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Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Prevention of suicide

Author Dr Tim Senior
Expert reviewer Mrs Patricia Delaney

Background

Aboriginal and Torres Strait Islander people die from intentional self harm at higher rates than non-Indigenous Australians in all states and territories. Overall, deaths from intentional self harm in Aboriginal and Torres Strait Islander men are 2.4 times that of non-Indigenous men, and 1.7 times higher for Aboriginal and Torres Strait Islander women. Deaths from intentional self harm occur at a much younger age in Aboriginal and Torres Strait Islander people – around three times higher for those aged under 25 years and for those aged 25–34 years.1 Rates of suicide have increased over the past 3 decades.14 

Research from Aboriginal communities suggests that suicide is less closely connected with biomedical models of ‘mental health’ and has different sociocultural meanings within those communities. Suicide may need to be conceptualised within a broader paradigm characterised by exclusion and disadvantage, rather than merely as part of a mental health diagnosis. Consequently conventional suicide prevention measures based on biomedical models of care may not meet community expectations. The method of suicide chosen (especially by young men) and the close-knit nature of community can impact on help seeking behaviour and have substantial impact on the family and the community. Thus, suicide prevention measures are more likely to succeed if they are implemented by people who are fully aware of local context. Once again, it is important for health practitioners to work with the local Aboriginal and Torres Strait Islander mental health workforce where available.

Screening

There is no evidence that screening for suicide risk leads to a reduction in intentional self harm morbidity and suicide related mortality rates.15 There are several tools available for screening for suicidal ideation, however, only one has been validated in a primary healthcare setting: the Symptom Driven Diagnostic System for Primary Care (SDDS-PC).16 This tool has 62 items, three of which relate to suicidal ideation. Although individual questions in this tool are reported to have good specificity and sensitivity, the positive predictive value is very low. This means that many people have to be screened to prevent one suicide. Although there is no analysis of adverse outcomes from screening tests for suicide, the fact that large numbers may be screened without benefit suggests there may be potential for harm. In the absence of any clear evidence on screening, clinicians should use their clinical judgement based on knowledge of the person and their community to assess the risk of suicide. It is worth emphasising that this is not a recommendation not to screen for suicide risk, but that the application of a uniform set of questions applied at a population level has not shown any benefit. Clinicians should think of the possibility of suicide and explore this, especially in those with:

  • a past history of intentional self harm
  • a history of mood disorders
  • hazardous alcohol consumption or use of other recreational drugs.

Managers of health services should note, too, that education of physicians has also been shown to reduce suicide rates.17 Given the clustering of suicide in some Aboriginal and Torres Strait Islander communities,18 practitioners should consider the impact on and their response to other community members also. (See Resources for useful information for health professionals.)

Interventions to reduce suicide risk

There is currently no evidence showing a favourable effect of behavioural interventions on people with suicidal ideation or suicidal behaviour, though there are some promising results for cognitive behavioural therapy or interpersonal therapy in those at risk. However, in these studies there are a large number of participants who have withdrawn from the study.19 There is also some evidence that these interventions may work by ‘enhancing effective contact with those who are suicidal’ and that other services such as telephone support or befriending services also have some impact.20

Chemoprophylaxis in the context of suicide prevention can be thought of as the use of pharmacological agents in mental health conditions, which prevents suicidal behaviour or deliberate self harm. This is particularly important given that some antidepressants have been reported to cause suicidal ideation, especially in adolescents. At a population level there is some evidence that suicide rates are reduced, but this is not so for individual patients with depression.21 There is no good evidence that pharmacological treatment is effective at preventing suicide or deliberate self harm attempts in personality disorders, bipolar disorder or schizophrenia.22–24 As suicide is a rare event, trials are likely to be underpowered to pick up reduced suicide rates. The goal of antidepressant treatment is improvement in symptoms and functioning, rather than suicide prevention.

