Research and Evidence in Suicide Prevention

prevention evidence insuicide Research and 1 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au Living Is For Everyone (LIFE) Framework (2007) ISBN: 1-74186-296-5 Online ISBN: 1-74186-297-3 Publications Number: P3 -2060 © Commonwealth of Australia 2008 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth. Requests and inquiries concerning reproduction and rights should be addressed to the Commonwealth Copyright Administration, Attorney-General’s Department, Robert Garran Offices, National Circuit, Barton ACT 2600 or posted at http://www.ag.gov.au/cca The Australian Government Department of Health and Ageing has financially supported the production of this review/ publication. While every effort has been made to ensure that the information contained in the review/publication is accurate and up-to-date at the time of publication, the department does not accept responsibility for any errors, omissions or inaccuracies.

Contents

Foreword...... 06 Suicide in Australia...... 30

Suicide trends and comparisons...... 30 Placing Australian rates in an Introduction...... 07 international context...... 33

Rate per 100,000...... 33 About suicide and suicide Indigenous Australians and suicide...... 34 Men and suicide...... 36 prevention...... 10 Suicide in rural and remote locations...... 37

Self-harm and suicide...... 38 What is understood by the term ‘suicide’...... 10 What we know about why people choose Suicide and people from culturally and linguistically diverse backgrounds...... 39 to take their own lives...... 10 Suicide in refugee communities...... 40 Suicide risk and protective factors Evidence of what works in suicide for suicide...... 12 prevention...... 42 Challenges in suicide prevention...... 12 What we know about risk and protective Types of prevention programs...... 42 Training for health professionals...... 42 factors for suicide...... 12 Applying a knowledge of risk factors to Gatekeeper training...... 42 Restricting access to means of suicide...... 43 suicide prevention...... 15 Applying a knowledge of protective factors Clinical interventions...... 43 Community capacity-building approaches...... 46 to suicide prevention...... 15 The importance of health and wellbeing in Addressing media coverage of suicide...... 46 Collaborative approaches suicide prevention...... 16 What we know about the impact of resilience to suicide prevention...... 47 and vulnerability...... 17 What we know about the impact of mental Evaluation of suicide prevention illness on suicide-related behaviours...... 18 programs...... 50 Mental health interventions to reduce suicidal behaviours...... 19 Challenges in evaluating suicide

What we know about the impact of life events prevention program effectiveness...... 50 on suicide-related behaviours...... 19 The importance of ongoing evaluation...... 50 What we know about suicide warning signs and tipping points...... 22 Appendix A: Life events and Warning signs...... 22

Tipping points...... 22 suicide – emerging issues...... 52

The Living Is For Everyone (LIFE) Appendix B: Incidence of death suicide prevention model...... 24 (suicide and self-inflicted injuries)

Rationale for the model...... 24 in regions of Australia...... 56 The three-pronged approach...... 24

The inclusion of ‘safety nets’...... 26

The LIFE (2007) model...... 26

Key features of the LIFE (2007) model...... 27

Eight domains of activity...... 27

Six overlapping areas of care and support...... 28 Appendix C: Examples of overseas suicide prevention strategies...... 60

Appendix D: Review of suicide risk factors...... 64

Glossary of terms...... 70

Endnotes...... 74

Acknowledgements...... 86 Foreword

06 In 2006, an independent review and consultation with The components of the new LIFE (2007) suite of www.livingisforeveryone.com.au Research and Evidence in Suicide Prevention Living Is For Everyone: key stakeholders on the LIFE Framework (2000) was materials are: commissioned. LIFE (2007) is the result of the review. • Living Is For Everyone: A Framework for Prevention of It provides a national framework for action based on Suicide in Australia, which outlines the vision, purpose, the best available evidence to guide population health principles, action areas, and proposed outcomes for approaches and prevention activities. It reflects a vision suicide prevention in Australia. It replaces the Living that suicide prevention activities will reduce suicide is For Everyone (LIFE) Framework (2000). The revised attempts and the loss of life through suicide by providing Living Is For Everyone Framework is based on the individuals, families and communities with access to understanding that: support so that no-one in crisis or experiencing personal adversity sees suicide as their only option. – suicide prevention activities will first, do no harm; – that there will be community ownership and The new LIFE Framework (2007) has been developed responsibility for action to prevent suicide; and in recognition of the widely differing audiences, each with a need for practical yet informed guidance on – that service delivery will be client-centred. suicide prevention. • Living Is For Everyone: Research and Evidence in Suicide Prevention (this document), sets the context The purpose of the LIFE (2007) materials is to provide for suicide prevention activity, summarising current information, resource materials and strategies that will research, evidence and statistics relating to suicide support population health approaches and suicide and suicide prevention in Australia. prevention activities undertaken across the Australian community and thereby contribute to a reduction in • Living Is For Everyone: Practical Resources for Suicide suicide and suicide attempts. Prevention is a set of fact sheets, organised around topic areas, providing practical information about The LIFE Framework (2007) outlines suicide prevention suicide prevention. The broad grouping of the topic activities, programs and interventions that reflect areas are: Universal, Selective and Indicated approaches that – About Suicide and Suicide Prevention; aim to build: – Conducting Suicide Prevention Activities • stronger individuals, families and communities; and Programs; and • individual and group resilience to traumatic events; – Suicide Prevention Interventions (Universal, • the capability for communities and individuals to Selective, Indicated). identify and respond quickly and appropriately to people in need; and • a coordinated response for the provision of care and support to individuals and for smooth transitions to and between care. community insuicideprevention. practical documents and resources to assist the wider commissioned. The review revealed the need for more with keystakeholdersonthe In early2006anindependentreviewincludingconsultation • • • of threerelateddocuments: The Suicide PreventionStrategy(NSPS). across theAustralianpopulation,withinNational suicide andpromotementalhealthresilience strategic frameworkfornationalactiontoprevent in Australia(theLIFEFramework(2007) A FrameworkforPreventionofSuicideandSelf-harm Strategy wasexpandedintothe In 2000,the(then)NationalYouth SuicidePrevention of $31millionallocatedbetween1995and1999. National Youth SuicidePreventionStrategy, withatotal following year, a further $18 million was allocated to the implement a national plan for youth in distress. In the $13 million was allocated over four years to develop and was on youth suicide; in the 1995–1996 Federal Budget, strategic approach to suicide prevention. The first focus Australia was one of the first countries to develop a national Introduction government policiesacrossAustralia). prevention activities,projectsandprograms Building partnerships and in Australia A frameworkforthepreventionofsuicideandself-harm in Australia); and evidencerelatingtosuicideself-harm aboutsuicide Learnings LIFE Framework(2000) (outlininggoals,principlesandactionareas); (describingthemanysuicide

(covering theresearch LIFEFramework consistedofapackage Living Is For Everyone: Living IsForEveryone: . Itprovideda was was

international andnationalresearch. supplemented byawidercanvassingofthemostrecent people bereavedbysuicide.Theconsultationswere providers,localcommunities,and groups, service health andotherprofessionals,carers,specialinterest policy makers,governmentdepartments,peakbodies, community andincludedacademicsresearchers, The consultationsinvolvedthewiderAustralian learning ofthesectorovertime. of suicideprevention,contributingtothegrowthand and contextualcontributiontothedevelopingfield resources wereseenasmakinganimportanthistorical Suicide PreventionStrategybeforeit,the presentation anddissemination.LiketheNationalYouth more accessibleintermsofcontent,language, redeveloped It becameapparentthattherewasaneedforthe LIFE Framework with suicideprevention,whohadnotseenthe local community organisations, all of whom were dealing providers, them. Therewerealsomanyindividuals,service people reported that they rarely referred to them or used the 2006: significantly, whilst the suicide prevention sector held of thefindingsfromindependentreviewundertakenin January to June 2007. These consultations confirmed many developed withextensiveconsultationoversixmonthsfrom The new LIFE Framework Living Is For Everyone Living (LIFE) Is Framework For (2007) Everyone LIFE Framework documents. documents in very high regard, most highregard,most documentsinvery resourcestobemade LIFEFramework

was

07 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

LIFE

LIFE (2007) . Figure 1 Figure . In the six years since the first . In the six years since resources aim to contribute to the resources aim to contribute resources build on and update the resources build on and was produced, there have been significant was produced, there LIFE (2007) LIFE (2007) statistics and information about suicide itself (unless those those (unless itself suicide about information and statistics prevention). suicide into insights offer statistics The three companion documents of the coverage materials are linked in terms of content and and there is some repetition across the documents target since each one is designed for a slightly different audience as shown in the The in Australia through up-to-date prevention of suicide clear communication of this research and evidence, strategy for action and information, and a logical all Australians. practical resources for The LIFE Framework (2000) Framework data and research of type and range the in improvements draw resources The prevention. suicide to relevant are that materials. those on meet the The documents have been developed to community requirements of a broader suicide prevention that includes local service providers, families, community often see the members, work colleagues – people who first signs of a potential suicide. academic with intent this reflect documents the of style The the resourcesand scientific styles minimised. The focus of extensive on less and prevention suicide on predominantly s

LIFE and , the new LIFE Framework LIFE Framework outlines the vision, purpose, action (this document) sets out the context contains fact sheets summarising the key

suite of documents was produced with three in Australia; Living Is For Everyone: for Suicide Practical Resources Prevention issues in suicide prevention, and documents resources in suicide prevention that are currently available. for suicide prevention activity, summarising the current summarising for suicide prevention activity, theories, research, evidence and statistics relating to suicide and suicide prevention in Australia; Living Is For Everyone: for Prevention of A Framework Suicide in Australia areas and evaluation framework for suicide prevention Living Is For Everyone: Research and Evidence in Suicide Prevention particularly those targeting groups at high risk in the particularly those targeting groups at high community; and amending content to provide a more comprehensive includes coverage of suicide prevention issues which expanding information on areas such as self-harm, resilience and protective factors. Governments (COAG) Agreement: the National Action Governments (COAG) Agreement: the National National Plan on Mental Health. A key element of the Action Plan is the commitment from the Australian Suicide Governments to double funding for the National million) to Prevention Strategy (from $61 million to $123 programs, enable the expansion of suicide prevention reflects a focus on practical implementation of suicide reflects a focus on practical prevention activities; they are reflective revising materials to ensure and of new initiatives and of a diverse Australia prevention including those developments in suicide Council of Australian arising from the July 2006 clarifying the purpose of the clarifying the purpose presented is it way the and information the that ensuring • • • Following these recommendations and based on the Following these recommendations and based previous reviews of the • • The review made recommendations for changes to The review made recommendations the documents including: • Introduction (continued) Introduction

(2007) main components:

Living Is For Everyone: Research and Evidence in Suicide Prevention 08 www.livingisforeveryone.com.au Figure 1: What doyouwanttoknow? recover afterasuicide. suicide, ortohelppeople you candoorsaytohelpprevent choose suicide,andtellsyouwhat more aboutsuicide,whypeople You wantsomethingthatexplains in Australia. priorities forsuicideprevention purpose, structure,principlesand You wanttoknowabouttheoverall and wellinformed. prevention activitiesarewellfounded You wanttoknowthatyoursuicide prevention. understanding ofsuicideand You wanttoknowaboutthelatest

Using the Living Is For Everyone resources Using theLivingIsForEveryone The Living Is For Everyone website:www.livingisforeveryone.com.auThe LivingIsForEveryone hasup-to-date informationonsuicide prevention activitiesinAustraliaandlinkstoawiderangeofresources,guidelinesfactsheets. of suicide. yourself maybeatrisk suicide –oryou of peopleaffected bya you thinkissuicidal,or associate ofsomeone work colleagueor employer, friend,family, service provider, professional carer, community member, You maybea Who are you? organisation. provider orcommunity professional, service or communityservices of parliament,health policy maker, member academic, researcher, You maybean Which document matches your needs? suicide preventioninAustralia. Outcomes andStrategiesfor Principles, ActionAreas,Planned and outlinestheVision,Purpose, current understandingsofsuicide of Australia providesasummary for PreventionofSuicidein AFramework Living IsForEveryone: Evidence inSuicidePrevention Researchand Living IsForEveryone: prevention inAustralia. relating tosuicideand research, evidenceandstatistics activity, summarisingcurrenttheories, the contextforsuicideprevention of informationandhelp. prevention andsuggestfurthersources summarise thekeyissuesinsuicide arranged aroundtopicareasthat is asetofplainlanguagefactsheets Resources forSuicidePrevention Practical Living IsForEveryone:

sets 09 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au About suicide and suicide prevention

What is understood by the term ‘suicide’

10 A death is classified as a ‘suicide’ by a coroner based www.livingisforeveryone.com.au Research and Evidence in Suicide Prevention Living Is For Everyone: on evidence that a person died as a result of a deliberate act to cause his or her own death. If there is contrary evidence, a coroner may classify the death as having been caused by someone else, or as accidental. If there is insufficient evidence, the coroner may not be able to reach a decision on the cause of death.

Suicide is almost always a very private act, although the legacy of suicide and its impact on those who are left behind may be very public and powerful. The attitudes of those left behind after a suicide range from confusion, through guilt, to anger and condemnation and they often struggle to understand the person’s motivation.2

Other commonly used references associated with ‘suicide’ include ‘suicide attempts’, ‘suicide threats’, ‘suicide plan’, suicide-related ‘behaviours’, ‘ideations’ and ‘communications’, ‘self-harm’ and ‘self-inflicted unintentional death’.

What we know about why people choose to take their own lives

This is a question that has been asked over millennia, in the writings of philosophers, religious leaders, sociologists, physicians and many others. In an attempt to find an answer researchers have gathered information in recent times from people who have considered or attempted suicide, and from families and health professionals connected to people who have suicided. Despite this ongoing inquiry there is no single or definitive answer, and no simple explanations are available about why people choose to take their own life. Edwin Schneidman, has suggested that suicide is The most recent theories about the types of suicide and 11 ‘chiefly a drama in the mind’3 and that people become different motivations to suicide suggest that it may be any suicidal when their vital needs (such as their need for one or combination of the examples below: achievement and nurturing) are frustrated. A common • a direct result of a mental illness, such as clinical goal appears to be to escape intolerable pain or feelings depression or schizophrenia. However, many people of hopelessness or ambivalence about life. As the with a mental illness are not affected by suicidal person becomes increasingly focussed on their problem, thoughts or behaviour, and not everyone who suicides they can see no other option than to take their own life. is mentally ill; In this situation, the positive and negative aspects of the www.livingisforeveryone.com.au person’s environment are critical to his or her survival.4 • an outcome of reckless behaviour or impaired Suicide may also involve a desire to convey a message, judgement. Suicide is, for example, often associated and it may include symbolic gestures linked to the with alcohol or other drugs, or it may result from chosen method and/or the location of the suicide. dangerous or life-threatening activities. Such behaviour is sometimes referred to as a ‘death wish’; Several researchers have attempted to develop a • an attempt to end unmanageable pain. It may be classification for suicide, with concepts such as escapist Living Is For Everyone: Research and Evidence in Suicide Prevention psychological pain and despair, stemming from guilt, suicides, aggressive suicides, revenge suicides, self- shame, or loss; or it may be chronic physical pain or destructive suicides, and suicides to ‘prove oneself.’5 6 7 debilitating illness; For some, suicide may be an impulsive and irrational • an attempt to send a message or gain a particular act. For some it may be a carefully considered choice, outcome such as notoriety, vengeance, defiance, particularly where the person believes that his or her or leave a particular legacy or aftermath; death will benefit others. Some people take their own life • an altruistic or heroic act, relieving others of a burden, or harm themselves apparently without warning; some dying to save another, or dying for a cause; and/or give some indication of suicidal intent, especially to friends and loved ones, but also to health professionals. • an expression of the person’s right to choose the manner of their death. And in some circumstances, the specific means or place of suicide has particular symbolic significance to the person.

There is a complex interrelationship of risk and protective factors that impacts on someone’s decision to take their own life. These are considered in the following section. Suicide risk and protective factors for suicide

Challenges in suicide prevention

12 Many factors help to shape a person’s self-image, life Risk and protective factors can occur: www.livingisforeveryone.com.au Research and Evidence in Suicide Prevention Living Is For Everyone: skills and ability to cope under pressure or when faced • at the individual or personal level and include mental and by life-changing circumstances. These factors include physical health, self-esteem, and ability to deal with difficult genetic make-up, previous life and family experiences, circumstances, manage emotions, or cope with stress; current and past physical and mental health, a range of cultural and gender-related factors, and a person’s • at the social level, which includes relationships and social support systems. Each individual is born with a involvement with others such as family, friends, unique genetic and biological make-up, into an existing workmates, the wider community and the person’s family and social situation, and into a culture, a socio- sense of belonging; economic circumstance, and a geographic location. • at the contextual level or the broader life environment All these factors predispose a person towards certain level which includes the social, political, environmental, attitudes, beliefs and behaviours which may also change cultural and economic factors that contribute to as circumstances change. The challenge in suicide available options and quality of life. prevention is to understand which components of these factors (individual, social, contextual) will help to lessen Risk and protective factors may be: a person’s adverse reaction to difficult events, and to • modifiable - things we can change; and identify which individuals are most likely to be badly • non-modifiable - things we cannot change. affected by adverse life events and which are most likely to be resilient. For example, in some areas of Australia there is a high incidence of suicide in isolated older men. Nothing can be done about their age or gender (non-modifiable factors that increase risk), but it is possible to change What we know about risk and their geographical location or their social isolation protective factors for suicide (modifiable factors).

People who attempt to take their own life usually have The reasons that people choose to take their own life are many risk factors and few protective factors. However, very complex. The many factors that influence whether risk and protective factors don’t explain everything about someone is likely to be suicidal are known as: suicide. Most people with multiple risk factors do not attempt to take their own life, and some who do take their • risk factors, sometimes called ‘vulnerability factors’ life have few risk factors and many protective factors. because they increase the likelihood of suicide-related Particular risk factors are more important for some groups behaviours; and than others. For example, the factors that may put a • protective factors, which reduce the likelihood of young man at risk are generally quite different to those suicide-related behaviours and work to improve a that increase the risk for a retired, older man. person’s ability to cope with difficult circumstances.

Risk and protective factors are often at opposite ends of the same continuum. For example, social isolation (risk factor) and social connectedness (protective factor) are both extremes of social support.

There may be a number of reasons why there is not a • A further challenge lies in the strong relationship straight one-to-one relationship between reduced risk and between socio-economic factors and health. the presence of protective and/or risk factors, including: At present in Australia, there is a strong link between geographic location (regional, rural and remote), socio- • The same life event can have very different impacts on economic disadvantage (low socio-economic status) individuals, depending on what else is happening in a and ill health. This relationship also exists for suicide, person’s life at the time and their ability to grow and learn and rates of suicide tend to be much higher in regional, from life’s challenges. To assist someone who is feeling rural and remote locations and in areas of higher socio- suicidal it is critical to understand their sense of self, their economic disadvantage. ability to cope and their personal competence. Figure 2 outlines some of the known risk and protective • People vary widely in their beliefs about what makes factors associated with suicide8-10, but risk and protective life worth living, and these views may also change over factors can never tell the whole story. It is critically time. To date, researchers have not yet been able to important to remember how complex suicide is. 14 explain how and why these differences occur. www.livingisforeveryone.com.au Research and Evidence in Suicide Prevention Living Is For Everyone: A list of risk and protective factors can provide a guide at the community level, and can inform effective local action. However, it tells us little about individuals and it can never provide an individual ‘check list’.

