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Care After a Suicide Attempt A report prepared for the National Mental Health Commission by The NHMRC Centre of Research Excellence in Suicide Prevention, Black Dog Institute, the University of New South Wales, in partnership with The University of Melbourne, Lifeline, and the Australian National University CONTENTS EXECUTIVE SUMMARY ....................................................................................................................................... 2 ACKNOWLEDGEMENTS ..................................................................................................................................... 6 1. INTRODUCTION ............................................................................................................................................ 7 1.1. BACKGROUND ...................................................................................................................................... 7 1.2. AIMS............................................................................................................................................................ 7 2. PROJECT METHODOLOGY ...................................................................................................................... 9 2.1. DEFINITIONS ......................................................................................................................................... 9 2.2. INVESTIGATORS .................................................................................................................................. 9 2.3. ADVISORY PANEL ............................................................................................................................... 9 3. WHAT WE KNOW ABOUT SUICIDE AND PREVENTING REPEATED SUICIDE ATTEMPTS ............................................................................................................................................................... 10 3.1. SUICIDE RATES ................................................................................................................................... 10 3.2. SUICIDE ATTEMPTS .......................................................................................................................... 13 3.3. RE-ATTEMPTS AND FAILURE OF CONTINUITY OF CARE ............................................. 13 3.4. PEOPLE’S EXPERIENCE OF HEALTH SERVICES AFTER A SUICIDE ATTEMPT .... 14 3.5. A SYSTEMATIC REVIEW OF THE LITERATURE: WHAT WORKS TO PREVENT FURTHER SUICIDE ATTEMPTS? ................................................................................................................ 16 4. FINDINGS FROM CAASA PARTICIPANTS: WHAT CARE ARE PEOPLE RECEIVING IN AUSTRALIA? ............................................................................................................................................................ 22 4.1. RESULTS FROM THE SEMI-STRUCTURED INTERVIEWS ................................................. 22 4.2. RESULTS FROM THE ONLINE SURVEYS ................................................................................. 39 4.3. DATA LINKAGE STUDY: MENTAL HEALTH CARE RECEIVED BY PEOPLE ADMITTED TO HOSPITAL FOR DELIBERATE SELF-HARM IN NSW ........................................ 60 4.4. WHAT DATA ARE AVAILABLE TO EVALUATE HEALTH SERVICE STRATEGIES AND PROGRAMS? ............................................................................................................................................ 70 5. KEY FINDINGS AND PRIORITIES ....................................................................................................... 72 6. REFERENCES ................................................................................................................................................ 78 APPENDIX A: PROJECT METHODOLOGY ................................................................................................ 85 APPENDIX B: ADVISORY PANEL MEMBERS ............................................................................................ 91 APPENDIX C: SUICIDE RATES ........................................................................................................................ 92 APPENDIX D: STUDY CHARACTERISTICS AND OUTCOMES........................................................... 95 APPENDIX E: SURVEY CODING FOR SPECIFIC ITEMS......................................................................... 1 APPENDIX F: DATASET DESCRIPTIONS ..................................................................................................... 2 1 EXECUTIVE SUMMARY Improving the care received by people after a suicide attempt is important for reducing suicide attempts and suicide deaths in Australia, not least because a suicide attempt is one of the strongest predictors of future suicide attempts. As such, this period represents a critical time for high quality care. To better understand how health services can improve the quality of care people receive following a suicide attempt, a clearer picture of peoples’ current experience is needed. To date, no systematic examination of people’s health service experiences after a suicide attempt has been undertaken in Australia. The stigma which continues to underpin mental illness and suicide within society infiltrates our ways of research where it is too often presumed that people are not capable or unwilling to talk. Consequently, the perspective of people with lived experience of suicidality has not been properly considered. This project aims to investigate the response of health services to people who have had a suicide attempt. More specifically, it aims to provide a better understanding of what support people currently receive, how helpful or otherwise these services are, and the barriers to improvement. Previous research has identified that the period immediately after discharge from psychiatric inpatient care represents a very high risk of death by suicide. Failure to provide outpatient follow-up care after suicide attempts is associated with increased risk of re-attempt and death by suicide. A review of suicide deaths in Western Australia (WA) found that one-third of men and over half of women who died by suicide had previously been hospitalised for self-inflicted injuries. There is evidence that implementing the following policies reduces suicide deaths: assertive follow-up in the week after discharge from inpatient care, assertive outreach for non-compliant patients, and 24-hour crisis teams. As such, the care that people receive after a suicide attempt must form a critical part of the national suicide prevention strategy. This is particularly important at a time when suicide rates have increased (from 2011 to 2012: ABS Causes of Death, 2012). Yet people’s experience of health services after a suicide attempt is at best, mixed. Clinical staff may harbour negative attitudes, anger, or irritation towards patients who have had a suicide attempt. Importantly, the attitude towards patients by clinical staff following a suicide or self-harm episode can strongly impact the individual and influence their future help-seeking behaviour. Many health professionals are committed to providing good care to those experiencing mental illness and suicidality. Nevertheless, they work within a health system which is under stress and where staff are increasingly stretched in their efforts to meet the expectations of the system and their patients. Recent research indicates that the most effective strategies are multi-level, multi-component, systems- based approaches. It is when a range of elements operates in conjunction with one another in a systematic way that suicide risk in the population is lowered and suicide prevention outcomes are maximised. Such systems approaches, for which there is current or emerging evidence, are described in this report. Chain of care models are likely to be part of a larger system aimed at preventing suicide and preventing reattempts. Intensive case management in the Australian context also has evidence for its effectiveness, as do brief contact strategies where they are preceded by good clinical care. The most promising psychosocial interventions for preventing re-attempts in adults are cognitive behavioural therapy and problem solving therapy. Evidence-based strategies and models are available and yet, appear not to be systematically and thoroughly implemented. Doing so requires a coordinated, systems-based approach which ensures that patients are not lost within the health care system. Improved routine data collections are needed to monitor improvements and to ensure that health systems are accountable to achieving these improvements. We used five primary methods to achieve the study’s aims: a systematic review of the literature regarding what works to reduce the risk of a re-attempt; online surveys with people who have had a suicide attempt and with caregivers; interviews with people who have had a suicide attempt and with caregivers; a data linkage study examining mental health care use following hospital admission for a suicide attempt; and a 2 review of currently available data. These methods identified a number of barriers. We were only able to use admitted patient data as the primary episode of treatment for the data linkage study since data on suicide attempts is not systematically collected in emergency departments. This misses out any patients who present to emergency but are not admitted. It was also not possible to conduct this study at a national level because the datasets are not available in every jurisdiction.

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