There is evidence that certain environmental measures are effective in reducing suicide rates. Interventions that have been shown to be effective include restricting the prescription of potentially lethal medications, restricting access to over-the-counter medications, and legislation to restrict access to toxic chemicals and firearms. Other broader environmental strategies, such as media policies, school programs and education of the general public, may be effective, although there is no clear evidence to support this at present.17 Evidence from population studies strongly suggests that improving access to primary healthcare services in general, and mental health services in particular, will also reduce suicide rates.25 This is particularly important for Aboriginal and Torres Strait Islander people, who have been shown to access health services much less often than non-Indigenous Australians prior to a suicide attempt.26

Recommendations: Suicide prevention
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Screening All people Screening for suicide risk is not routinely recommended N/A IC15,19
People with any one of the following:
  • past history of intentional self harm
  • a history of mood disorders
  • hazardous alcohol consumption or use of other recreational drugs
Consider asking about past and current suicidal ideation and intent as part of a comprehensive medical history Opportunistic GPP15,17
Behavioural All people No specific behavioural interventions are recommended for prevention of suicide N/A IC15
People at increased risk of suicide from history or clinical judgement Consider local methods of enhancing effective contact with volunteer or professional agencies, particularly access to Aboriginal mental health workers Ongoing IIIC20
Chemoprophylaxis All people Medication is not recommended for the prevention of suicide beyond a clinically indicated use for diagnosed conditions (eg. major mental illness) N/A IB21–24,27,28
Environmental Communities Remove access to lethal methods of suicide both in the community and the household Ongoing IC17

Communities

Advocate for community based health promotion programs that holistically address the multifactorial nature of social and emotional wellbeing (eg. sports events, caring for country programs, healthy lifestyle festivals)

Ongoing

GPP

N/A

Provide education for primary care health professionals to recognise and respond to psychosocial distress and depression

Ongoing

IC17

N/A

Integrating mental health services with alcohol and other drug services can improve service access to youth who are at risk of suicide

Ongoing

GPP25

Resources

Australian Indigenous Mental Health (Royal Australian and New Zealand College of Psychiatrists)
http://indigenous.ranzcp.org

Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice
www.ichr.uwa.edu.au/ files/user5/Working_Together_book_web.pdf.

References

  1. Thomson N, MacRae A, Burns J, et al. Overview of Australian Indigenous health status. Health Infonet, April 2010 cited 2011 October 10. Available at www.healthinfonet.ecu.edu.au/health-facts/overviews.
  2. Hunter E, Milroy H. Aboriginal and Torres Strait Islander suicide in context. Arch Suicide Res 2006;10(2):141–57.
  3. Gaynes B, West S, Ford C, Frame P, Klein J, Lohr K. Screening for suicide risk in adults: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med 2004;140(10):822–35.
  4. Broadhead WE, Leon AC, Weissman MM, et al. Development and validation of the SDDS-PC screen for multiple mental disorders in primary care. Arch Fam Med 1995;4(3):211–9.
  5. Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: a systematic review. JAMA 2005;294(16):2064–74.
  6. Hunter E, Harvey D. Indigenous suicide in Australia, New Zealand, Canada, and the United States. Emerg Med (Fremantle) 2002;14(1):14–23.
  7. Robinson J, Hetrick SE, Martin C. Preventing suicide in young people: systematic review. Aust N Z J Psychiatry 2011;45(1):3–26.
  8. Goldney R. Suicide prevention: a pragmatic review of recent studies. Crisis 2005;26(3):128–40.
  9. Schneeweiss S, Patrick A, Solomon D, et al. Variation in the risk of suicide attempts and completed suicides by antidepressant agent in adults: a propensity score-adjusted analysis of 9 years’ data. Arch Gen Psychiatry 2010;67(5):497–506.
  10. Cardish R. Psychopharmacologic management of suicidality in personality disorders. Can J Psychiatry 2007;52(6 Suppl 1):115S–27S.
  11. De Hert M, Correll C, Cohen D. Do antipsychotic medications reduce or increase mortality in schizophrenia? A critical appraisal of the FIN-11 study. Schizophr Res 2010;117(1):68–74.
  12. Ernst C, Goldberg J. Antisuicide properties of psychotropic drugs: a critical review. Harv Rev Psychiatry 2004;12(1):14–41.
  13. Campo J. Youth suicide prevention: does access to care matter? Curr Opin Pediatr 2009;21(5):628–34.
  14. Sveticic J, Milner A, De Leo D. Contacts with mental health services before suicide: a comparison of Indigenous with non-Indigenous Australians. Gen Hosp Psychiatry 2011;Dec 8 (Epub ahead of print).
  15. Mulder R. Antidepressants and suicide: population benefit vs. individual risk. Acta Psychiatr Scand 2010;122(6):442–3.
  16. Stone M, Laughren T, Jones ML, et al. Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration. BMJ 2009 Aug 11;339:b2880.
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