Figure 2: Examples of risk and protective factors

Risk factors for suicide Protective factors for suicide

Individual gender (male) gender (female) mental illness or disorder mental health and wellbeing chronic pain or illness good physical health immobility physical ability to move about freely alcohol and other drug problems no alcohol or other drug problems low self-esteem positive sense of self little sense of control over life circumstances sense of control over life’s circumstances lack of meaning and purpose in life sense of meaning and purpose in life poor coping skills good coping skills hopelessness positive outlook and attitude to life guilt and shame absence of guilt and shame

Social abuse and violence physical and emotional security family dispute, conflict and dysfunction family harmony separation and loss supportive and caring parents/family peer rejection supportive social relationships social isolation sense of social connection imprisonment sense of self-determination poor communication skills good communication skills family history of suicide or mental illness no family history of suicide or mental illness

Contextual neighbourhood violence and crime safe and secure living environment poverty financial security unemployment, economic insecurity employment homelessness safe and affordable housing school failure positive educational experience social or cultural discrimination fair and tolerant community exposure to environmental stressors little exposure to environmental stressors lack of support services access to support services • • • • protective factors.Activitiesmayinclude: initiatives shouldfocusonconstellationsofriskand Most researchersrecommendthatsuicideprevention group aremoreorlesslikelytobecomesuicidal. from riskfactorsalonewhichindividualswithinan‘atrisk’ to taketheirownlife.Itisextremelydifficultdetermine be categorisedas‘atrisk’donotandwilleverchoose The mainreasonisthatthemajorityofpeoplewhocan risk, ratherthanattemptingtoidentifyindividualsatrisk. identify populationsorspecificgroupsthatmightbeat understanding ofriskfactorsinsuicideisbestusedto The mostrecentresearchsuggeststhatan • • • suicide involvesidentifying: Applying anunderstandingofriskfactorstoprevent factors tosuicideprevention Applying aknowledgeofrisk which oftheriskfactorscanbechanged(modifiable) individuals whoaremostlikelytobebadlyaffectedby existing riskfactors(individual,social,contextual)that to reducethelevelofrisk. resilient; and these riskfactors,andthosewhoaremostlikelytobe are presentforaparticularpersonorgroupofpeople; been recentlydischargedfrom mental healthcare. who haveattemptedtotaketheirownlife,or are incurrentcrisis.Suchgroupsmightincludethose reducing riskandincreasingprotection feel mostcomfortable. their peers,intheplacestheyfrequentandwhere assistance forpeoplebereavedbysuicideprovided the rightapproach.Forexample,non-judgemental support providing seeking behaviours. teachers andotheradults,encouraginghelp- positive peerrelationshipsandwith young peoplesocialandemotionalskills,fostering and personalcompetence.Forexample,teaching that helptobuildself-esteem,psychologicalstrength increasing individualprotectivefactors to affordablehousing. networks, improvedemploymentprospectsoraccess mental illness.Forexample,developingsocialsupport geographically isolatedoldermenorpeoplewitha such asremoteIndigenouscommunities,sociallyor structural changesthattargetspecific‘atrisk’groups reducing thatisintherightplace,attime,using

exposure tosocialandcontextualrisk easier accesstoappropriatecareand

through activities

for peoplewho through

Everyone facesnewchallengesandoftenencounters Everyone a worker, astudent,mentor, acolleagueorfriend. different attitudesandbehaviours–asaparent, dreams andfears. environment, theirpastexperiences,andhopes, person’s ‘lifespace’includestheirphysicalandsocial the personandbyperson’s environment.Each Human behaviourisshapedbothbyfactorswithin and wellbeing. worth livingandthefactorsthatbuildindividualhealth what makespeoplestrong–the factors that make life behaviour now includes an emphasis on understanding illnesses and weaknesses, the scientific study of human events. life builds resilienceandtheabilitytocopewithadverse a focus in suicide prevention, to understand better what Only relatively recently have protective factors become increase vulnerabilityorexposuretosuicidalthinking). overwhelmingly on understanding risk factors (those that Suicide researchhashistoricallyconcentrated prevention protective factorstosuicide Applying aknowledgeof and ongoingmentaldisorder(about10%ofpeople). reaction (about10%ofpeople),andchronicdisruption (about 20%ofpeople),delayedintenseemotional overtime of people),initialshockfollowedbyrecovery resilience accompaniedbymilddisruption(about60% individuals respondtopotentiallytraumaticevents: suggested thattherearefourdifferentwaysinwhich and bouncebackfromadverselifeevents.Ithasbeen what givesanindividualtheresiliencetocopewith about whatmakeseachpersonwhoheorsheis,and There havebeen,andwillcontinuetobe,manytheories circumstances, includingadverseevents. and theperson’s capacitytoadjustchanginglife impact ondifferentpeople,dependingthecontext different However thesamelifeeventcanhaveavery associated expectations,responsibilitiesandevents. stress astheyjugglethemanydifferentrolesand 22-34 After many years of concentrating on human 35

36 Life’s differentrolesdemand

38 37 11-21

15 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

and secure support environments; and availability of sensitive professionals/ carers and mental health practitioners. Sense of self; social skills; sense of of sense skills; social self; of Sense problem stability; emotional purpose; solving skills; and physical health. Genes; gender and gender identity; personality; ethnicity/culture; socio- economic background; and social/ geographic inclusion or isolation. Family history and context; previous physical and mental health; exposure to trauma; past social and cultural experiences; and history of coping. Support and understanding from family, local community, friends, local doctor, school; level of connectedness; safe The four main groups of factors that

support of family and friends; support of family and groups); peer community, of adversity; (non-threatening, empathetic); servicemental health workers, hospital emergency personnel; a quick response capability within the community in times of adversity; and support from local service providers. positive and supportive relationships; positive and supportive (neighbourhood, local social connectedness and support during times community understanding safe and secure support environments sensitive professional carers, general practitioners, coordinated and integrated service delivery and Individual health and wellbeing: Predisposing or individual factors: Life history and experience: Social and community support: Figure 4: to ability to respond positively influence a person’s adverse life events The key social support systems that assist in building The key social support capacity to respond positively individual resilience and are: to adverse life events • • • • • • • •

summarises summarises the

Figure 3 Figure

39 Figure 4 Figure Emotional stability includes: Emotional skills; humour; and empathy. Problem solving skills includes: Planning; problem solving; help-seeking; and critical and creative thinking. Physical health includes: Health; physical energy; and physical capacity. Sense of self includes: Self-esteem; secure identity; ability to cope; and mental health and wellbeing. Social skills include: Life skills; communication; flexibility; and caring. Sense of purpose includes: Motivation; purpose in life; spirituality; beliefs; and meaning. Individual health and wellbeing Factors that contribute to individual health Factors that contribute to individual health It is generally accepted that these building building these that accepted generally is It

40-44 Mind Body Heart Behaviour Spirit Self- image (Adapted from Maslow, 1943; Beautrais, 1998; Kumpfer, 1999; 1943; Beautrais, 1998; Kumpfer, (Adapted from Maslow, Rudd, 2000) and wellbeing four main groups of factors that work together to build four main groups of factors that work together situations manage to capacity the and resilience individual that may cause anxiety or emotional instability. Figure 3: social interactions also influence a person’s reaction to reaction social interactions also influence a person’s from difficult circumstances. Accumulated experiences of the the past (cultural, social, family), and anticipation all impact future (expectations, hopes, dreams and fears) events ability to manage the range of on the individual’s that can occur throughout life. blocks related to a person’s sense of self, social skills, skills, social self, of sense person’s a to related blocks solving problem stability, emotional purpose, of sense and strengthen to together work health physical and skills challenges. for life’s prepare the individual family life and External factors and experiences such as From birth, each person develops his or her sense of From birth, each person of coping with life. There have beenself and unique ways individuals develop and buildmany theories about how to life. their resilience and attitude The importance of health and of The importance prevention in suicide wellbeing they are. the main building blocks for what makes each person who who person each makes what for blocks building main the

Living Is For Everyone: Research and Evidence in Suicide Prevention 16 www.livingisforeveryone.com.au (see thoughts andbehavioursabout takingone’s ownlife expectations oflifecanacttoincrease thelikelihoodof The interactionbetweenanindividual’s resilienceand their changing event. to expecttheworstoutcomefromatraumaticorlife- develop aviewoftheworld(‘worldview’)thatleadsthem life hasinvolvedmanynegativeexperiences,theymay and havehappenedaroundthem.Wheresomeone’s and despair, influencedlargelybytheeventsthat happen During theirlife,peoplemovebetweensituationalhope has to offer, for example a hopeful or a despairing future. experiences helps to create a particular view of what life hopes, dreams and fears). The accumulation of life in the present, and in anticipating the future (expectations, experiences (cultural,social,andfamily)fromthepast, to life events is strongly influenced by accumulated life and their social interactions with others. The response shaped by their experiences and particularly by their family As each individual develops, their expectations of life are to riskorapotentiallytraumaticsituation. to respondeitherpositivelyornegativelywhenexposed opposite endsofacontinuum,reflectingperson’s ability Resilience andvulnerabilityareoftenviewedasbeingat cope withpotentiallytraumaticincidents. may makeapersonmorevulnerableandlessableto lack offamilysupportorexposuretoabusetrauma that issupportiveandcaringwillenhanceresilience,while contribute toresilience.Forinstanceafamilyenvironment to vulnerability, andoftentheyarethesamefactorsthat difficult ortraumaticlifeevents. predisposes apersontorespondinnegativeway ‘ challenging lifeeventsmaybeconsideredtomore become discouragedordefeatedwhenfacedwith On theotherhand,peoplewhohaveatendencyto problem-solving skills effectively to work through difficulties. family for support, and using coping strategies and ones. Being resilient involves engaging with friends and turning potentially traumatic experiences into constructive through the positive and the negative experiences of life, misfortune orchange. It is the ability to bounce back, recover from, or adjust to to adaptandrespondpositivelystressfulsituations. Individual ‘ from adifficultsituation. times andmayevenbeabletomakesomethinggood during theirlife.Mostpeoplecanhandlethesetough experiencesstressanddifficultcircumstances Everyone of resilience andvulnerability What weknowabouttheimpact vulnerable Figure 5 resilience ’. Vulnerability isthecharacteristic that ). ’ is a person’s capacity or competence 46 It is the ability to learn and grow 47 Manyfactorscontribute 48

vulnerability meetssituationaldespair Figure 5: feeling unloved,helpless,hopelessness,nootherchoice humiliation, insufficientresourcestocope,suspiciousness, guilt, loneliness,fear, hurt,embarrassment,disappointment, Typical responses: THE POTENTIALTOTAKE ONE’SOWNLIFE experiences of negativelife and expectations The accumulation despair Situational life experiences of positive and expectations The accumulation hope Situational Thepotentialtosuicide:whereindividual anger, sadness,shame,anxiety, stressors to handlelife behaviours, ability help-seeking strategies, Personal coping resilience Individual life stressors unable tohandle socially withdrawn, inability tocope, of self-worth, Diminished sense vulnerability Individual

17 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

58 59 60 for a mental disorder have been shown to have a for a mental disorder have been shown to to the significantly higher risk of suicide compared of suicide general population. They are at particular risk in- immediately following discharge from psychiatric patient care or emergency departments, especially or was an if the person has previously been suicidal involuntary admission, and where they live alone or assist these people are exposed to work stresses. To post-discharge and reduce the risk, it is important to provide effective ‘safety nets’ within communities led to the through treatment of the circumstances that admission, management of work and other stresses, and improved follow-up and ongoing assessment of suicide risk. phases of recovery risk of acting be at increased upon their suicidal ideas due to a delayed response to treatment. It is therefore important to educate individuals, family and carers about this and how to mood recovers minimise the risk until the patient’s and the suicidal ideas abate. The strongest links are with clinical depression, The strongest links are schizophrenia, alcohol or other bipolar disorder, and drug abuse, borderline personality disorder, behavioural (e.g. conduct, oppositional) disorders in children and adolescents. than people with schizophrenia and mood disorders for suicide- it is in the general population, and the risk has related behaviours is more marked if the person more than one mental illness. treatment Psychiatric inpatients and people receiving People diagnosed with depression may in the early among Suicide is a more common cause of death • There is also a complex, circular relationship between between relationship circular complex, a also is There suicide-related and factors risk other illness, mental to rise give itself may illness mental a having behaviours; a example, For thoughts. suicidal exacerbate that events that decisions reckless make may state manic a in person thoughts. suicidal in result and stress unbearable cause are associated to some degree Most mental illnesses and/or suicide. with suicide-related behaviours • • •

Mental 49 , and classifying 54 particularly where the 53 to suicide, this does not The severity of mental illnesses The severity of mental linked

50,51 However, only a small percentage However, 52 It suggests that the high incidence of mental 56 57 four times as many negative life events as the general general the as events life negative many as times four population, and depressed patients reported high levels of negative life events before the onset of their depression. in so do self-harm or suicide who people many Although predisposing have also most events, critical to response social or mental health risk factors. ill-health (in particular, depression) can be the result of the ill-health (in particular, accumulation of stressful life events involving threat, loss, humiliation or personal defeat. Suicide attempts and life events are strongly linked. behaviours suicide-related trigger can event life negative A suicide attempters reported in some people. In one study, More importantly, mental illness (as broadly defined) may mental illness (as broadly More importantly, simply be an outcome of other events that are occurring life. There is a growing or have occurred in a person’s body of recent research which suggests that there is a strong link between mental illness, genetic factors and life events. To imply that all those who suicide have a mental illness imply To mental illness can itself be a barrier to seeking help since still carries with it significant stigma as people who have suicidal thoughts or feelings them ‘mentally ill’ may isolate them and discourage support. from seeking appropriate help, treatment and While mental illness is mean that everyone who takes their own life is mentally when they ill or is emotionally or intellectually disturbed be an make that decision. For some, suicide may it may be impulsive and irrational act, but for others, a carefully considered choice others. person believes that his or her death will benefit of people whose suicide is related to mental illness varyof people whose suicide is related to mental from 30% to ranging considerably from study to study, 90% of all suicides. ever attempt of people diagnosed with these conditions be relied suicide and a diagnosis of mental illness cannot behaviours. on as a reliable predictor of suicide-related emotions and ability to relate to others, and inability to emotions and ability to cope with life events. persistent being to episodic or brief being from range may illnesses including anxiety and and disabling. Mental be diagnosed by a qualified mood disorders should Estimates of the percentage mental health professional. Mental illness has been shown to have a strong Mental illness has been behaviours. relationship with suicide-related of illnesses where people illness describes a group disturbed mood, poor may show irrational behaviour, perceptions or thoughts, disturbed judgement, abnormal What we know about the impact the impact know about What we suicide- illness on of mental behaviours related

Living Is For Everyone: Research and Evidence in Suicide Prevention 18 www.livingisforeveryone.com.au mental healthissues. to peoplewhopresentaGeneralPractitionerwith care initiatives thattargettheprovisionofmultidisciplinary way. Theapproachisreflectedinrecentgovernment assist inprovidingthecareandsupportanintegrated the person’s conditionandcircumstances,whowill trained teamofhealthprofessionalswhounderstand the righttreatmentandassistanceincludinghavinga of suicide.Inprovidingthis,itisimportanttoprovide for thosewhohaveamentalillnesscanreducetherisk creating asecure,safeandempatheticenvironment a senseofcaring,bettersocialconnectednessand behaviours. preventative measureneededtoreducesuicide-related The effectivetreatmentofmentalillnessisnottheonly benefits ofthesedrugsoutweightherisk. Australian andNewZealandresearchwhichshowsthatthe increase suicidalthinking.Thishasbeendisputedbyrecent antidepressants have limited effectiveness and may actually that forgroupssuchaschildrenandadolescents, use ofantidepressantswithsomeresearchersproposing However, therewasdebateinrecentresearchaboutthe reduce suicidalthoughtsandbehavioursinsomestudies. serotonin levelsinthebrain,havealsobeenshownto Antidepressant medications, such as those that influence admission tohospital. is particularly severe or the person is unsafe, it includes social support, or a combination of these. If the illness Treatments include medication, counselling, therapy and suicides wouldbereducedbyapproximately20%. were treatedin50%ofallpeoplewiththeseconditions, alcohol/drug/substance abuse disorders and schizophrenia) associated withsuicide-relatedbehaviours(i.e.depression, One studyestimatedthatifthethreedisordersmost methods reducessuiciderateswithinthesegroups. schizophrenia) through medication, counselling or other Effective treatmentofamentaldisorder(e.g.depression, reduce suicidalbehaviours Mental healthinterventionsto 71 Thereisalsoevidencethatproviding 63-70 61

However it is not possible to accurately assess the relative between suicideattemptsandlifeevents. findings indicateastrongandimmediaterelationship adverse lifeeventsasthegeneralpopulation.These who attemptedsuicidereportedfourtimesasmany Additionally, asearly1975,itwasfoundthatpeople adverse lifeeventsthanpeoplewhodonot. own livesarelikelytohaveexperiencedmorerecent control studieshaveshownthatpeoplewhotaketheir attempts. Aresearchreviewfoundthatmanycase- one ormoreadverselifeeventsoftenprecedesuicide There isagrowingbodyofevidencesuggestingthat depending onthecontextandperson’s capacities. differentimpactonpeople, can haveavery professional andsociallives.Howeverthesamelifeevent circumstances andcontinuetofunctionintheirpersonal, Most peoplecancopewithchangingandchallenging are allnormalhumanresponsesduringsuchtimes. and difficultcircumstances.Stress,sadnessanxiety atsometimeexperiencesadverselifeevents Everyone behaviours of lifeeventsonsuicide-related What weknowabouttheimpact suicide-related behaviours. of howfactorsmayinteracttoimpactonsuicideand Figure 6 events andpersonalsocialcircumstances. related behaviourscanbelinkedtocombinationsoflife Appendix A).Whatisclearthatsuicideandsuicide- to suicide-relatedbehavioursisnotconclusive(see Australian researchontherelationshipoflifeevents illness, suchasschizophrenia,thanthosewhodonot. greater impact on people who have a severe mental illness, economic hardship, loss or grief) may have a events (unemployment, relationship conflict, physical For example,thereissomeevidencethattraumaticlife that often determines the outcomes and consequences. the individualresponds,ratherthaneventsthemselves, people respond differently to different events and it is how on aperson’s decisiontotaketheirlife. as family experiences, personality traits and mental illness impact of immediate life events and other risk factors such on the following page, provides a summary onthefollowingpage,providesasummary 74 This is because 73

19 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au Figure 6: Personal factors and life events that have been linked to suicide

Domains Strong evidence of a link to suicide Some evidence of a link to suicide and and suicide-related behaviours suicide-related behaviours

Age 25-44 age group Developmental stages Older age

Personal Genetic factors Personality characteristics Gender (male) Gender identity (gay, bisexual) Vulnerability

