with little activity (38.8 per 100,000) Relative risk of suicide in highest SES group with greatest level of preventive activity was 0.91 (0.81-1.02) compared to the lowest SES group with no activity.

We are currently reworking the analysis…

     When designing programs we need a balance between increasing protective factors and reducing risks Universal approaches to improve ‘resilience’ and ‘connectedness’ We need to raise awareness about issues, alert people to avenues for care, and provide tools to further their skills We need clear and supported pathways to care I offer you an example…

Constructing a Healthy Industry in Queensland

‘Mates in Construction’

A suicide prevention and social capacity building program, with a vision for resilient & resourceful apprentices and workers, confidently facing life challenges.

‘Mates in Construction’

What does it do?

• • General awareness training about mental health problems and the problem of suicide (ASIST etc) • Life Skills Toolbox raises awareness of health and wellness, provides strategies, encourages access to care • • ‘Connectors’ provide links to existing services Provides an access line for crisis management and referral Deals with serious problems immediately

“I was providing General Awareness Training to a group of apprentices when I noticed one of them affected by the presentation.

In the break he said – “John, I was ticking all the boxes! All that stuff about the signs of suicide fits one of my mates. I think we might stand at his grave one day and say – If only we had known!”.

We contacted the young man’s parents. They confirmed he had been thinking about suicide, and decided on when and where to do it as well… See this young apprentice may just have saved a life; it just does not get much better than that!”

Client Numbers

New Archived Active Age 15-24 25-34 35-44 45-55 56+

Number

182 105 77 13 24 33 21 5

%

14 25 34 22 5

OzHELP Problem LIST Relationship Financial Family Work related Alcohol Legal Personal Injury/Health Anger Drug Suicide Ideation Employment Mental Health Problem (diagnosed) Fatality/Grief Suicide Intervention Cases 63 55 54 40 35 32 32 32 31 30 28 23 20 13 % 11 9 9 7 6 5 5 5 5 5 5 4 3 2

   A part of me still believes in the importance of reducing risk factors - unemployment, socio economic exclusion, abuse, depression.

But the programs from the NYSPS which have endured, and have continued to have long term impact, are about resilience, connectedness, increased awareness, clear information for when crises occurs, and help-seeking.

We need to develop an attributable impact ratio (AIR) (cf. attributable risk or protective fraction) to get a clearer handle on just what works in the long term.