Culture Indigenous Second generation immigrants Loss of cultural identity Asylum seekers

Family life Ongoing family discord Family history of mental illness Child custody disputes Family history of suicide Financial disputes Domestic violence Separation/divorce 20 Children under care/protection www.livingisforeveryone.com.au Research and Evidence in Suicide Prevention Living Is For Everyone: Adoptee

Health and Mental illness Physical illness or disability wellbeing Sudden deterioration in quality of life

Location/housing Rural or remote location Imprisonment Forced dislocation Homelessness

Financial wellbeing Financial difficulties Low socio-economic status Bankruptcy

Education Performance anxiety Bullying at school Lack of connectedness to school Unexpected or perceived academic failure

Risk behaviours Previous suicide attempts Gambling Self-harm Reckless behaviour Substance abuse Criminal/legal issues

Social networks Loss of social status/purpose Social isolation Lack/loss of social support Peer group pressure Cyber bullying Rites of passage Suicide pacts

Employment Professions/trades at risk Dismissal/retrenchment Unemployment Violence/assault in workplace Work stress Workplace bullying Retirement

Traumatic incidents Public humiliation Discrimination/vilification Abuse Surviving major incidents Sudden death or accident of loved one Suicide bereavement

Other Seasonal patterns Economic recession Disasters/catastrophes Inappropriate media reporting Figure 7: people areathighestriskoftakingtheirownlives. effects oflifeexperiences,toidentifythezoneinwhich from mentalhealthresearch,individualresilienceandthe interaction. is somedebateabouttheextentandtypeofthis life eventsinteractwitheachother, althoughthere The researchsuggeststhatmentalillnessand negative lifeexperiences and expectationsof The accumulation Situational despair life experiences expectations ofpositive The accumulationand Situational hope Figure 7 The linkbetweenindividualvulnerability, situationaldespair, mentalillnessandpotentialtotakeone’s ownlife bringstogethertheevidence HIGHEST RISKOFTAKING ONE’SOWNLIFE

Positive mentalhealth and thoughts abnormal perceptions impaired moodsand Dysfunctional behaviour, Mental illness and decision-making balanced judgement positive functioning, Healthy attitudetolife,

vulnerable totakingtheirownlife. and areexperiencingmentalillnessparticularly accumulation ofadverselifeevents(situationaldespair) It makesclearthatvulnerableindividualswhohavean ability tohandlelifestressors help-seeking behaviours, Personal copingstrategies, Individual resilience to handlelifestressors socially withdrawn,unable self-worth, inabilitytocope, Diminished senseof Individual vulnerability 21 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

’. It suggests suggests It 76 tipping point ). Figure 8 Figure bullying or violence. an argument with a loved one or significant person the breakdown of a relationship friend or public role model the suicide of a family member, a media report about suicide the onset or recurrence of a mental or physical illness unexpected changes in life circumstances experiencing a traumatic life event, such as abuse, the increasing likelihood of suicide-related behaviours, although they do not necessarily occur sequentially (see some indicators of times at which people may be under some indicators of times at which people to as ‘triggers’ particular stress. Sometimes referred also disorders or ‘precipitating events’, they include mental substance or physical illnesses, alcohol and/or other or the abuse, feelings of interpersonal loss or rejection, (unexpected experience of potentially traumatic life events points can be changes in life circumstances). Tipping someone who thought of as the ‘final straw’ that may lead has been considering suicide to take action. may act as Examples of events and circumstances that a tipping point include: • • • • • • • For the purposes of suicide prevention, precipitating events and triggers to suicide can be categorised into four different types of precipitating events, based on Tipping Points interactions complex from result behaviours Suicide-related some individual; some factors: of range wide a between background; cultural or socio-economic or family to related issues; lifestyle and community social, to related some frequently most The illness. mental to linked others and own their take people why understanding for model cited or ‘trigger’lives is the ‘threshold’ model. at exists behaviours suicide-related for potential the that in many people. The thresholda certain ‘threshold’ level as such factors by determined is person each in in a person’s genetic predisposition, biochemical factors (feelings state emotional their traits, personality physiology, supportof hopelessness), and the presence of ongoing cultural). economic, (social, systems own life risk of taking their The point at which a person’s event(s), increases due to the occurrence of precipitating in symptoms such as a negative life event or an increase of a mental disorder may be called a ‘ points varyTipping for every individual, but there are

purpose in life. all the time; of feelings sudden as such mood, in changes dramatic happiness after a long period of sadness or depression; giving away possessions or saying goodbye to family and/or friends; and/or ‘no way out’; the person); expressing feelings of hopelessness; their suicide plan; unusual for (especially when this is out of character or saying they have no reason for living or have no increased use of alcohol or other drugs; withdrawing from friends, family or the community; abnormal anxiety or agitation; abnormal sleep patterns – not sleeping or sleeping expressions of rage, anger or revenge; engaging in reckless or risky behaviours; there’s expressing feelings of being trapped, or that threatening to hurt or kill themselves; about looking for ways to kill themselves, or talking talking or writing about death, dying or suicide It should be noted that most people show some of these signs at some time, especially when they are tired, stressed or upset without being suicidal. • • • • • • • • • • • • • • Suicide warning signs may be a cry for help, and they associates and friends, can provide a chance for family, professionals to intervene and potentially prevent the may suicide from happening. The following behaviours common be considered as warning signs and are more their own life: among people who are considering taking Warning signs Warning is the earliest indication that A suicide warning sign a heightened risk of immediate someone might be at indicates that a person is having suicide. A warning sign taking their own life and may even serious thoughts about this action. be making plans to take The warning signs and tipping points can be likened The warning signs and that give early warning of the to potential ‘signposts’ behaviours. potential for suicide-related What we know about suicide know about What we warning points and tipping signs

Living Is For Everyone: Research and Evidence in Suicide Prevention 22 www.livingisforeveryone.com.au Figure 8: Risk factors bereavement U financial stress U isolation social orgeographical U substanceabuse alcohol orother U ofsuicide family history U orabuse family discord,violence U gender –male U mental healthproblems U Examplesoftypicaltriggersorprecipitatingeventstosuicide Warning signs orbehaviour impairedjudgement uncharacteristic or U prior suicideattempt U senseofpurposeinlife no reasonforliving, U friends,familyorsociety withdrawing from U druguse increasing alcoholor U there’s nowayout feeling trapped–like U hopelessness U Tipping point orsuicidemethods media reportonsuicide U being abusedorbullied U argument athome U ofpeergroup famousormember suicide ofsomeone U relativeorfriend death orsuicideof U illnessoraccident debilitating physical U loss ofstatusorrespect U relationship ending U Imminent link oranti-socialbehaviour impulsive, aggressive U means has accesstolethal U has planinmind U expressed intenttodie U 23 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

81 indicated and ’ can be seen to to seen be can ’ measures can be 77 adapted Gordon’s adapted Gordon’s selective recovery 79 , Universal ’ and ‘ and the 2000 version of the ) is primarily a clinical model that 80 universal preventative measures can be care ’, ‘ 78 Figure 9 Figure selective ) to provide the basis for the Australian National measures target individuals who are at high risk. treatment Figure 9 Figure are not appropriate for people experiencing normal human human normal experiencing people for appropriate not are frustration, episodic sadness, anger, reactions (anxiety, depression) in response to adverse life events. Terms such as ‘ than rather illness an are emotions human these that imply circumstances. stressful to reactions human normal minimise the amount of disability. the In the 1980s, with increasing awareness of contextual, complexity of the factors (risk, protective, model personal) that influence any illness, the traditional was replaced by the Jr. prevention model, introduced by R.S. Gordon than on It focussed on different groups of clients rather the treatment mechanisms. a whole population or a whole applied to everybody, community; risk; and applied to a sub-group at known increased indicated This approach is now the basis of suicide prevention in the United States. In 1994, Mrazek and Haggerty model to include the whole ‘spectrum’ of interventions (prevention, treatment, maintenance, recovery). This Mrazek and Haggerty spectrum was further adapted ( Mental Health Strategy Australian National Suicide Prevention Strategy. This spectrum ( long-term towards progress about assumptions makes that terms uses also It treatment. for need the and care The three-pronged approach The three-pronged approaches to care in the health sector were Traditionally, secondary and tertiary based on the concepts of primary, prevention. Primary prevention aims to prevent the onset of a particular disorder; secondary prevention aims to but identify and treat persons who have no symptoms and have developed risk factors or preclinical disease; tertiary prevention aims to minimise the effects of an and prevent complications established disorder,

interventions).

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people who may be at high risk of suicide (defined people who may be at high risk of suicide as in and life events, including mental health; and and life events, including mental health; and of prevention model that supports implementation activities and services across the community that of address the needs of the broader population, and of specific groups identified as being at risk the impact of the interaction of personal factors a suicide warning signs and tipping points, requires risk and protective behaviours; resilience and vulnerability;

• • The research and evidence related to: • • Rationale for the model suicide prevention model prevention suicide The Living Is For Everyone Is For Living The

Living Is For Everyone: Research and Evidence in Suicide Prevention 24 www.livingisforeveryone.com.au Figure 9: • • • events. Modificationsrequiredinclude: accurately therangeofhumanresponsestostressful applicable tosuicidepreventionandreflectmore indicated theneedforanewmodelthatismoredirectly As aresult,recentresearchandconsultationshave removing medicalandtechnicallanguageusing moving thefocusfromdefiningpathwaystosuicide, moving fromamentalhealthfocustoon plain language; and wellbeing; to definingthealternativepathwaysimprovedhealth with informationonpredisposingorinfluentialfactors is specifictosuicideprevention; towardsaperson-centredapproachthat interventions individual healthandwellbeing;fromclinically-oriented

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• • • • respecting andbuildingonthecollectiveknowledge promoting theimportanceofevaluationallsuicide responding to the need for community-based ‘safety including lessonslearntfromthesuicideprevention of whatworksanddoesnotworkinsuicideprevention; prevention activitiesinordertobuildtheevidencebase suicide research; safety initiatives in the medical profession, and from from systems theory, from safe handover and patient net’ functions between interventions, based on evidence

Early treatment literature. life events;and and experienceofroutinehumanresponsestoadverse

m Standard treatment e

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a r e 25 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

107

should be be should i 108 109 The MHCA report sees the essential role that that role essential the sees report MHCA The 110 .’ workplaces, and community groups. community-based services and foster to support recovery care; after discharge from clinical effective client hand-over practices between services and back into the community; and cooperation and communication between health professionals, community support services, families, individuals, health professional groups and services services and groups professional health individuals, and that interventions across the community, according way integrated and coordinated a in provided to the needs of the individual and community; and the into back and options, treatment between moving community through: discharge has been found to be 213 times greater discharge has been found in the general population; than would be expected men and 40 times higher in 27 times higher among the general male and female women, compared to population respectively. – – – for men, the rate of suicide in the first 28 days after for men, the rate of suicide suicide rates were at 12 months post discharge, withthe responsibility for suicide prevention rests people support to provided be should nets’ ‘safety a massive investment in a range of community-based community-based of range a in investment massive a care) services’ community of range ‘full a by played be to needs treatments. clinical conventional between gaps the fill that The LIFE (2007) model on the The LIFE (2007) model is therefore based premise that: • • • • the need to modify the Mrazek This evidence suggests of mental health interventions,and Haggerty spectrum for support and care in the gaps to respond to the need segments. ‘Community-based in between the model’s which focus safety nets’ are needed to bridge these gaps who are on providing the support needed by people stages of feeling suicidal and are in transition between professional care and support. proposal recent the in part, in mirrored, also is This for (MHCA) Australia of Council Health Mental the from ‘ clinical from discharge (after services support recovery

98 ’ ’, which ). It is after leaving after leaving 106

97 ’ 99 ’. Current evidence 100 , and year continuity of care 105 In complex health systems, In complex health systems,

86-92 , month 93-96 101 universal, selected, indicated 103 104 the transfer of professional responsibility , week 102 clinical treatment; a patient has a change of location of care, and/or to another. the care of a patient shifts from one provider treatment; inpatient care than before a person begins this inpatient care than before a person begins this type of treatment. The risk is elevated in the first day patients are 200 more times more likely to suicide after the risk of suicide is greater after leaving psychiatric Health care itself is complex with many steps involved Health care itself is complex with many steps Intervention - To take action or provide a service so as to produce an a service so as to produce take action or provide Intervention - To health or outcome or modify a situation. Any action taken to improve a disease or dysfunctional behaviour. change the course of, or treat to another when: • • in most types of care. The statistical probability of error in most types of care. The statistical probability grows… increases as the number of steps in a process most health care services are now organised around networks or areas of service provision. Clinical handover refers to: care provider ‘the transfer of information from one health handover and patient safety is increasingly emphasised handover and patient safety is increasingly in the health sector. and the Quality In 2004, the Australian Council for Safety of Health Care (p.18) declared that: ‘ well documented that failures in complex systems well documented that at the points of handover of tend to occur primarily case, between the component responsibilities – in this parts of the spectrum. points are increasingly being failures at these handover importance of providing safe clinical recognised, and the The Mrazek and Haggerty spectrum of mental health The Mrazek and Haggerty interventions is a complex network of loosely connected interventions involving many players (the community, and several different types friends, clinicians) family, of interventions ( The inclusion of ‘safety nets’ of ‘safety The inclusion i • • on a temporary or permanent basis The suicide literature also provides strong evidence that major system failures occur in the transition zones between clinical responsibilities. suggests that: attention to the transitions between health services,attention to the transitions between health duty of care with greater emphasis on responsibility and for the patient. The British National Safety Agency is pursuing a policy of ensuring ‘ it defines as ‘ and accountability for some or all aspects for a patient or group of patients, to another person or professional group There is a move in Australia and overseas to pay more There is a move in Australia and overseas

Living Is For Everyone: Research and Evidence in Suicide Prevention 26 www.livingisforeveryone.com.au 2. 1. prevention modelare: prevention activities support (see occur acrosseightoverlappingdomainsofcareand To reducethe lossoflifethroughsuicide,activitieswill Eight domainsofactivity • • • following specificfeatures: Haggerty modelwasfurtheradaptedfor of thereview In light of the research and consultations undertaken as part Key features oftheLIFE(2007)model it includes community-based ‘safety nets’ to support it includescommunity-based‘safetynets’tosupport language,to the newmodelusesmoreeveryday the individual’s health,wellbeingandresponsestolife is most critical. things aremostlikelytogowrongandwhensupport handover points between interventions. This is when – that people are most exposed to risk at these systems generally, andinrelationtosuicideparticular This reflects the strong evidence – both from health another, oraredischargedbackintothecommunity. people as they move from one treatment setting to make itaccessibletoawideraudience;and with noapparentwarning; reactions andaneedforimmediatespecialisedcare move fromapparentgoodhealthdirectlyintoadverse and totheneedforspecialisedcare.Individualscan linear path;fromrisk,towarningsign,tippingpoints adverse eventsanddonotalwaysfollowalogicalor vulnerability andresilience.Theyresponddifferentlyto people respondandcopedifferently, intheir andvary events areatthecentreofmodel,recognisingthat and resilience. ofabusetobuildstrength children whoaresurvivors and totheirelevatedriskofsuicide;orworkingwith taken theirownlifetorespondgriefandloss, for instance,workingwithfamiliesofthosewhohave promotes self-helpandsupport.Thismightinclude, resilience, strength,capacityandanenvironmentthat communities whoareidentifiedas‘atrisk’tobuild Selective interventions families, schoolsandcommunities. suicide, andtocreatestrongermoresupportive of suicide,reduceinappropriatemediacoverage population orpopulationstoreduceaccessmeans Universal interventions Figure 10 LIFE Framework(2007) ). Theeightdomainsofthesuicide

LIFE (2007)continuumofsuicide aimtoengagethewholeofa entailworkingwithgroupsand LIFE (2007) , the Mrazek and , theMrazekand with the

5. 4. 3. 8. 7. 6. targeted andintegratedsupportcare, the firstpointofprofessionalcontactthatprovides treatment andspecialisedcareisneeded.This Finding andaccessingearlycaresupport exposure toriskarehigh. providing supportandcarewhenvulnerability circumstances andpotentialtippingpoints; being alertto,signsofhighorimminentrisk,adverse Symptom identification toprovidesupportfortheperson. action ifnecessary early signs of risk in the individual and to take immediate increase local capacity to be alert and responsive to specific family, or for community professionals – to professionals providingorsharingthecare,for Another partmightbetoprovideeducationforother manage the situation, the problems or the symptoms. the risk.Apartofthismightbetohelpperson or haveearlysignsofanillness,knowntoheighten early signsofsuiciderisk,orwhomaybeinasituation, Indicated interventions needed topreventrecurrences. issues andawarenessofthestrategiesthatmaybe to increasebroadercommunityeducationaboutthe environment ofself-help.Thismaybetheopportunity cope, andtobuildstrengthresiliencewithinan friends andfamilytosupportpeopleadapt, professionals, workplaces,communityorganisations, Ongoing careandsupport family andtheirlocalcommunity. protective factors for the individual, their immediate future. Alongside this, efforts can be made to improve suicide to remove them or to reduce their impact in the a time to directly focus on distal or background risks for risk of adverse health effects. In particular, this may be integrated care to consolidate recovery and reduce the preparing forapositivefuture,entailingcontinuing Longer-term treatmentandsupport assist recovery. underlying conditions,andtoimprovewellbeing behaviours, comprehensivelytreatandmanageany integrated, professionalcaretomanagesuicidal Standard treatment further informationandcareasneeded. toensuretheclient’smonitors interventions accessto whenspecialisedcareisneeded: target people who are showing whichentailsknowing,and involvinghealth to assist in when 27 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au provides a summary of the range of types of LIFE (2007) continuum of suicide LIFE (2007) continuum activities prevention 10 Figure and interventionssuicide prevention activities that are of community response to reducing essential for a whole risk of suicide, suicide attempts, the rate of suicide, the in individuals. For each activity/ and of suicidal behaviours intervention the the following is defined: the target group; and who might be involved in the proposed outcomes; activity/ intervention. ); );

); ). They are: targeted

specialised care promoting self-help pathways to care responding to help-seeking responding to help-seeking ). ); suicide prevention model identifies six suicide prevention model ); promoting local understanding and support LIFE (2007) individual, family and community growth and communities can build resilience and improve their and communities can build resilience and of adversity general health and wellbeing during times ( and development individuals who might be feeling suicidal ( support and care suicidal or support for those who are feeling chronically are exposed to greater risk of suicide ( and prevention and of the capacity for individuals and local prevention and of the capacity for individuals early warning communities to recognise and respond to people signs and to take appropriate steps to make safe ( environment that supports self-help ( environment that supports interventionto assist people to resolve issues and/or ( access appropriate help behaviours maintaining an environment where individuals, families maintaining an environment where individuals, building the capacity for meeting the needs of building the capacity for meeting the needs local providing access to specialist care and integrated increasing understanding of suicide and suicide increasing understanding of suicide and suicide assisting people to help themselves and creating an an creating and themselves help to people assisting signs and providing early recognising early warning emergency staff, health professionals, primary health care practitioners and hospital personnel). The effective implementation of the model assumes The effective implementation of the model local the development and maintenance of close working partnership between community-based friends and associates as ‘recovery support’ (family, well as community-based service providers and health centres) and health sector professionals (local doctors, • • • • • • Six overlapping areas of care and support and care of areas Six overlapping The people for required support and care of areas overlapping ( who may be feeling suicidal

Living Is For Everyone: Research and Evidence in Suicide Prevention 28 www.livingisforeveryone.com.au Figure 10: LIFE Framework continuum of suicide prevention activities

Target Outcomes Who is involved? groups

Universal Activities Reducing access to means of suicide, altering Involving: individuals, families, consumer and intervention that apply to media coverage of suicide, providing community carer organisations, multicultural organisations, everyone (whole education about suicide prevention and creating local councils, sporting and recreational clubs, populations) stronger and more supportive families, schools workplaces, media, educational organisations, and communities. providers of education and information on mental health and suicide prevention, service clubs and pubs.

Selective For communities Building resilience, strength and capacity and an Involving: individuals, families, consumer and intervention and groups environment that promotes self-help and help- carer organisations, multicultural organisations, potentially seeking and provides support. local councils, sporting and recreational clubs, at risk workplaces, media, educational organisations, Divisions of GP, service clubs and pubs. 29 Indicated For individuals at Building strength, resilience, local understanding, Involving: individuals, families, consumer and intervention high risk capacity and support; being alert to early signs carer organisations, multicultural organisations, of risk; and taking action to reduce problems GPs, police, gerontologists, rehab providers, and symptoms. emergency workers, specialist physicians, sporting and recreational clubs, workplaces, educational organisations, service clubs and pubs. www.livingisforeveryone.com.au

Symptom When Being alert to signs of high risk, adverse health Involving: GPs, help lines, police, gerontologists, identification vulnerability and effects, and potential tipping points; and providing rehab providers, emergency workers, specialist exposure to risk support and care. physicians, teachers, pharmacists, workplaces are high family and friends and other gatekeepers.

Early Finding and Providing first point of professional contact; Involving: GPs, psychologists, allied mental treatment accessing targeted and integrated support and care; health professionals, Aboriginal Health Workers, Living Is For Everyone: Research and Evidence in Suicide Prevention early care and and monitoring and ensuring access to further emergency departments, police, gerontologists, support information and care. emergency workers, specialist physicians, community health services, help lines, crisis teams, school counsellors.

Standard When Providing integrated professional care to manage Involving: psychiatrists, psychologists, GPs, allied treatment specialised care suicidal behaviours and improve wellbeing as a mental health professionals, Aboriginal Health is needed step in recovery. Workers.

Longer-term Preparing for a Providing ongoing integrated care to consolidate Involving: psychiatrists, psychologists, GPs, allied treatment positive future recovery and reduce the risk of adverse mental health professionals, families, workplaces, and support health effects. local community organisations and clubs, rehabilitation services, Aboriginal Health Workers, help lines.

Ongoing Getting back Building strength, resilience, and adaptation and Involving: GPs, allied mental health professionals, care and into life coping skills, and an environment that supports Aboriginal Health Workers, community support self-help and help-seeking. service providers, families, local community organisations, workplaces and clubs.

‘Safety Nets’ for people moving between treatment options, and back into the community. This includes: • community-based services to support and foster recovery after discharge from clinical care; • effective client hand-over practices between services and back into the community; and • effective cooperation and communication between health professionals, community support services, schools, families, workplaces and community groups. Suicide in Australia

30 The Australian Bureau of Statistics is responsible for www.livingisforeveryone.com.au Research and Evidence in Suicide Prevention Living Is For Everyone: gathering data from each of the state jurisdictions and compiling the annual publication Causes of Death. The number of suicides in any given year is always underestimated to some extent.111 There are some issues around quality of data due to inconsistent coronial practices, however there are ongoing efforts to make the statistics as accurate as possible.

Suicide trends and comparisons

Suicide in Australia accounts for 2.5% of all male deaths and 0.7% of all female deaths (2005 figures). Figure 11 provides a comparison of rates of suicide as a cause of death for males and females, with other high incidence causes. As is common in most countries internationally, the suicide rate for men in Australia is significantly higher than that for women.

Suicide rates are usually expressed in terms of deaths per 100,000 people. Figure 12 shows the 2005 suicide rates (per 100,000) for all Australian States and Territories over a five year period to 2005.

NOTE: In jurisdictions with smaller populations, one or two suicides can have a significant impact on the total rate.112 (Source: AustralianBureauofStatistics) Figure 12: (Source: AustralianBureauofStatistics) Figure 11: Murder, assault Influenza, pneumonia Car, bikeaccidents Diabetes Suicide Breast cancer Cancer oftheairways Heart disease Causes Total Australian CapitalTerritory Northern Territory Tasmania Western Australia South Australia Queensland Victoria New SouthWales State Total

AgestandardisedsuicideratesbyAustralianStateandTerritory, 2000-2005 Selected causesofdeathinAustraliabygender 111 111 Males Deaths 169 182 360 393 438 Males Deaths 67,241 130 1,331 1,224 1,775 1,657 17 4,694 15,682 1,657 26 37 52 444 9 8 22 34 49 99 112 111 Females 63,473 69 1,703 414 1,754 444 2,719 2,705 15,515 Females 0.2 2.0 1.8 2.6 2.5 <0.1 7.0 23.3 Males % ofalldeaths 10.3 10.6 22.5 15.6 10.0 14.8 11.6 9.9 8.0 Rates (per100,000) 0.1 2.7 0.7 2.8 0.7 4.3 4.3 24.4 Females 31 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

When viewed together, a picture emerges of the main When viewed together, that have high suicide numbers and geographic locations Appendix B). high suicide rates (see

5 to 9.9 Below 5 Not mapped* Distribution (by rate per 100,000) of deaths through suicide and self-inflicted injuries 100,000) of deaths through suicide and Distribution (by rate per

shows the geographic distribution of deaths shows the geographic Published in the Public Health Information Department Unit from Average annual rate of suicides over the four years 2001 to 2004 Average death registrations supplied by the Australian Bureau of Statistics 20 and above 15 to 19.9 10 to 14.9 *data not mapped for area with 1 to 4 deaths (indirectly age-standardised) Rate (indirectly Source: (Source: PHIDU, University of Adelaide, 2006) NOTE: Figure 13: across Australia (2001-2004) Statistical Subdivision rate per 100,000 population by ABS mortality Age-standardised Figure 13 Figure injuries by absolute through suicide and self-inflicted 100,000) for statistical number and by rate (per subdivisions.

Living Is For Everyone: Research and Evidence in Suicide Prevention 32 www.livingisforeveryone.com.au ii other countries(2002) Figure 14: Rate per100,000 fully understandingdifferences. andanotherwithout the reportedsuiciderateofonecountry It isproblematictomakemeaningfulcomparisonsbetween the World HealthOrganisation(WHO) a selection of countries whose system for providing data to data aboutdeaths. countries is difficult due to the different ways of collecting and lowerthanothers.Makingcomparisonsbetween The suicide rate in Australia is higher than some countries context international Placing Australianratesinan

The WHOpublishesdata onthecausesofdeathindifferent countries. Norway Germany Canada Sweden Australia Argentina Singapore USA Malaysia United Kingdom Netherlands Spain Brazil Italy Greece Country

Age-standardisedsuicideratesinsome Figure 14 shows the suicide rates for shows thesuicideratesfor 10.4 10.2 9.8 9.5 8.0 7.8 7.4 6.3 5.4 5.0 2.8 Rate per100,000 10.7 10.6 10.6 10.4 ii

is similar to Australia’s. bodgbddeathdalyestimates.xls) (Source: WHO,http://www.who.int/healthinfo/statistics/ Denmark Country Russian Federation Hungary Finland Japan Belgium Korean Republic Poland Austria Switzerland Cuba France New Zealand Chile Ireland 10.9 Rate per100,000 36.0 22.7 20.6 18.7 17.6 17.2 15.2 14.3 13.5 13.5 13.2 12.2 11.5 11.1

33 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

121

120 and treatment for mental illnesses, such as depression, using a combination of traditional and modern treatment methods. surrounding suicide and mental health, and employ surrounding suicide and mental health, and culturally appropriate techniques and methods. culturally competent staff in developing services that are Indigenousculturally appropriate. This includes involving people in the consultation, negotiation and decision of ownership community establish to process, making suicide prevention activities and other initiatives; recognising and harnessing the broad range of skills and expertise of Indigenous people to improve health and wellbeing and reduce suicidal behaviours; reduced to contributing factors significant are present, Australians Indigenous among health mental and physical are communities and families on effects the that and passed from one generation to the next; Indigenous population; social issues affecting Australia’s and suicidal behaviours. Indigenous people have a have people Indigenous behaviours. suicidal and not that wellbeing and health of understanding holistic whole. a as community the but individual, the affects only including health, of aspects all includes being Well health; spiritual and cultural social, physical, mental, illness promotion, rather than focusing on mental and suicide; communities; and providing regular screening and culturally appropriate drawing on the expertise of Indigenous people anddrawing on the expertise of Indigenous people and past both loss, and trauma that understanding providing coordinated services combat the range of to reflect how Indigenous people view health, mental health health mental health, view people Indigenous how reflect reflect a focus on wellbeing and mental health local encourage ownership and involvement from show respect for cultural beliefs and attitudes • Implications for suicide prevention Implications for suicide prevention activities and interventions Effective suicide prevention strategies in Indigenous communities are likely to involve: • • • • As is the case amongst non-Indigenous Australians, As is the case amongst choose to take their own life are Indigenous people who a range of risk factors and more likely to be experiencing behaviours differs between the rate of suicide-related throughout Australia. Indigenous communities strategies in Indigenous Effective suicide prevention communities need to: • • • •

118 113 114 115 116 and 119 117 assist people who may be at risk of suicide or who have been affected by suicide; compared with the wider Australian community also people. older for particularly suicide, for factor risk a poses to cause a person to lose their sense of purpose and meaning in life. Suicide among Indigenous people is likely to be a response to the broader social context of disintegration of their culture and communities; Indigenous communities as a result of the continuing Indigenous communities as a result of the and loss and traumatisation from past dislocation the deaths mistreatment, as well as current grief from of family and community members and friends; system is disproportionate to the total population; domestic violence or abuse, and alcohol and other domestic violence or abuse, and alcohol and drug abuse; that suicide of another family or community member may increase the likelihood of ‘copy-cat’ suicides; known environmental risk factors for suicide, including known environmental risk factors for suicide, lack of education, low socio-economic status, poverty, to poor employment prospects, reduced access services, living in rural or remote communities, loss of cultural identity and social isolation is known loss of cultural identity and social isolation trauma and grief are ever present within many trauma and grief are ever present within many prison the number of Indigenous inmates in Australia’s many Indigenous people have been affected by the many Indigenous people have been affected Indigenous people are often exposed to a number of Indigenous people are often exposed to a lack of access to culturally appropriate services to Australians Indigenous amongst health poor relatively • • • • for suicidal behaviours and self-harm. These include: for suicidal behaviours and self-harm. These • population as a whole. Over the past 30 years Indigenous Indigenous years 30 past the Over whole. a as population Indigenous young with dramatically, increased has suicide the most at risk. males (aged 17-23) being among some groups of Indigenous The high suicide rate in young males) is often attributed Australians (particularly the risk to a number of factors that combine to magnify Suicide among Australia’s Indigenous population is Indigenous Suicide among Australia’s the general Australian population, significantly higher than suicide the years, some in that, suggesting estimates with in specific communities is rate for Indigenous people than that for the Australian as much as 40% higher Indigenous Australians and Australians Indigenous suicide • •

Living Is For Everyone: Research and Evidence in Suicide Prevention 34 www.livingisforeveryone.com.au 35 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au Men 127

It is also valuable 128 130 131 and/or 126 It is important that professional carers, 129 and prefer to solve problems on their own, without and prefer to solve problems being a burden on others; adequately not do services these that feeling a or area situation. their in help not would and needs their for cater a feeling that help-seeking displays weakness or failure a feeling that help-seeking their in services support available of awareness of lack • • such as general practitioners, actively ask men about such as general practitioners, actively ask initiate their mental and emotional state, as men rarely conversations about these topics. Implications for suicide prevention suicide prevention Implications for activities and interventions prevention Recent studies propose that effective suicide and mental programs for men should promote physical skills and strengths, rather health, drawing on men’s than on perceived ‘failings’ or shortcomings. respond well to services that encourage problem- over solving and enhance their ability to gain control their emotions and circumstances. that target the to introduce suicide prevention programs not seek help family and friends of suicidal men who do themselves. 123 125 iii 124 Life events such as depression, 122 not seeking help for emotional difficulties or communicating their feelings of despair or hopelessness to others; negative emotions or distress, which may result in more chronic and severe emotional responses to adverse life events; isolation. For some, these events can lead to feelings ofisolation. For some, these events can lead risk; shame and guilt, which can further increase men undergoing traumatic life events. Potentially Potentially events. life traumatic undergoing men likelihood men’s increase may that events life traumatic separationof suicide include relationship breakdown, social and stress financial unemployment, children, from accounts for around a quarter of all deaths among menaccounts for around a in their middle years; men in prison or custody; and men from Indigenous communities. men living in rural or remote areas; young or in their middle years (20 to 44 years old Suicide Suicide old years 44 to (20 years middle their in or young older men (over 75); tendency not to recognise or respond to their own that result in instant death; higher likelihood in men to choose methods of suicide

Source ABS 2007. Suicides. 2005 -Catalogue No. 3309.0 ABS Source Suicide accounts for more than one quarter of all all of quarter one than more for accounts Suicide 44 and 20 of ages the between men among deaths years in Australia. problems, relationship difficulties, financial unemployment, a significantwork stress, and alcohol and drug abuse play age group. role in determining the risk of suicide in this • • be at risk. But men of all ages and backgrounds can • • respond quickly and effectively to any warning signs. respond quickly and effectively men who are the most at risk are: Statistics tell us that the • • Suicide is four times more common in men than women, women, than men in common more times four is Suicide means This lives. own their took men 1,657 2005, in and own lives in Australia everythat five men take their day. very life own their take to decision the make men Many to essential is it so signs warning few showing quickly, Men and suicide Men and • Various reasons for the relatively high rate of suicide in Various men in Australia have been suggested. They include: • • iii

Living Is For Everyone: Research and Evidence in Suicide Prevention 36 www.livingisforeveryone.com.au Figure 15: • • differences insuiciderates. There aremanypossiblereasonsfortheseregional 20.1 per100,000population). remoteareas(rate: the highestratesrecordedinvery remote) regional, outerremoteandvery categories ofremotenessareas(i.e.majorcities,inner Figure 15 can haveasignificantimpactontherate. numbers inruralandremoteareas,oneortwosuicides metropolitan areasbecausewiththesmallpopulation widely fromyeartoyear, comparedtoregionaland more among men.Actualrates,whilehigh,canvary risen substantiallyoverthepastfewdecades,especially Suicide ratesinruralandremotecommunitieshave remote locations Suicide inruraland (Source: AustralianandNewZealand AtlasofAvoidable Mortality, PublicHealthInformationDevelopment Unit,UniversityofAdelaide,2006) ASGC Remoteness Easier accesstomeansthatleadimmediatedeath. Economic andfinancialhardship.Changesinthe possibly unsafe. where peoplecanfindthemselvesfeelingaloneand also likelytobemoresecludedorisolatedlocations be moreavailableinruralandremoteareas.Thereare Firearms andotheraggressivemeansofsuicidemay breakdown, gamblingorsubstanceabuse. lead tootherproblems,suchasrelationshipconflictor and areallknownriskfactorsforsuicide.Theymayalso difficulties canleadtodepressionandhopelessness, communities. Bankruptcy, unemploymentandfinancial substantial effectonmanypeopleinruralandremote drought) inregionalAustraliahaveadirectand economy andextremeclimateevents(e.g.floods, Inner Regional:3 Inner Regional:2 Classification Very Remote:5 Major Cities:1 showsthedifferentratesofsuicideforfive Remote: 4 Suicide ratesfordifferentregionsbasedonremoteness1997–2001 0 Avoidable Mortality:Suicide&Self-inflictedInjuries(ASR)per100,000population 134 135 133

Theyinclude:

5 132 with 1 0 • • • • • Combinations ofsuicideriskfactors.Formanypeople Oftenruraland Reduced accesstosupportservices. Less help-seeking.Manyruralpeopleareresilientand Social isolation.Manypeopleinruralandremote Within themanyIndigenouscommunitiesinruraland Within support andcaredifficultor, insomecases,impossible. telephones. This makes accessing traditional methods of not haveaccesstotheinternetandsomedo remotes areas. Many people living in rural Australia do areas may not be appropriate for people living in rural and thatcaterforpeopleinmetropolitan Services services. suchasmentalhealth of communitysupportservices, remote communities do not have access to a range or theircommunity. from seekinghelpindifficulttimesfamily, friends in regionalandruralareas.Thiscandiscouragethem resourceful, andhaveastrongsenseofself-sufficiency contribute tosuicidalbehaviour. This canleadtolonelinessanddepression contact withfamily, friendsandothersupportnetworks. Australia aresociallyisolated,withlessface-to-face economic marginalisation. communities atriskof and environmentalfactorsexistthatputpeopleinthese remote Australiaawiderangeofsocial,psychological to increasetheriskofsuicidalbehaviour. in ruralandremoteAustralia,riskfactorsmaycombine 1 5 suicide includingsocialand 20 25 215 283 1,491 2,717 7,612 Deaths

132 37 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

140 139 147 139 and 142 144 and Those people who engage in repetitive 143 141 people who self-harm report suicidal thoughts at the time time the at thoughts suicidal report self-harm who people who people of 85% to 55% between and self-injuring of self-harm have a history of at least one suicide attempt; suicide. likely self-harm (more than two episodes) are more to suicide than those with only one episode, die by between a quarter and a half of people who suicide have previously carried out a non-fatal act of self-injury; attempt suicide both score significantly higher on measures of depression and suicidal thoughts than the latter group have the general population. However, a more negative attitude towards life and report more traumatic experiences. despite having no apparent intention to die, up to 41% ofdespite having no apparent intention to die, non-suicidal self-injury is a strong risk factor for people who engage in self-harm and those who people with borderline personality disorder, but also personality disorder, people with borderline serious inflict deliberately may psychosis a with people occurs in a variety of other psychiatric disorders; and occurs in a variety of injury and this may result in death, though on themselves, common most The suicide. to intend not did person the compulsive, is however, self-injury, deliberate of form It is more likely to occur when theimpulsive, and repeated. may or may person The difficulty. in or distressed is person behaviour. or thoughts suicidal have not There is a complex link between self-harm and suicide; and self-harm between link complex a is There • • report typically themselves harm deliberately who People low self- feeling hopeless, anxious and rejected, having in events the with cope to difficult it finding and esteem their feelingstheir lives. They often find it difficult to explain tension orto others. They say that they do it to release themselves punish to pain, emotional reduce to pressure, others letting avoid to shame, and guilt of feelings to due sense a themselves give to or feeling, are they how know also may self-harm Deliberate lives. their over control of requiring illness mental underlying an of symptom a be treatment by a health professional. • • •

138

136

137 refers to the attempt to inflict physical harm iv In this group, self-harm is not usually accompanied by suicide-related behaviours or ideation; populations the prevalence of non-suicidal self-injury has been found to be as high as 60%, while the most recent estimate of self-injuryadolescents is 6.2%; in Australian disabled usually cannot express their emotions verbally. young people aged 11-25 years. In adult psychiatric psychiatric adult In years. 11-25 aged people young people who are developmentally or intellectually A recent publication by the American Association of Suicidology proposes publication by the American Association of Suicidology proposes A recent use of the generic term 'self-harm' to cover a range of behaviours. • • once the problem is resolved. Others may self-harm over a much longer period, whenever they feel pressured or distressed, and use it as a way of coping, particularly where they have not learned or cannot use more positive ways of coping. Groups who are prone to self-harm include: frequently access public emergency and psychiatric frequently access public emergency and psychiatric health services. Self-harm varies with the individual. Some people while others may do deliberately self-harm regularly, it only once or twice and then stop. They may injure themselves in response to a specific problem and stop skin causing sores or scarring, and inhaling or sniffing skin causing sores or scarring, and inhaling harmful substances. friends, Self-harm causes distress for patients, families, on the and carers. It also places considerable burden often as people who self-injure Australian economy, describe injuries a person inflicts on himself or herself describe injuries a person inflicts on himself burning without necessarily the intent to suicide. Cutting, common and ingesting toxic substances are the most methods methods of deliberate self-harm but other punching include taking overdoses of medications, body against something, oneself, throwing one’s at one’s pulling out hairs, scratching, picking or tearing ‘Self-harm’ self and is often done in secret and without to one’s self-injury’anyone else knowing. The terms ‘deliberate or ‘non-suicidal self-injury’ are also often used to enhancing social connectedness and participation in the enhancing social connectedness providing gatekeeper training to community as well as for men at risk. ensure support and care Self-harm and suicide Implications for suicide prevention suicide prevention Implications for activities and interventions should focus on increasing Suicide prevention efforts servicesthe availability of support in these regions and iv

Living Is For Everyone: Research and Evidence in Suicide Prevention 38 www.livingisforeveryone.com.au • • • • • Deliberate self-harmshouldalwaysbetakenseriously: activities andinterventions Implications forsuicideprevention adequate careandsupportforpeoplewhoself-injure people whoself-injureandthoseattemptsuicide people whorepeatedlyinjurethemselvesmaycometo some researchsuggestspeoplewhoself-harm one ofthemajorpredictorssuicideisaprevious people whoself-injureorattemptsuicide. of suicidemayalsobeeffectiveinreducing community recognitionandresponsetowarningsigns repeated, andpossiblyfatal,behaviour. or attempttotaketheirownlivesisessentialprevent control theirpainandmayconsidersuicide; severely, ormaystarttobelievetheycannolonger feelings, thepersonmayinjurethemselvesmore to relievetensionorcontrolnegativethoughtsand fails all controloverlife.Additionallyiftheself-injury that thingswillneverimproveortheyhavelost have similarfeelingsofhopelessness,oftenbelieving of hopelessnessandpossiblysuicidalthoughts; feel thattheycannotstop,andthismayleadtofeelings real; accidental deathisvery accompanying thedeliberateself-harm,riskof with life.Howeverevenifthereisnosuicidalintent and thatharmingthemselvesistheirwayofcoping indicates thattheydonothaveanyintentionofdying are atincreasedriskofsuicide,butotherevidence suicide attempts; episode ofdeliberateself-harm,includingprevious 145 146 Increasing

expectations. It is important to particularly consider consider particularly to important is It expectations. their meet to fail or traumatic be can immigration others, for However, opportunities. employment and educational better and reunion family including experience, positive very a is immigration some, For of migrationonthem. the differentreasonsthatpeoplemigrateandimpacts oforigin;andtheratesuicidemayalsoreflect country particular groupsgenerallymirrorsthesuiciderateof the factthatinearlystagesofsettlement,ratefor to Australia,whichinsomecasesisaccountedforby There is great diversity in the rate of suicide for immigrants suicide ratesandmentalillnessareunclear. contributions ofpreandpostimmigrationfactorsto ofbirth.ThisissoinAustralia,buttherelative the country countries appear, overall,tobehigherthanthatfoundin country, andsuicideratesamongimmigrantstoWestern to move fromoneculturetoanothervariescountry of suicideandsuicidalthinkingamongpeoplewho While suicideoccursinmostcultures,thephenomenon diverse backgrounds culturally andlinguistically Suicide andpeoplefrom • • • • number ofreasons: a for backgrounds (CALD) diverse linguistically and culturally from people to relation in prevention suicide refugees mayhaveexperiencedwarandtrauma,fled a significantnumberofpeoplefromCALDbackgrounds for somewhoareelderly, becomesociallyisolated, itself in can culture new a to adapting of process the or depression. put themathighriskforposttraumaticstressdisorder entire socialfabricoftheirlives.Theirexperiencesmay their homecountry, and losttheirfamily, friendsandthe andsupportsthatareavailable; and of services operate,orsimplyunaware oftherange how services language andculturalbarriers,maybeconfusedabout becauseof find itdifficulttousemainstreamservices available. Theymayalso culturally appropriateservice available incommunitylanguages,orthereisno becauseinformationisnot suicide supportservices or arereluctanttodoso.Often,theymissouton do notseekhelpfortheirmentalhealthproblem, experience thatplacesthematriskofsuicide; from theircultureandlandofbirthmaybeatraumatic suffer healthproblemsorareunemployed,separation and customs; values language, beliefs, cultural in differences wide are there where particularly experience stressful a be

148

39 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au Suicide in refugee communities

While the research does not provide consistent rates for Implications for suicide prevention mental illness affecting immigrants who are refugees, activities and interventions the overall rate of mental illness is widely believed to be significantly higher than in the general Australian Positive experiences in the new country contribute population.149 Studies from the United States estimate the favourably to mental health and wellbeing. Studies of incidence of mental illness among refugee children to be immigrants and refugees suggest that social support 40-50%.150 Closer scrutiny of this research reveals post and cultural integration are protective factors for suicide traumatic stress disorder (PTSD), depression and anxiety among immigrants.155 Migration can be a very stress- disorders are diagnosed most frequently,151 although a inducing phenomenon, but experiences differ both pre range of other mental illness and social and behavioural and post migration156 and mental illness is a significant problems are also widely reported.152 PTSD has attracted risk factor for suicide among refugees. Suicide prevention the most research attention and now constitutes a activities needs to specifically address this issue. separate field of investigation in its own right. Past Effective suicide prevention activities in refugee 40 trauma may take the form of events experienced or www.livingisforeveryone.com.au Research and Evidence in Suicide Prevention Living Is For Everyone: communities need to include culturally appropriate mental witnessed, where lives have been threatened or people health interventions, particularly for people who have have been killed. Also significant is the loss of family, experienced pre-migration torture and trauma, refugee friends, relatives, personal belongings and possessions, camp internment, periods of containment in immigration livelihood, country, and social status. detention and post-migration stresses.157 The risk factors most commonly found to increase the likelihood of suicide among refugees and immigrants include exposure to violence and trauma, lack of family support, living with a mentally ill family member, family stress, being alone or unaccompanied, prolonged (more than 6 months) incarceration in immigration detention centres,153 poor coping skills and resettlement stress. Poverty, discrimination and acculturation stress are all thought to be linked to low self-esteem, depression and suicide attempts.154 Enduring stresses around housing, physical illness, quality of relationship with their partner, and finances are also associated with elevated risk of mental illness and suicide-related behaviours. 41 www.livingisforeveryone.com.au Living Is For Everyone: Research and Evidence in Suicide Prevention Caution is However, the the However, 165-167 172 173 169 170

168

The program aimed at reducing 174 There are no published data on the impact impact the on data published no are There 171 was a suicide prevention program initiated within the US Air Force in 1996. suicide risk factors and enhancing protective factors, including changing policies and social norms, reducing the stigma of help-seeking for mental illness and improving awareness of mental health issues. the location and sample characteristics can have a the location and sample characteristics can significant effect on outcomes. for health professionals Training and diagnosis the on program educational postgraduate A practitioners general all to offered depression of treatment 1980son the island of Gotland in Sweden in the early the on rates suicide in decline significant a to linked was increase an (including outcomes related other and island in prescription of antidepressants). impact of primary on suicide care physician education with mostly and time-limited was Gotland on rates females. countries. other in rates suicide on programs similar of and practitioners general for programs education Several produced have Australia in professionals care health other positive outcomes in terms of increased knowledge and no is there but patients, at-risk of detection regarding skills evidence regarding long-term changes in clinical practice or reduction of actual suicide rates. Gatekeeper training One of the most effective gatekeeper training programs Evidence about the effectiveness of suicide prevention Evidence about the effectiveness of suicide elsewhere. activities is quite limited, both in Australia and suggests that evidence from other countries However, treatment of physician education in the recognition and access depression, gatekeeper training, and restricting that to lethal means of suicide are promising approaches may have an impact on suicide rates. design, required in relation to such evidence, as study

, 158-160 161 . indicated , a number of of number a , indicated 164 and has been further and 162 . selective , universal LIFE (2007) Following the United Nations Guidelines for for Guidelines Nations United the Following 163 prevention refers to activities targeting the prevention refers to activities targeting the interventions are aimed at specific at-risk Living Is For Everyone for (LIFE) A Framework governments have adopted comprehensive approaches people for interventions as well as domains, these across C). Appendix (see suicide by bereaved gatekeepers; screening of at-risk individuals; treatment for pharmacotherapy, (including suicide attempt who individuals means to access restricting care); follow-up psychotherapy, of suicide; and media guidelines for responsible reporting of suicide. National Suicide Prevention Strategies when it was introduced in 2000 developed in Across these three broad categories, five major types and undertaken regularly been have interventions of researched: suicide awareness and education programs and physicians care primary public, general the for selective populations (e.g. psychiatric patients); while strategies address specific high-risk individuals showing This model formed the basis early signs of suicidality. of the Prevention of Suicide and Self-harm in Australia Suicide prevention programs can take many forms. Suicide prevention programs can take many of preventative A popular framework involves three types interventions: Universal and education); general population (e.g. health promotion objectives of suicide prevention strategies in a number objectives of suicide prevention strategies of countries. programs of prevention Types The high incidence of suicide worldwide has prompted The high incidence of suicide worldwide has including a wide range of suicide prevention initiatives, programs in comprehensive national suicide prevention USA and Australia, New Zealand, the United Kingdom, the main many other countries. Appendix C summarises in suicide prevention in suicide Evidence of what works of what Evidence

Living Is For Everyone: Research and Evidence in Suicide Prevention 42 www.livingisforeveryone.com.au impossible torestrict. prevent, asmeansarereadilyavailable andalmost Hanging isaparticularlydifficult methodofsuicideto hanging, makingupalmosthalf ofallsuicidedeaths. the mostcommonmethodofsuicide atpresentis must alsobetakenintoconsideration. accordingly, andthepossibilityofmethodsubstitution legislation). Policiesandinitiativeshavetobeadjusted of compliancewithaccessrestrictions(e.g.firearm determine frequentlyusedsuicidemethods,andlevels suicide worldwide,itrequiresconstantmonitoringto one ofthemosteffectiveapproachestopreventing Although meansrestrictionhasbeenshowntobe • • reductions insuiciderates: domestic gas,barbiturates)hasbeenlinkedtosignificant Restricting theavailabilityofmeanssuicide(e.g.guns, Restricting accesstomeansofsuicide impressive results. other settings(e.g.schools,workplaces)havehadless referral pathways,andsimilarprogramscarriedoutin environment withformalisedgatekeeperrolesand program wasimplementedinahighlystructuredmilitary violence amongtheAirForcepersonnel.However, the accidental deaths,homicideandincidentsofdomestic reductions inlevelsofotherrelatedproblems,suchas It achieveda33%declineinsuiciderateaswell restriction ofaccesstobarbituratesinAustralia research ontheimpactofreformtogunlawsin other means(i.e.throughsubstitution). using thismethod,withoutanincreaseintheuseof the 1960swasassociatedwitha23%dropinsuicide found amethodofinstant(suicide)completion impulsive youngpeople—mighthavemoreeasily Australians contemplatingsuicide—inparticular, that ‘ have beensubstituted. using firearmsandnoevidencethatalternativemethods Australia hasshownasignificantdeclineinsuicides had thegunlawreformsnotoccurred,more 175

178 179 176 177 Theauthorsconcluded 181 InAustralia, 180 ’ (p370).

someone fromtakingtheirownlife. evidence toprovetheireffectivenessinpreventing promising, although there is a lack of strong scientific Other approaches to suicide prevention also appear Counselling andrelated therapies Clinical interventions remains unclear. antidepressants inreducingtheriskofsuicide However, despite numerous studies, the role of may reducetheriskofsuicidewithinthesegroups. such as depression, bipolar disorder and schizophrenia, Medication for major mood and psychotic disorders, Medication treatment forthisgroupofwomen. scientifically evaluatedandproventobeaneffective emotions andimproveself-help.DBThasbeen develop skillstocopewithemotionaldistress,regulate techniques toenhanceinterpersonalcommunication, suicide attempts. engaging inrepeateddeliberateself-harm,including therapy forwomenwithborderlinepersonalitydisorder Dialectical behaviourtherapy(DBT)wasdevelopedas reduce repeatedsuicideattemptsandself-harm. ofsuicide-relatedbehaviourshavebeenshownto history of an emergency card alerting others to an individual’s therapy (see below), problem-solving therapy, and provision for mental illness. Therapies such as dialectical-behavioural better patientfollow-up),andcounsellingpsychotherapy attempts (e.g.improvingadherencetotreatmentand clinical interventions for people with a history of suicide 191 192 186 DBTusescognitiveandbehavioural

182 187 Initiatives include Initiativesinclude

183-185

188-190

43 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

204

Ten years after the introduction years after the introduction Ten 205 199 Consequently, many countries have Consequently, There have been promising results from Similar studies are underway in Australia. Similar studies are underway 201 202 203 200 related behaviours. evidence Further information about the research and suicide can relating to media reporting and portrayal of be found at www.mindframe-media.info. As an example, a community-based phone support As an example, a community-based established in Italy produced program for the elderly promising results. of the service, suicide rates amongst people over 65 lower than the general years of age were significantly population. of suicide media coverage Addressing linking media reports of There is strong evidence suicide rates both overseas and suicide to increased in Australia. of developed guidelines for responsible coverage suicide, including a resource for media professionals in Australia. between some overseas studies demonstrating a link rates. media guidelines and a reduction in suicide of media research on the impact More recently, evidence guidelines in Australia has found convincing on the quality that these guidelines have had an impact suicide- of reporting of suicides as well as on reducing

195 196

Examples are: are: Examples 193 197 198 Positive results are reported in anecdotal 194 educational and primary care settings; school-based competency and skill enhancement programs; and bereaved by suicide. literacy programs; support for suicide survivors and communities crisis centres and counselling; and mental health public awareness, education and suicide risk in screening for depression repeat use of services and referral outcomes. Many phone-based crisis counselling services worldwide shows that have been operational for decades and data both individuals in crisis and third parties concerned these wellbeing, frequently use about somebody else’s services. and evidence, as well as studies examining ‘clients counsellors’ satisfaction with the services provided, • • their impact on suicide rates. their impact on suicide • • • Community capacity-building approaches approaches Community capacity-building community-based and population general of range wide A may also lead to positivesuicide prevention programs is limited scientific evidence ofoutcomes, although there However, studies assessing the services’ impact upon However, results. actual suicide rates have yielded inconclusive help to Some studies show that suicide hotlines may reduce suicide rates among particular groups (e.g. young white females).

Living Is For Everyone: Research and Evidence in Suicide Prevention 46 www.livingisforeveryone.com.au Peoples MentalHealthandEmotionalWellbeing) Torres Islander and/or Strait Aboriginal for Framework Strategic National A Framework: Wellbeing Emotional suicide preventioninitiative(forexamplethe special interestgroupsthatalsolinkcloselywiththe specific target which strategies other many are there Strategy. Drug However, National the and Strategy Health overlap withsuicidepreventionaretheNationalMental initiative ( and strategiesthatoverlapwiththesuicideprevention policies government current of type and range the in ofsuicidepreventionprogramscanbeseen the delivery in collaboration and coordination greater for need The (COAG) agreements. through arangeofCouncilAustralianGovernment to launchinitiativesforjoined-upgovernmentincluding Australian governmentshavecommencedandcontinue operational agenciesandcommunityengagement. connection andcooperationbetweencentral,line way to‘pooledresourcing’,devolveddecision-making, Internationally, the‘showerhead’isincreasinglygiving (3) (2) (1) which flaggedtheneed: a reportentitled‘AJointFrameworkforSocialPolicies’, Policy ReviewStaff(intheOfficeofCabinet)published In theUnitedKingdomasearly1975,Central potential forsystemicwasteofscarceresources. confusion ofresponsibilityandaccountability, andthe ‘shower headeffect,’canresultinduplicationofeffort, departments anddiverseagencies,describedasthe ofprogramsfrommultiple The traditionaldelivery prevention. for addressingcomplexsocialissuessuchassuicide and linearsystemsofaccountabilityarenotadequate that structuresandsystemswithhierarchicalcontrol It hasbeenrecognisedbygovernmentsacrossAustralia suicide prevention Collaborative approaches to and groups’. priorities betweendifferentprograms,problems to developacollectiveviewamongministerson boundariesand across service to providebetteranalysisofcomplexproblemscutting affect individuals, asthey ‘to improvecoordinationbetweenservices, Figure 16 206 207 208

). The two major policy areas that that areas policy major two The ). 210

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at threelevels: prevention ofsuicideinAustralia,actionisneeded To improvecooperation andcollaborationforthe prevention (asshownin policies andstrategiesthathaveanimpactonsuicide individuals. Andtherearemanyoverlappinggovernment delivery, particularlywithhighriskpopulationsor providersinvolvedinservice non-government service communities, families,communitydevelopment)and many governmentagencies(health,humanservices, under sharedgoalsofreducingsuicide,andthereare sectors. Thereareanumberofagenciesoperating and suicidepreventionarelocatedacrossmany and theknowledgeresourcestodealwithsuicide multiple causesandsuicidepreventioniscomplex, approaches. Thedecisiontotakeone’s ownlifehas to whole-of-governmentandacrossgovernment prevention, inparticular, isanareathatlendsitself for possiblecoordinationandcollaboration.Suicide Australian governmentshavealreadysettheframework • • • service delivery atthelocallevel. delivery service providerstowards collaborative government andservice need toharnesstheemergingculturalchangeswithin Is ForEveryone underlie agroup’s functionsandbehaviour. Ifthe Cultural level budgeting andreporting; Systems level delivery; prevention policyandservice collaboration andthebetterintegrationofsuicide andimprovecooperation, of joined-upservices changes thatcansignificantlyimprovethedelivery range ofpubliclyavailableguidelinesforstructural delivery.and amoreseamlessservice Therearea be expectedtodeliverbothabetterpolicyframework introduction ofjointplanningandimplementationcould non-government agenciesinsuicideprevention,the prevention. Giventherangeofgovernmentand governance andprojectmanagementinsuicide Structural level, , includingtheattitudesandbeliefsthat , includingsharingofinformation, includingtoolsforeffectivecollaborative initiativeistobesuccessful,itwill Figure 16 ). 212

Living

47 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

Local capacity and ownership: Engaging local leaders Engaging local leaders and ownership: Local capacity that and reciprocity: Recognising Partnership Policy frameworks are broad Devolution and flexibility: Incentives such as funding Provision of incentives: across sectors (business, community, government). (business, community, across sectors cross-sectoral issues require genuine complex social and beyond government – and partnerships – within for outcomes. a shared responsibility enable devolution of serviceand flexible enough to planning and delivery to the local or regional level. can all be used to and recognition of autonomy stimulate change. 7. 8. 9. 10.

They are: 213-217 Facilitation: Central agencies facilitating and enabling, Facilitation: Central agencies facilitating and supplement: and complement augment, that Activities A focus on outcomes: A balance of short-term and A focus on outcomes: open, common set of Shared knowledge: An A long-term commitment to resources: Preferably commitment to resources: A long-term of services experience A client focus: The client’s the policy objectives. rather than controlling and directing. Policy makers collaborating with service deliverer and and the community sector to augment, complement supplement existing programs and services to deliver long-term results and clear overall outcome, with long-term results and timely reporting. resources and knowledge. five years or more, but a minimum of three years. five years or more, but to policy development and and support is central service delivery. 5. 6. 3. 4. 1. 2. Ten principles have been broadly promoted across been broadly promoted principles have Ten coordinated to be applied to achieve government service provision.

Living Is For Everyone: Research and Evidence in Suicide Prevention 48 www.livingisforeveryone.com.au Figure 16: Policy Indigenous Program Personal Support Employment services, DEEWR -Disability headspace Foundation Health Youth Mental Programs Employment Disability Coordination Indigenous Office of Linking suicidepreventiontootherrelatedgovernmentpoliciesandstrategies

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233-236

Although there is evidence evidence is there Although 237 In addition, current evidence evidence current addition, In 230-232 238-243 226-229 on limited scientific evidence. may approaches prevention suicide some that suggesting care primary means, restricting (e.g. rates suicide reduce physician education and gatekeeper training), there is an planned, well of development continued for need urgent evidence-based programs and research evaluating their effectiveness in Australia. mental health literacy). between differences significant are there that shows suicide, by die who those and suicide attempt who people attempt who people involving studies that suggesting suicide. suicide may not be applicable to those who notion of aThere is also limited evidence to support the completion, to thinking suicidal from suicide to pathway against protect may that factors of effectiveness the on or suicide-related behaviours. of multitude a by influenced are rates suicide Moreover, fact, In controlled. be cannot which of many variables, been have suicide of incidence the in reductions bigger observed naturally occurring socio- in some cases following economic changes (e.g. major economic fluctuations, wars, purposefullythrough than rather situation) political in changes implemented national suicide prevention strategies. The importance of ongoing evaluation the in literature and research of amount large a Despite area, suicide prevention remains an inexact process based The measures used to evaluate suicide prevention to addition in include, also should therefore programs suicide of prevalence the rates, suicide on reductions or thinking behaviours; suicide-related attempts; vulnerabilities predisposing in changes communication; factors protective and hopelessness); illness, mental (e.g. compliance behaviour, help-seeking skills, coping (e.g. connectedness, social illness, mental for treatment with

224

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222 223 225 that the required outcomes and impacts can be achieved. that the required outcomes and impacts can suicide Challenges in evaluating effectiveness program prevention Systematic evaluation of all suicide prevention projects,Systematic evaluation of all suicide prevention continued the for essential is programs and activities that ensure will It practice. best of development evidence, of foundation solid a on based are interventions and appropriately, allocated are effort and resources that prevention programs prevention Evaluation of suicide of suicide Evaluation would be required. studies evaluating the effectiveness of suicide prevention programs require very sizes to produce large sample accurate and meaningful results if the only measure of that prove success used is suicide rate reduction. To an intervention in the national results in a 15% reduction suicide rate, a study sample of almost 13 million people statistical point of view, death by suicide is a relatively statistical point of view, rare event, with approximately 1 suicide death per 10,000 people in the Australian population per year. This causes a serious dilemma regarding the choice of the most appropriate measures to be used when 0.01% that Given programs. prevention suicide evaluating of the Australian population dies by suicide each year, program duration, the diversity of risk populations being program duration, the diversity of risk populations difficulties targeted by programs, and methodological (e.g. small sample sizes, lack of control groups and using retrospective evaluations). Despite the immeasurable human tragedy of each suicide and the distress of those left in its wake, from a Despite the large number of suicide prevention initiatives Despite the large number of suicide prevention properly internationally and in Australia, few have been evaluated for their effectiveness and impact. short There are several reasons for this, including

Living Is For Everyone: Research and Evidence in Suicide Prevention 50 www.livingisforeveryone.com.au All suicide prevention initiatives should be guided by 51 current evidence and include an evaluation component based on meaningful and measurable outcomes. This will allow the critical components of effective suicide prevention programs to be identified and refined, and to guide future suicide prevention efforts.

Suicide prevention programs should also monitor any

negative or harmful effects that may occur, always www.livingisforeveryone.com.au ensuring that an intervention follows the guiding principle of ‘first, do no harm.’244

Suicide prevention initiatives should be multimodal and complementary, targeting a wide range of high risk groups. The diverse approach to suicide prevention is essential because there is no single, readily identifiable, high-risk population that constitutes a sizeable proportion Living Is For Everyone: Research and Evidence in Suicide Prevention of overall suicides and yet is small enough to target easily and have an effect.245

Many national suicide prevention programs focus on universal, population-wide interventions (e.g. public awareness education, mental health literacy programs), somewhat neglecting the selective and indicated approaches and sometimes overlooking certain high-risk groups.246 There is a need to strike a balance between population-based approaches, and interventions with high-risk groups that focus on identifying and managing suicide-related behaviours and mental illness.

Materials to guide and assist the evaluation of suicide prevention programs have been developed under the National Mental Health Strategy249 and to support implementation of the LIFE Framework. 250 is

Figure A3 Figure shows how and Figure A3 Figure

248 Figure A2 Figure show the most common life Figure A3 Figure ). and Figure A3 Figure events associated with those in the Central Coast of events associated with those in the Central some time NSW who chose to end their own lives at on over the past ten years (this analysis is based Coronial data from 279 suicide cases recorded in the Database in NSW Central Coast). the life events vary for this sample by gender – females previous were more likely than males to have had a suicide attempt, have a history of sexual abuse, had Males recent treatment for depression or be bereaved. relationship, in this sample were more likely to have had twelve physical or financial problems, recent (past months) criminal record or criminal issues, alcohol/drug/ substance abuse or mental illness other than depression. the whether showing available data no is there However, pattern of life events shown in did who Coast Central NSW the on people for same the for available is data national Where lives. own their take not the general population, it is indicated with a grey circle (see These results appear to support the results of studies studies of results the support to appear results These Office in the that have been undertaken by the Coroner’s (data collected and Central Coast of New South Wales analysed every year since 1995 combining police, provided medical and post-mortem data with information by surviving family and friends). A2 Figure

. Depression Depression . Figure A1 Figure

shows, in the opinion of people bereaved 247 Figure A1 Figure involved in substance abuse (alcohol or illicit drugs) or had financial problems. On the other hand, women who have ended their life were more likely to have had mental health issues (other than depression) or to have experienced depression or emotional problems. As by suicide in this national sample, there are significant differences between men and women in terms of which life events seem to have been most influential in their men who ending their own life. Based on this study, have suicided are more likely than women to have been suicide. The results are shown in 68% in present as identified were problems emotional or 36%; in illness mental 45%; in conflict family cases; of 30%; in problems financial 34%; in abuse substance of history family and 21%; in problems health physical in provided factors possible of list a (from 13% in suicide the survey). on life events feedback involving Australia in undertaken research Recent suicide by bereaved people hundred three over from identified some of the critical life events influencing be treated as indicative only – until more definitive and be treated as indicative only – until more definitive published. validated research has been undertaken and Recent Australian research Literature on the impact of life events on mental illness Literature on the impact of life events on mental has or their impact on suicide and suicidal thinking only recently emerged. There is very little validated or life rigorously reviewed research on the link between should events and suicide. The material in this appendix Life events and Life events issues – emerging suicide Appendix A: Appendix

Living Is For Everyone: Research and Evidence in Suicide Prevention 52 www.livingisforeveryone.com.au Figure A1: (Source: Researchintosuicidebereavementbytheauthors,2006) (continued) Life eventsandsuicide-emergingissues Appendix A: family history ofsuicide family history physical healthissues financial problems alcohol/drug/substance abuse mental healthissues family orrelationshipconflict depression oremotionalproblems deceased Personal characteristicsofthe more frequent forfemales more frequent formales Life eventsthathaveimpactedonaselectionofrecentsuicidesinAustralia

13 20 32 38 32 46 66 % ofmaledeceased

77 % offemaledeceased 9 28 16 7 58 40 68 % ofalldeceased 13 21 30 34 36 45 53 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

15 13 12 11 8 7 6 6 6 5 4 1 % of all deceased 40 37 31 25 20 18 17 248

Life events that are linked to suicides in the NSW Central Coast Region (1999 to 2005) to suicides in the NSW Central Coast Life events that are linked associated with another suicide history of sexual abuse gambling problem history of unresolved narcotic abuse at time of death current AVO family law problems history of unresolved amphetamine abuse mental health problems excluding depression post-mortem – marijuana bereavement financial problems history of unresolved cannabis abuse criminal record or problem within past 12 months previous suicide attempts seen by mental health worker in past 12 months history of unresolved alcohol abuse major physical problems Life events recent treatment for depression relationship problems (Source: Central Coast NSW Coroner’s Database, 1999-2005) Database, 1999-2005) (Source: Central Coast NSW Coroner’s Life events and suicide-emerging issues and suicide-emerging Life events (continued) Figure A2: Appendix A: Appendix

Living Is For Everyone: Research and Evidence in Suicide Prevention 54 www.livingisforeveryone.com.au (Source: CentralCoastNSWCoroner’s Database,1999-2005) Figure A3: (continued) Life eventsandsuicide-emergingissues Appendix A: 0 % ofsuicideswitheachattribute 10 Life eventsthatdistinguishbetweenmaleandfemalesuicidesinNSWCentralCoastRegion

20 30 40 50

More likelyinfemalesuicides UÊ*ÀiÛÕÃÊÃÕVìÊ>ÌÌi«Ì UÊÃÌÀÞÊvÊÃiÝÕ>Ê>LÕÃi UÊ,iViÌÊÌÀi>ÌiÌÊvÀÊì«ÀiÃÃ UÊ iÀi>ÛiiÌ UÊ-iiÊLÞÊiÌ>Ê i>Ì ÊÊ«>ÃÌÊ£ÓÊÌ Ã UÊÃÃV>Ìi`ÊÜÌ Ê>Ì iÀÊÃÕVì UÊ>ÞÊ>ÜÊ«ÀLiÃ UÊ ÕÀÀiÌÊ6"Ê>ÌÊÌiÊvÊì>Ì UÊ>L}Ê«ÀLi UÊÃÌÀÞÊvÊÕÀiÃÛi`Ê>ÀVÌVÊ>LÕÃi UÊÃÌÀÞÊvÊÕÀiÃÛi`Ê>« iÌ>iÊ>LÕÃi UÊÃÌÀÞÊvÊÕÀiÃÛi`ÊV>>LÃÊ>LÕÃi More likelyinmalesuicides UÊ iÌ>Ê i>Ì Ê«ÀLiÃÊiÝVÕ`}Êì«ÀiÃÃ UÊ >ÀÊ« ÞÃV>Ê«ÀLiÃ UÊÃÌÀÞÊvÊÕÀiÃÛi`Ê>V Ê>LÕÃi UÊ*ÃÌÀÌiÊqÊ>ÀÕ>> UÊ,i>ÌÃ «Ê«ÀLiÃ UÊ À>ÊÀiVÀ`ÊÀÊ«ÀLiÊÜÌ Ê«>ÃÌÊ£ÓÊÌ Ã UÊ>V>Ê«ÀLiÃ (where dataisavailable)shownthus the generalpopulationinAustralia Approximate incidenceofeventsin % ofmaledeceased % offemaledeceased 55 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au , Figure B1 Figure ). The areas shown Figure B1 Figure has zoomed in on the data from

result of several factors - social, cultural, economic and result of several factors - social, cultural, economic environmental, rather than psychological factors. Figure B2 Figure relatively focusing on the regions in Australia that have high rates and relatively high numbers of suicide (excluding the two outlying locations - Bathurst/Melville from and Brisbane City, attention as triangles are those that require considerable coming and support for preventing suicide over the most likely a years. The wide variability geographically is )

can be Figure B1 Figure Figure B1 Figure are in rural/remote Australia ) Figure B1 Figure plots the suicide numbers (x axis) and the plots the suicide numbers (x axis) and the Figure B1 Figure Areas with high numbers of suicides and self-inflicted Areas with high numbers of suicides and self-inflicted Areas with comparatively high numbers and high Areas with low absolute numbers of suicides and self- Areas with low absolute numbers of suicides South Metropolitan Perth, East Metropolitan Perth, Adelaide, Cairns City Northern Adelaide, Western Part A and Greater Hobart. injuries but low rates (per 100,000) e.g. Brisbane and Newcastle (shown at the bottom right of rates of suicide and self-inflicted injuries e.g. North Metropolitan Perth, South East Metropolitan Perth, inflicted injuries but high rates (per 100,000) Mandurah, e.g. Bathurst-Melville, Mackay City Part A, at the top Rockhampton and Litchfield Shire (shown left of area covered by each statistical division. Many of the areas identified in or have a high Indigenous population, both of which are known risk factors for suicide. Others are in major Australian cities, particularly Perth, Adelaide, Cairns and Hobart, due to the comparatively larger number of suicides occurring in these areas. Some of the differences shown in attributed to variations in the population and geographic 2. 3. The three groupings of statistical divisions are as follows: The three groupings of statistical divisions 1. Figure B1 Figure of suicide rates (y axis) highlighting three patterns This makes suicide-related behaviours across Australia. suicide it possible to identify statistical divisions where prevention activities could be focussed. There is wide variability in the incidence of death by suicide suicide by death of incidence the in variability wide is There The followingor self-inflicted injuries throughout Australia. with people) 100,000 (per rates the compare charts for injuries self-inflicted or suicide by deaths number the 2001-2004. between divisions statistical Australian injuries) in regions of Australia in regions injuries) Incidence of death of Incidence self-inflicted and (suicide Appendix B: Appendix

Living Is For Everyone: Research and Evidence in Suicide Prevention 56 www.livingisforeveryone.com.au 57 www.livingisforeveryone.com.au Living Is For Everyone: Research and Evidence in Suicide Prevention 450 Brisbane City

400 Average rate = 11.8 Average 350 300 Newcastle 250 North Metropolitan Perth 200 Northern Adelaide South East Metropolitan Perth 150 Western Adelaide Western South West South West Metropolitan Perth East Metropolitan Perth Greater Hobart 100 Rockhampton Average no. = 46.9 Average 50 Cairns City Part A

Mackay City Part A Comparatively higher numbers and higher rates High numbers but low comparative rates Low numbers but high comparative rates Comparing deaths by suicide or self-inflicted injuries (number and rates) in Australia (2001-2004) suicide or self-inflicted injuries (number Comparing deaths by Bathurst-Melville Litchfield Shire Number of deaths by suicide or self-inflicted injuries Mandurah 0 0

20 40 60 80

100 120 140 Rate of deaths by suicide or self-inflicted injuries (per 100,000) (per injuries self-inflicted or suicide by deaths of Rate Incidence of death (suicide and self-inflicted injuries) in regions of Australia in regions injuries) and self-inflicted of death (suicide Incidence (continued) Appendix B: Appendix (Adapted from Public Health Information Development Unit, University of Adelaide, 2006) Figure B1:

Living Is For Everyone: Research and Evidence in Suicide Prevention 58 www.livingisforeveryone.com.au (Adapted fromPublicHealthInformationDevelopmentUnit,UniversityofAdelaide, 2006) Figure B2: (continued) Incidence ofdeath(suicideandself-inflictedinjuries)inregionsAustralia Appendix B: Rate of deaths by suicide or self-inflicted injuries (per 100,000) 10 20 30 40 50 60 0 0 Number ofdeathsbysuicideorself-inflictedinjuries Ord Daly Kangaroo Island Lyell Comparing deathsbysuicideorself-inflictedinjuries(numberandrates)acrossAustralianStatistical Alligator Divisions (2001-2004)– numbers ofsuicide relatively highratesand Barkly East Arnhem Litchfield Shire Kalgoorlie/Boulder CityPartA Vasse Shire PartA Beaudesert

Mandurah Fitzroy Mackay CityPartA Hervey BayCityPartA Hervey Central NT 50 Rockhampton Bundaberg Average no.=46.9 Ipswich City(PartinBSD) Greater Launceston Darwin City zooming inonFigure B1 Far NorthSDBal 100 Cairns CityPartA Eastern MiddleMelbourne Greater Hobart Outer West Sydney Western Melbourne Sunshine Coast East MetropolitanPerth (excludesBathurst-MelvilleandBrisbaneCity) South West MetropolitanPerth Western Adelaide Southern Adelaide 150 Inner Sydney Gold CoastCityPartB South EastMetropolitanPerth Southern Melbourne Northern Adelaide 200 North MetropolitanPerth Average rate=11.8 Newcastle

250 59 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

encouraging people to seek help early Providing earlier intervention and support to prevent problems and reduce the risks that might lead to suicidal behaviour Providing on-going support and services to enable people to recover and deal with the issues that may be contributing to their suicidal behaviour to services and support Providing people at risk and people in crisis, crisis immediate an provide to the reduce help to and response severity of any immediate problem Providing effective support to those who are affected by suicidal behaviour or a completed suicide Ensuring greater public awareness awareness public greater Ensuring of positive mental health and wellbeing, suicidal behaviour, potential problems and risks amongst all age groups and • • • • Scotland •

To reduce risk in key high To risk groups To promote mental To wellbeing in the wider population • England •

Promote mental health and wellbeing, and prevent mental health problems Improve the care of people who are experiencing mental disorders associated with suicidal behaviours and others affected by a by affected others and suicide or suicide attempt Improve the care of people who make non-fatal suicide attempts families/whanau Support friends family), (extended • • New Zealand • •

activities that apply to Indicated Selective (activities that apply to communities and groups ‘at risk’) to everyone) Objectives Universal (activities that apply times of heightened risk) ( Examples of overseas Examples strategies prevention suicide Appendix C: Appendix

Living Is For Everyone: Research and Evidence in Suicide Prevention 60 www.livingisforeveryone.com.au Appendix C:Examplesofoverseassuicidepreventionstrategies(continued) Other Access tomeans Media prevention) key issuesinsuicide understanding ofthe (improving our evidence Research and Objectives • • • New Zealand means ofsuicide Reduce accesstothe behaviour bythemedia and portrayalofsuicidal Promote thesafereporting interventions rates, causesandeffective Expand theevidenceabout • England • • • To promoteresearch To reducetheavailability To improvereporting on suicideand methods and lethalityofsuicide the media of suicidalbehaviourin prevention target toreducesuicides Lives: OurHealthierNation progress towardsSaving To improvemonitoring of

• Scotland • availability anddisseminationof Improving thequality, collection, with duerespectforconfidentiality sensitively andappropriately suicidal behaviourisundertaken media ofacompletedsuicideor reporting byanysectionofthe Ensuring thatanydepictionor anduseofresources services implementation ofresponsesand to ensurethebetterdesignand and oneffectiveinterventions suicide andsuicidalbehaviour information onissuesrelatingto 61 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au To minimise the distress felt among families, minimise the distress felt among To friends and in a community following a death by suicide and ensure that individuals are not isolated or left vulnerable so that the risk of any related suicidal behaviour is reduced improve access to information relating to To suicidal behaviour and on where and how to get help, and to encourage suicide research and improve access to research findings To promote positive mental health and well being being well and health mental positive promote To and bring about positive attitude change towards mental health, problem solving and coping in the general population among reduce the risk of suicidal behaviour To high risk groups and vulnerable people • • Ireland • • implementation of guidelines for a suitable suitable a for guidelines of implementation response to suicide-related matters means of carrying out suicide relevant suicide and self-harm issues and development the in media the support To restrict access, where possible, to the To and to provide appropriate follow-up action by support services dealing with suicide and mental health issues and timely response mechanisms for those seeking help out by the voluntary/community sectors, bereaved families and individuals who have made previous suicide attempts provide support for research evaluation of To being issues ill-health, ensure early recognition of mental To for people provide appropriate training To accessible develop coordinated, effective, To carried enhance the support role currently To To raise awareness of mental health and well raise To • • • • • • • Northern Ireland •

Other Access to means (improving our our (improving understanding of the key prevention) suicide in issues Media Research and Research evidence Indicated ‘at risk’) (activities that apply to everyone) Selective (activities that apply to communities and groups Objectives Universal times of heightened risk) (activities that apply to Appendix C: Examples of overseas suicide prevention strategies (continued) strategies suicide prevention of overseas C: Examples Appendix

Living Is For Everyone: Research and Evidence in Suicide Prevention 62 www.livingisforeveryone.com.au Appendix C:Examplesofoverseassuicidepreventionstrategies(continued) Other Access tomeans Media issues in suicide prevention) understanding ofthekey (improving our and evidence Research times of heightened risk) (activities thatapplyto Indicated ‘at risk’) communities andgroups (activities thatapplyto Selective everyone) (activities thatapplyto Universal Objectives

• • • • • • • • • • • USA behaviour and delivery ofeffectivetreatment behaviour anddelivery Implement training for recognition of at-risk Promote effortstoreduceaccesslethal Improve reportingandportrayalsofsuicidal systems Improve andexpandsurveillance Promote andsupportresearchonsuicide Develop andimplementcommunity-based Increase accesstoandcommunity Develop andpromoteeffectiveclinical Develop andimplementstrategiestoreduce for support broad-based Develop Promote awarenessthatsuicideisapublic means andmethodsofself-harm in theentertainmentandnewsmedia behaviour, mentalillnessandsubstanceabuse suicide prevention suicide preventionprograms abuse services linkages withmentalhealthandsubstance professional practices prevention programs of mentalhealth,substanceabuseandsuicide the stigmaassociatedwithbeingaconsumer suicide prevention health problemthatispreventable

• • • • • • Canada • • • • • • • • • • • • Increaseopportunitiesforreporting systems Improveandexpandsurveillance andsupport Increasecrisisintervention and communities standards ofcare)tosupportclients,families professional practice(effectivestrategies, Develop andpromoteeffectiveclinical gatekeepers, volunteersandprofessionals targetingkey provision ofeffectiveintervention, warning signsandat-riskbehavioursfor Increase trainingforrecognitionofriskfactors, activities prevention primary of number the Increase activities andbereavement prevention, intervention stigma, tobeassociatedwithallsuicide Develop andimplementastrategytoreduce prevention andintervention Develop broad-basedsupportforsuicide that suicideisourproblemandpreventable Canada of part every in awareness Promote Canadian National Suicide Prevention Strategy Prevention Suicide Canadian National connected withtheCASPBlueprint fora Increase funding and support for all activities of suicidemethods Reduce theavailabilityandlethality Increase media knowledge regarding suicide effective evaluationtools Promote andsupportthedevelopmentof Promote and develop suicide-related research bereaved bysuicide andsupporttothose Increase services regional, and provincial/territorial uniqueness high-risk groupswhilerespectinglocal for delivery andservice Prioritise intervention provincial/territorial levels diversity andcultureatlocal,regional, based suicide prevention programs, respecting Develop, implement and sustain community- components/services/families linkages betweenthecontinuum-of-care Improve accessandintegrationwithstrong

63 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

Judd et al. (2006a)* Judd et al. (2006b)* et al. (2005)* Taylor Resources (selected) Resources ABS (2007)* De Leo et al. (2006)* ABS (2005)* De Leo et al. (2006)* Hunter and Milroy (2006)* Caldwell et al. (2004)* De Leo et al. (2006)* Evidence level A A A A

rural and remote Risk factor Gender: male Age: middle-age and elderly Race and ethnicity: ATSI Geographical location:

over the period of 1997-2000 (i.e. conclusive results of studies; high quality evidence-base, including extensive research reviews and meta- (i.e. conclusive results of studies; high quality evidence-base, (i.e. reasonably conclusive results of studies; moderate evidence-base) linking the risk factor to suicide. (i.e. reasonably conclusive results of studies; moderate over the period of 1999-2003 suicide This Appendix and the analysis and categorisation of the evidence has been prepared by Professor This Appendix and the analysis and categorisation Diego De Leo and Dr Karolina Krysinska Research and Prevention from The Australian Institute for Suicide Queensland. Brisbane, (AISRAP), Griffith University, highest age-specific suicide rate in 2005 Good evidence linking the risk factor to suicidal ideation and/or non-fatal suicidal behaviour, however more however more ideation and/or non-fatal suicidal behaviour, Good evidence linking the risk factor to suicidal research is needed to ascertain the link to fatal suicidal behaviour. research Strong evidence Strong autopsy studies, controlled family studies, follow-up studies, clinical studies, twin analyses, data from case-control psychological etc. where applicable and/or reliable epidemiological data) linking the risk studies, adoption studies, molecular genetics studies factor to suicide. Good evidence Good Geographical location: higher suicide rates were reported in men (especially young men) in rural and remote populations (40.4 and 51.7 per 100,000, respectively) compared with metropolitan populations (31.8 per 100,000). Age: (ABS, 2007): 1. Males: 30-34 age group (27.5 per 100,00) 2. Females: 35-39 age group (6.9 per 100,000) Race/ethnicity: was the leading external cause of death for Indigenous males (ABS, 2005). Risk factor category Demographic factors Selected Australian data (for details, see listed resources) B. is needed in the area. research suicide, however more C. Some evidence linking the risk factor to D. Levels of evidence A. * Studies conducted in Australia NOTE: Review of suicide risk factors of suicide Review Appendix D: Appendix

Living Is For Everyone: Research and Evidence in Suicide Prevention 64 www.livingisforeveryone.com.au metropolitan populations(31.8per100,000). and 51.7per100,000,respectively)comparedwith young men)inruralandremotepopulations(40.4 higher suiciderateswerereportedinmen(especially Geographical location: males (ABS,2005). was theleadingexternalcauseofdeathforIndigenous Race/ethnicity: 2. Females:35-39agegroup(6.9per100,000) 1. Males:30-34agegroup(27.5per100,00) (ABS, 2007): Age: Selected Australiandata(fordetails,seelistedresources) Demographic factors Risk factorcategory highest age-specificsuicideratein2005 overtheperiodof1999-2003suicide overtheperiodof1997-2000

rural andremote location: Geographical ATSI Race andethnicity: middle-age andelderly Age: male Gender: Risk factor

A A A A level Evidence Taylor etal.(2005)* Judd etal.(2006b)* Judd etal.(2006a)* De Leoetal.(2006)* Caldwell etal.(2004)* Hunter andMilroy(2006)* De Leoetal.(2006)* ABS (2005)* De Leoetal.(2006)* ABS (2007)* Resources (selected) Appendix D:Reviewofsuicideriskfactors(continued) * StudiesconductedinAustralia Comment: Psychopathology andpsychiatrichospitalisation Risk factorcategory to sixmonthsafterdischarge. from a psychiatric hospital, and it remains elevated for up significantly increased within the first weeks after discharge institution tends to increase the risk of suicide, and risk is of social support. Also, being hospitalised in a psychiatric compliance with medication, and availability and quality of mental health services, effectiveness of treatment, important role. These include quality and availability of suicide: other risk and protective factors play a very and psychopathology alone is not a sufficient predictor a psychiatric diagnosis engage in suicidal behaviour, that only a relatively small proportion of individuals with factor for suicide attempts. It has to be noted; however, disorders, and personality disorders, is also a serious risk particularly affective disorders, substance abuse, anxiety related disorders, and schizophrenia. Psychopathology, disorder, especiallyaffectivedisorders,substance- who die by suicide have a diagnosis of a psychiatric the risk even further. The overwhelming majority of people diagnosis of more than one mental disorder) increases suicidal behaviour, andpsychiatriccomorbidity(i.e.a the strongestriskfactorsforbothnon-fatalandfatal A diagnosis of a mental disorder is among disorders) (and otherpsychotic Schizophrenia and bipolardisorder) (incl. majordepression Mood disorders Risk factor recent discharge hospitalisation and Psychiatric disorder) more thanonemental (i.e. adiagnosisof comorbidity Psychiatric disorder disorder), adjustment post traumaticstress disorders (including anxiety/somatoform mental disorders, disorder), organic antisocial personality (esp. borderlineand personality disorders disorders: Other psychiatric disorders Substance-related

A A level Evidence A A A A Fleischmann etal.(2005) Ernst etal.(2004) De Leo&Spathonis(2003) Cavanagh etal.(2003) Bostwick &Pankratz(2000) Bertolote etal.(2004) Arsenault-Lapierre etal.(2004) Resources (selected) Shah &Ganesvaran(1999)* Qin &Nordentoft(2005) Owens etal.(2002) Hoyer etal.(2004) Chatterton etal.(1999)* Tanney (2000) Snowdon &Baume(2002)* Lester (2006) Lester (2000) etal.(2006) Krysinska Hawton etal.(2005) Harris &Barraclough(1997) 65 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au Baldessarini & Hennen (2004) Brent & Mann (2005) Brent et al. (2002) Roy (2006) Roy et al. (2000) Resources (selected) Resources Cheng et al. (2000) Cooper et al. (2005) Gerson & Stanley (2002) Hawton & Harris (2006) Owens et al. (2002) Stanley et al. ( 2001) (2000)* Thacore & Varma Barber et al. (1998) Marzuk et al. (1997) A A Evidence level A A B D Genetic factors Family history of suicide and psychopathology Risk factor History of suicide attempts Suicidal ideation Self-mutilation Aborted suicide attempts

Studies indicate that individuals whose relatives relatives whose individuals that indicate Studies A history attempt is a major risk of a suicide Family history of psychopathology and suicidal behaviour Previous non-fatal suicidal behaviour and non-fatal suicidal behaviour Previous suicidal ideation Risk factor category Risk factor category increased risk of suicide. suicide. of risk increased social modelling (e.g. family member(s) who die by suicide suicide by die who member(s) family (e.g. modelling social may become ‘role model(s)’ for their relatives pointing to solution’ effective and ‘acceptable an as suicide to out psychiatric to predisposition genetic a and problems) life schizophrenia, disorders, affective (e.g. disorders to linked are which impulsivity and/or alcoholism) and For example, adoption studies show a higher prevalence prevalence higher a show studies adoption example, For biological among disorders psychiatric and suicide of relatives of people who die by suicide than among their adoptive parents. Also, there is a higher occurrence of non-identical among than pairs twin identical in suicide twins. A variety of explanations regarding the familial including proposed, been have suicide to vulnerability Comment: diagnoses and behaviour suicidal of history a have other and depression (especially disorders mental of risk. suicide of levels elevated have disorders) affective females with a diagnosis of borderline personality disorder) disorder) personality borderline of diagnosis a with females an of history a Also, suicide. of risk increased at be might individualaborted suicide attempt (i.e. an event in which an makinghas suicide intent but changes his/her mind before have might sustained) is injury physical no and attempt the an increased risk of actual suicidal behaviour. absence of a suicide plan; however, does not imply that that imply not does however, plan; suicide a of absence are behaviours suicidal many as suicide of risk no is there (i.e. self-harm or Self-mutilation unplanned. and impulsive die) to intent the without behaviour self-injurious deliberate however, behaviours; suicidal from distinguished usually is (particularly behaviour of type this in engage who individuals within one year after the initial attempt, and studies show show studies and attempt, initial the after year one within 5-10that suicide risk remains significantly elevated even ideation suicidal Although attempt. initial the after years quite is suicide) and/or self-harming about thoughts (i.e. in population, general the in phenomenon frequent a lead tosome cases vague thoughts about suicide might The behaviour. self-harming by followed plan detailed a Comment: suicidal behaviour andfactor for both repeated non-fatal attempt who individuals of 1% Approximately suicide. outcome fatal a with behaviour suicidal their repeat suicide * Studies conducted in Australia Appendix D: Review of suicide risk factors (continued) of suicide risk D: Review Appendix

Living Is For Everyone: Research and Evidence in Suicide Prevention 66 www.livingisforeveryone.com.au Appendix D:Reviewofsuicideriskfactors(continued) * StudiesconductedinAustralia Comment: Life eventsandcopingpotential factor forsuicidalideationandbehaviour. a risk factor for suicide. Also, chronic physical pain is a risk (including epilepsy and multiple sclerosis), and HIV/AIDS is disease,neurologicaldiseases disease, chronicpulmonary of a somatic illness, especially cancer, coronary heart Comment: Physical status Risk factorcategory gay andlesbianpopulations. suicide ratesdonotappeartobeincreasedamongthe results of(scarce)studiesconductedtodate,completed adolescents andyoungadults.However, basedupon behaviour andideation,especiallyamonghomosexual orientation seemstobeariskfactorfornonfatalsuicidal than individualswhowerenevermarried.Homosexual of suicide,andmarriedpeoplehavelowersuiciderates divorced, widowedorseparatedhavethehighestrates of suiciderisk.Studiesshowthatpersonswhoare Comment: Marital statusandsexualorientation life events. and willingnesstoaskforhelp,mediatetheimpactof solve problems,availabilityandqualityofsocialsupport, psychopathology, abilitytocopewithstressand the person’s reaction.Otherfactors,including and thesubjectiveexperienceofeventdetermines individuals facedwithlifeadversitiesbecomessuicidal, suicidal ideationandbehaviour, onlyaminorityof stresses canbeimportant‘triggering’riskfactorsfor cope. Ithastobenoted;however, thatalthoughlife might alsonegativelyaffecttheindividual’s abilityto other typesofevents,includingpositivelifechanges, suicidal behaviour. Dependingontheindividualcase, frequently reportednegativelifeeventspreceding childhood and/oradulttraumaareamongthemost physical healthproblems,bereavement,imprisonment, Relationship problems,familydiscord,mentaland population, especiallyinthemonthpriortosuicide. and negativelifeeventsthanpeopleinthegeneral fatal suicidalbehaviourexperiencemorestressors Reviews of studies indicate that a diagnosis Reviews ofstudiesindicatethatadiagnosis Marital statusisassociatedwiththelevel People whoengageinnon-fataland

significant other, problems, lossof and physicalhealth discord, mental problems, family (e.g. relationship Negative lifeevents Chronic physicalpain HIV/AIDS) neurological diseases, ischemic heartdisease, disease, pulmonary (e.g. cancer, chronic Physical illness Risk factor Transgender (GLBT) Gay, Lesbian,Bisexual, Sexual orientation: separated, single divorced, widowed, Marital status: Low copingpotential trauma) childhood andadult imprisonment, bullying, bereavement,

A A A level Evidence D A A Yufit (2005) Thacore &Varma (2000)* Isometsa (2005) Houston etal.(2001) Fortune etal.(inpress) Tang &Crane(2006) Fishbain (1999) Snowdon &Baume(2002)* Harwood etal.(2006b) Harwood etal.(2006a) Hawgood etal.(2004) Harris &Barraclough(1994) Resources (selected) McDaniel etal.(2001) Catalan (2000) Stack (2002b) Lorant etal.(2005) Kposowa (2000) Cantor &Slater(1995)* 67 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au Kelleher et al. (1998) Pritchard & Amanullah (2007) Stack (2000a) Burvill et al. (1982)* Burvill (1998)* Dusevic et al. (2001)* Stack (2000b) Joiner et al. (2005) Mann (2003) Raust et al. (2007) Heeringen et al. (2004) Van Praag (2001) Van Resources (selected) Resources Judd et al. (2006a)* Judd et al. (2006b)* Page et al. (2006)* et al. (2005)* Taylor Stack (2000a) (2007) Stack & Wasserman C C A C Evidence level A A

abnormalities in the ventro-medial prefrontal of cortex, hyper-activity hypothalamic-pituitary- adrenal axis Religion: lack of sanctions against suicide Migration: high suicide rates in country of origin, acculturation stress, social isolation, language barriers Hypo-activity of system serotonergic Other neurobiological factors: abnormalities in dopaminergic and noradrenergic systems, Risk factor Low socio-economic status Unemployment

Studies looking at the neurobiology of suicidal Sociological studies consistently find a Neurobiology Risk factor category Socio-economic and cultural factors levels of cholesterol, abnormalities in dopaminergic and and dopaminergic in abnormalities cholesterol, of levels noradrenergic neurotransmitter systems, and hyperactivity of other brain systems (such as the hypothalamic-pituitary- although behavior, suicidal in involved be might axis) adrenal the mechanism of the association remains unclear. Comment: fluid cerebrospinal the of levels decreased show behavior and serotonin) of (metabolite acid 5-hydroxyindoleacetic prefrontal ventromedial the in abnormalities neuroanatomical cortex of people who attempt or die by suicide. Also, low observed could increase in some studies. A migrant status example (for individuals vulnerable in suicide of risk the with individuals and/or country their leave to forced people barrier, language a to due psychopathology) pre-existing stress of acculturation, and social isolation. Lower suicide rates were reported in countries with religiousLower suicide rates were reported in countries with aresanctions against suicide, mostly countries which topredominantly Muslim or Roman Catholic. In regards groups migrant diverse among suicide of rates migration, a with origin of countries of rates suicide reflect to tend country host the of rates the toward trend convergence occupations at increased risk of suicide, for example being addition, In veterinarians. and physicians, dentists, nature the but suicide, of risk the elevates unemployed suicide and unemployment between relationship the of religion including factors, socio-cultural Other clear. not is risk. suicide of levels impact to seem also migration, and Comment: correlation between high suicide rates and low socio- high-status few are there although status, economic * Studies conducted in Australia Appendix D: Review of suicide risk factors (continued) of suicide risk D: Review Appendix

Living Is For Everyone: Research and Evidence in Suicide Prevention 68 www.livingisforeveryone.com.au * StudiesconductedinAustralia Appendix D:Reviewofsuicideriskfactors(continued) pain (i.e.‘psychache’)areamongpsychologicalrisk living, perfectionism,andpsychologicalsuffering thinking, aggressionandimpulsivity, lackofreasonsfor poor problem-solving,‘all-or-nothing’ (‘black-and-white’) predictors ofsuicidalideationandbehaviour. Also, of thestrongest,strongereventhandepressionitself, expectations regardingone’s futureandoneself)isone individuals. Forexample,hopelessness(i.e.negative and thusincreasetheriskofsuicideinvulnerable psychopathology, negativelifeevents,andsocialfactors, the impactofothersuicideriskfactors,including Comment: Psychological factors Risk factorcategory the imitativesuicidalbehaviour. suicidal ideationseemtobeparticularly vulnerableto elderly, of individualsincrisisand/orwithahistory magnitude oftheWerther effect,andtheyoung, and thesocioculturalcontextseemtoinfluence content ofthestory, thesocialstatusofdeceased, publicity giventothesuicidestory, theplacementand ‘copycat’ suicides/the‘Werther effect’).Theamountof may leadtotheoccurrenceofimitativesuicides(i.e. indicate thatinappropriatemediareportingofsuicide availability ofthemethod.Also,resultsmanystudies symbolic/cultural meaningofthemethod)and the method,culturalfactors(e.g.gendersocialisation, behind thebehaviour, theindividual’s familiaritywith upon severalfactors,includingtheintentandmotivation Comment: Environmental factors reduced ornonexistent. of beingfoundandrescuedbyothersareseverely when theyengageinsuicidalbehaviors:theirchances isolated andlonelypeopleareathigherriskofdeath to maintaingoodinterpersonalnetworks.Inaddition, results fromadverselifecircumstancesand/orinability tocopewithlifestressors.Suchisolationmay necessary having insufficientsocialsupport,andotherresources frequently describedasalienatedfromtheirfamiliesand life crises,andsuicidality. Peopleatriskofsuicideare psychopathology, ineffectivecopingwithstressand loneliness havebeenrelatedtomanyaspectsof Comment: Social networks factors forsuicide. Lackofsocialsupport,isolation,and Thechoiceofamethodsuicidedepends Psychological factorsmightexacerbate

Social isolation psychological pain perfectionism, to solveproblems, rigidity, lowability for living,cognitive lack ofreasons and impulsivity, high aggression cognitive factors: psychological and Other Hopelessness Risk factor suicide media reporting of Inappropriate suicide lethal meansof and availabilityof Easy accessto support Lack ofsocial

A A A level Evidence A A A De Leoetal.(1998) Bille-Brahe &Jensen(2004) Yufit (2005) etal.(2005) Williams Shneidman (1993) Joiner etal.(2005) Beck etal.(1990) Beck etal.(1985) Resources (selected) Pirkis etal.(2006)* Pirkis etal.(2002)* Pirkis &Blood(2001) (2005) Hawton &Williams Hassan (1995)* &Gunnell(2000)* Wilkinson Maris etal.(2000) (1999)* De Moore&Robertson De Leoetal.(2003)* De Leoetal.(2002)* Yufit &Bongar(1992) Judd etal.(2006b)* Judd etal.(2006a)* 69 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au , including 2 Suicidal thinking and/or A community takes responsibility responsibility takes community A Any behaviours causing Features of therapy that are common Engagement with longer-term Engagement with longer-term Enquiry into protective factors for suicide Whether there is the capacity to bring see risk factors. Mental processes and conscious intellectual Mental processes and conscious intellectual Effectiveness: about an effect or outcome. Community ownership: together work to agrees and suicide, as such issue, an for solutions. sustainable and effective develop to Connectedness: (‘resilience people within capacities the on focused has factors’) and on external ‘protective factors’ with connectedness and belonging of sense person’s a family, with connections that evidence is There others. for suicide of risk reduce can adult significant a or school or partner a to connectedness of Feelings people. young be to appear children of care for responsibility or parent protective factors,and ‘connectedness’ within a community has been linked to health and wellbeing. Contagion or imitation: behaviour resulting from exposure to suicide. Continuing care: treatment, support and care where needed. Deliberate self-harm: destruction or alteration of body tissues, with or without attempted suicide the intent to die. It includes self-injury, and other forms of intentional injury to self. Distal factors: Cognitive: activities such as planning, reasoning, problem solving, thinking, remembering, reasoning, learning new words or imagining. Common factors: position of to success, despite the differing theoretical used. each therapist and the specific techniques

1 An incident within one’s life that An incident within one’s This paradigm focuses on Client-centred therapy or the person- The period after a loss (usually The use of methods (often evidence-based) evidence-based) (often methods of use The - The ability of a community’s organisations, - The ability of a community’s - Enhancing and/or developing personal groups and individuals (collectively) to build their groups and individuals (collectively) to build structures, systems, people and skills, so they are better able to define, implement, manage and achieve their shared objectives. aptitude, strength, coping and/or independence. aptitude, strength, coping and/or independence. Community Individual (psychodynamic) or the achievement of new patterns of the on ...concentrate (behavioural), future the in behaviour ‘here and now’ experiences of the client’. Clinical paradigm: repairing damage within a disease or medical model of human functioning. centred approach is a movement associated with with associated movement a is approach centred of capacity ‘the emphasises that psychology humanistic of understanding personal a at arrive to individual each than rather intuition and feelings using destiny, her or his being guided by doctrine and reason. Rather than focusing on the origins of client problems in childhood events Client-centred: that achieve improvements and/or optimal outcomes. outcomes. optimal and/or improvements achieve that Capacity building: or negative health outcomes. Bereavement: through death) during which grief is experienced and mourning occurs. Best practice: Aboriginal and/or Torres Strait Islander: Aboriginal and/or Torres see Indigenous Australians. Adverse life event: disruption, has the potential to cause emotional upset, Glossary terms of

Living Is For Everyone: Research and Evidence in Suicide Prevention 70 www.livingisforeveryone.com.au a rangeofissuesusingmulti-faceted approach. Integrated response: lives orhaslived. is acceptedassuchbythecommunityinwhichs/he Australian AboriginalorTorres StraitIslanderperson;and or Torres StraitIslanderdescent;andidentifiesasan Indigenous Australians: with theaimofpreventingaconditionfromarising. are showingearlysignsofriskforhealthproblems, Indicated intervention: maybenecessary.likely inthenearfuture;intervention Imminent risk: enhances therapeuticwork. that permitstheclienttoexperiencesafety, andthus Holding environment: or otherdifficultcircumstances. help orsupportinordertocopewithadverselifeevents Help-seeking: other medicalservices. referrals tospecialists,hospitals,laboratories,and provider, whocoordinatespatientcareandprovides specifically designatedperson,suchasaprimary-care Gatekeeper: experiences. information extractedfromliteratureandrecorded Evidence-based: to theconsumptionofresources(time,cost,labour). Efficiency: result oroutcome. Efficacy: ofterms(continued) Glossary The capacity of a service todeliveradesired The capacityofaservice Theproductionofanagreedoutputrelated Aninformalcommunityleaderora Theprocessofanindividualaskingfor Thepointatwhichsuicideisextremely Approachesthatarebasedon Interventions thatrespondto Interventions Referstoatherapeuticsetting Working withindividualswho ApersonwhoisofAboriginal

perceived tobenegativebythoseinvolvedandresults Loss: Jurisdiction: change thecourseofortreatdysfunctionalbehaviour. taken toimproveaperson’s healthandwellbeingorto Intervention: long-term care. symptomidentification,treatmentand early intervention, coordination/provision ofhealthpromotion,prevention, Pathways tocare: which researchgoeson. world –asetoftacitassumptionsandbeliefswithin shared setofassumptionsabouthowweperceivethe inside theboundariesinordertobesuccessful.Itisa defines boundaries;and2)ittellsyouhowtobehave unwritten) thatdoestwothings:1)itestablishesor Paradigm: expertise fromarangeofdisciplines. thatdrawson providing coordinatedclientservice professionals, agencies,organisations,andpersons Multi-disciplinary approach: Multi-faceted: health andwellbeingamongpopulationsindividuals. Mental healthpromotion: require intervention. an individual’s thinkingandemotionalabilitiesmay illness ordisorderthatresultsinsignificantimpairmentof Mental disorder: through which information or support is provided. Medium: in long-termchange. Lossisproducedbyanincidentwhich The mode, means or carrier (person or resource) Themode,meansorcarrier(personresource) Asetofrulesandregulations(writtenor Insuicidepreventionitreferstoanyaction Commonwealth, StateorTerritory. Having manyaspectsorfacets. Arecognised,medicallydiagnosable Amodelthatencompassesthe Actiontomaximisemental Approaches thatinvolve

71 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

Includes the spectrum Activities that target population A Statistical Division (SD) is an Factors such as biological, psychological, psychological, biological, as such Factors Capacities within a person that promote Capacities within a person Deliberate damage of body tissue, often in Deliberate damage of body tissue, often in The act of purposely ending one’s life. The act of purposely ending one’s at causing death, and suicide attempts. Some writers also include deliberate recklessness and risk-taking behaviours as suicide-related behaviours. individuals. This might include working with the families of individuals. This might include working with instance children for those bereaved through suicide or, time. who have been traumatised or abused over Self-injury: the intent to response to psychosocial distress, without or self-harm. die. Sometimes called self-inflicted injuries Statistical division: (ASGC) Australian Standard Geographical Classification purpose, defined area which represents a large, general relatively regional type geographic area. SDs represent homogeneous regions characterised by identifiable social between and inhabitants the between links economic and the economic units within the region, under the unifying influence of one or more major towns or cities. They consist of one or more Statistical Subdivisions (SSDs) in aggregate, the whole of Australia without and cover, gaps or overlaps. They do not cross State or Territory boundaries and are the largest statistical building blocks of States and Territories. Suicide: behaviours: Suicide-related of activities related to suicide and self-harm including suicidal thinking, self-harming behaviours not aimed Resilience: as mental health and wellbeing, positive outcomes, such from factors that might otherwise and provide protection of suicide. Resilience is often place that person at risk to bounce back from adversity’. described as ‘the ability to resilience include personal Factors that contribute for dealing with adversity, coping skills and strategies cognitive and emotional skills, such as problem-solving, and help-seeking behaviours. communication skills Risk factors: the increase to thought are that agents cultural and social be can factors Risk ideation. suicide/suicide of likelihood as genetic ordefined as either distal (internal factors, such such factors, (external proximal or factors) neurochemical factors - means lethal of availability the or events life as which can ‘trigger’ a suicide or suicide-related behaviours). Selective intervention: or community groups at higher risk for a particular or particular problem, rather than the whole population

Interventions targeting targeting Interventions Non-modifiable factors that may The capacity and willingness of Capacities, qualities, environmental see risk factors. The use of identified and trained peers The use of identified The care system that forms the first point The care system that forms the first point Interventions to support and assist the Preventing conditions of ill health from arising. arising. from health ill of conditions Preventing Recovery restoration is the process of a gradual A person who, through a well-founded fear of or ‘forced migrant’. of a satisfying, hopeful and meaningful way of life. Refugee: being persecuted (for reasons of race, religion, nationality or membership of a social or political group), is displaced from their country unable or unwilling to of origin and is return. Sometimes referred to as a ‘displaced person’ Proximal factors: Proximal Receptivity of client: the person to receive and absorb information and support. Recovery: services such as general practitioners, Aboriginal medical services, school counsellors and community-based health and welfare services. factors: Protective and personal resources that drive individuals towards and health. growth, stability, and level of isolation. Prevention: Primary care: assistance. of contact for those in the community seeking It includes community-based care from generalist bereaved after a suicide has occurred. factors: Predisposing susceptibility to suicide-related increase a person’s factors, behaviours, such as genetic and neurobiological background culture, socio-economic personality, gender, have experienced or witnessed profoundly traumatic have experienced or witnessed profoundly or wartime rape, events, such as torture, murder, of the combat, characterised by recurrent flashbacks fatigue, anxiety, traumatic event, nightmares, irritability, forgetfulness, and social withdrawal. Postvention: populations rather than individuals. They include activities activities include They individuals. than rather populations targeting activities as well as population whole the targeting peoples Aboriginal or rural as such subgroups population peoples. Strait Islander and Torres (PTSD): Disorder Stress Post Traumatic who A psychological disorder affecting individuals Peer education: aimed at increasing awareness or to provide information change. influencing behaviour Population-based interventions: Glossary terms (continued) of

Living Is For Everyone: Research and Evidence in Suicide Prevention 72 www.livingisforeveryone.com.au from family, friendsandnormalactivities. possessions, talkingaboutsuicideorthewithdrawal increased riskofsuicide,suchasgivingaway Warning signs: schools andcommunities. or tocreatestrongerandmoresupportivefamilies, means ofsuicide,toreducemediacoverage prevention, theseincludeactivitiestoreduceaccess the wholeofapopulationorpopulations.Insuicide Universal intervention: increase insymptomsofamentaldisorder. precipitating event,suchasanegativelifeeventoran suicide increasesduetotheoccurrenceofsome Tipping point: it to be received, understood and meaningfully applied. support at the most appropriate or opportune moment for Timeliness ofservice: appropriate useofresources. over thelong-termthroughadequatefundingand Sustainability: to-face counselling. andface- forms, includinginformationprovision,services issue, problemoradversity. Supportcantakemany Support: Suicidology: of suicide among populations or specific target groups. Suicide prevention: completing suicide. Suicidal ideation: ofterms(continued) Glossary To assistwiththeburdenorweightofan Scientificstudyofsuicide. Thepointatwhichaperson’s riskof The abilityofaprogramtofunction Behavioursthatindicateapossible Thoughtsaboutattemptingor Actions or initiatives to reduce the risk Provision of information, service or Interventions thattarget Interventions

Moore, B.(ed)(2004). London. A handbookfortheCaringProfessions Raphael B.(1984). 7th Edition.Washington, DC:AmericanPsychiatricPress. Edgerton, JE.(1994). Other mainreferences: 2 1 NOTE: Oxford UniversityPress:Melbourne. 31(5), 893-903. American AcademyofChildandAdolescentPsychiatry ofthe risk between4and13yearsofage,Journal A. (1992). Seifer, R.,Sameroff,A.J.,Baldwin,C.P. &Baldwin, Ed., pp.157,Maidenhead:OpenUniversityPress. McLeod, J.(2003) of thereport. are commonusage,otherscitedinthebody These termsarefromavarietyofsources,some Child andfamilyfactorsthatameliorate The AnatomyofBereavement: An IntroductiontoCounselling American PsychiatricGlossary The AustralianOxfordDictionary . Hutchinson: . 3rd ,

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Social , vol. 34, , vol. 39, , vol. 25, no. 4, American Journal of Suicide and Life Life and Suicide , vol. 35, no. 3, pp. 251-264. 251-264. pp. 3, no. 35, vol. , Psychological Medicine Death Studies Child and Adolescent Social , vol. 18, no. 3, pp. 189-203. , vol. 360, pp. 1126-1130. , vol. 160, no. 8, pp. 1525-1526. Qin, P., Agerbo, E. & Mortensen, P.B. (2002). P.B. Agerbo, E. & Mortensen, Qin, P., historyRuneson, B. & Asberg, M. (2003). Family of Eberly, K.R., Conner, Conwell, Y., Duberstein, P.R., L. Gregg, & B. Andrews, C., Barrowclough, N., Tarrier, E., Hicks, B.M. & Patrick, C.J. (2005). Verona, Yoder, K.A. & Hoyt, D.R. (2005). Family economic economic Family (2005). D.R. Hoyt, & K.A. Yoder, Jackson, H. & Nuttall, R.L. (2001). Risk for Jackson, H. & Nuttall, R.L. (2001). Risk for (2001). & Garcia, P. Rodriguez, P.J. Gutierrez, P.M., of the family stress model. Threatening Behaviour Psychopathy and sucidiality in female offenders: mediating influences of personality and abuse. Journal of Consulting and Clinical Psychology vol. 73, no. 6, pp. 1065-1073. pp. 319-340. Suicide risk in relation to family history of completed case- suicide and psychiatric disorders: a nested control study based on longitudinal registers. The Lancet suicide among suicide victims. Psychiatry S. & Caine, E.D. (2004). Suicide at 50 years of age and older: perceived physical illness, family discord and financial strain. pp. 137-146. (2004). Risk of non-fatal suicide ideation and behaviour clinical, of influence the - schizophrenia onset recent in social, self-esteem and demographic factors. Psychiatry and Psychiatric Epidemiology 927-937. pp. 11, no. application ideation: suicidal adolescent and pressure preadolescent suicide-related behaviours: An preadolescent suicide-related behaviours: ecological model. Journal Work a model Suicide risk factors for young adults: testing across ethnicities.

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85 Living Is For Everyone: Research and Evidence in Suicide Prevention www.livingisforeveryone.com.au

The diversity reference group to the project were The diversity reference group to the project Jill Fisher (Chair), Mick Adams, Melba Townsend, Julian Krieg, Nooria Mehraby, Shorey, Travis Gerald Wyatt, Hilary Knack and Samantha Harrison. advisoryThe following three Australian Government of the committees contributed to the development Living Is For Everyone Resources: The National Advisory Council on Suicide Prevention; The Community and Expert Advisory Forum; and Group. The Indigenous Strategies Working There were many hundreds of people who attended the community consultations. Specialist advisers who commented on and assisted Specialist advisers who commented on and Professor with various drafts during the project included Professor Beverley Raphael, Professor Diego De Leo, Hazell, Professor Don Zoellner, Trevor Ian Webster, Hunter, Professor Edward White, Professor Ernest Angela Dr. Karolina Krysinska, Lorraine Wheeler, Dr. Don Dr. Dudley, Michael Susan Beaton, Dr. Kirsner, Coroner). Spencer and John Arms (NSW Central Coast

The main sub-consultants were Professor John The main sub-consultants were Professor Sunrise Mendoza, Associate Professor Nicholas Procter, Institute Solutions, GKY Internet, Auseinet, the Australian Griffith for Suicide Research and Prevention (AISRAP, and the University), Oxygen Kiosk, DDSN Interactive Four Design Group. The lead consultants were Corporate Diagnostics Pty Ltd,The lead consultants were Corporate Diagnostics and United Synergies Ltd, Professor Graham Martin and Greengage Judith Murray (University of Queensland) Dr. and editing Additional Communications. and Research Pty Ltd. Public Policy review were provided by NOVA The Living Is For Everyone suite of documents have been prepared for the Department of Health and Ageing by a consortium of organisations supported by a wide network of specialist consultants, advisers and community consultations. Acknowledgements

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