National Guide

Chapter 20 | Mental health

Suicide: Recognising & responding to risk







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      3. Suicide: Recognising & responding to risk

Mental health | Suicide: Recognising and responding to risk

Dr Timothy Senior 

Key messages

  • Involvement in cultural and community activities supports and protects social and emotional wellbeing (SEWB).1
  • Routine screening for suicide risk, or the use of current risk assessment scoring tools, is not recommended.2–4
  • Healthcare practitioners should enquire about suicide plans in people identified as most at risk.4
  • Evidence from population studies strongly suggests that improving access to primary healthcare services in general, and mental health services in particular, is associated with reduced suicide rates.
  • Suicide prevention measures are only likely to succeed if they are developed and implemented by the local Aboriginal and Torres Strait Islander community.
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People with higher risk of suicide, including:
  • previous suicide attempt or non-suicidal self-injury
  • anxiety disorders
  • post-traumatic stress disorder, including complex trauma
  • complex and compounded loss, including loss of freedom/incarceration, loss of identity, bereavement and separation
  • sexual abuse history
  • drug use disorders
 Use strength-based principles to guide a conversation about suicidal ideation, including specific plans for suicide or self-harm (see Box 1)

Manage according to clinical judgement, relevant clinical guidelines and local community resources		 Opportunistically and as clinically indicated Good practice point Meta-analysis5 The lack of evidence for specific treatments to prevent suicide is likely due to the comparison being treatment as usual

Clinicians should make every effort to identify suicidal plans in those at highest risk, and manage according to clinical judgement, clinical guidelines and local community resources
People after a recent suicide attempt or self-harm Use strength-based principles to guide a conversation about suicidal ideation, including specific plans for suicide or self-harm

Manage according to clinical judgement, relevant clinical guidelines and local community resources, including referral to/connecting with traditional healers when available (see Centre of Best Practice in Aboriginal & Torres Strait Islander Suicide Prevention (CBPATSISP) Policy concordance in Useful resources)		 As clinically indicated Good practice point Aboriginal and Torres Strait Islander-specific national guidelines3 Suicidal ideation is not a good indicator of who may make a suicide attempt or self-harm; people who have made plans are at higher risk

The lack of evidence for specific treatments to prevent suicide is likely due to the comparison being treatment as usual
People affected by recent suicide of a family member or friend Use strength-based principles to guide a conversation about suicidal ideation, including specific plans for suicide or self-harm

Manage according to clinical judgement, relevant clinical guidelines and local community resources		 As clinically indicated Good practice point Aboriginal and Torres Strait Islander-specific national guidelines3  
Type of preventive activity - Behavioural
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People after a suicide attempt or self-harm Consider psychosocial interventions based on clinical judgement and availability and cultural appropriateness of local services (see Postvention programs in Useful resources) As clinically indicated Conditional Systematic reviews6,7
Aboriginal and Torres Strait Islander-specific report8		 Cochrane reviews in adults and children and adolescents show uncertain evidence that interventions based on cognitive behavioural therapy, dialectical behaviour therapy or mentalisation-based therapy may reduce repeat episodes of self-harm

Many communities have locally led postvention programs
Type of preventive activity - Medication
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
People with a mental health condition Do not prescribe medication routinely for the purpose of reducing suicide and self-harm N/A Conditional Systematic reviews7,9 No evidence that medication reduces self-harm or suicide

Medication should be used according to clinical judgement for the management of underlying mental health condition
Type of preventive activity - Environmental 
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
Health service staff Provide Aboriginal and Torres Strait Islander mental health first aid training or other similar gateway training As required Good practice point Systematic review10 No strong evidence that mental health first aid reduces suicide or self-harm attempts, but probably increases confidence and skills in ability to handle mental health crises in others
Health services and practices Advocate for community-based strategies to remove access to lethal methods to self-harm both in the community and in the household As required Conditional Systematic review11 Removal of means can help prevent suicides, although there are some circumstances specific to Aboriginal and Torres Strait Islander suicide that mean the opportunities may be more limited, and this should be led by the community themselves
Health services and practices Advocate for community-led health promotion programs that holistically address the multifactorial nature of cultural, social and emotional wellbeing As required Good practice point Aboriginal and Torres Strait Islander-specific cohort study1
Aboriginal and Torres Strait Islander-specific report8		 Community leadership, development and participation are essential for effectiveness of suicide prevention programs
Health services and practices Do not implement suicide prevention programs that are not led and codeveloped by the community N/A Strong Aboriginal and Torres Strait Islander-specific report8 Programs that are not led and developed by the community have been shown to be ineffective and actually harmful

Box 1. Ways of asking about suicide

Questions to ask:

Have you ever felt like this before?
Have you ever felt so bad that you’ve hurt yourself or tried to kill yourself?
Many people when they feel this bad have thought about hurting themselves or even killing themselves. Has this happened to you?
Other people with similar problems sometimes lose hope. Has this happened to you?
Have you thought about how you would kill yourself?
Have you made any plans?
What stops you from doing that?
And, as a follow up question to many of the others, Can you tell me more about that?

Asking about suicide intent does not make it more likely.
  • Consider developing systems to record presentations with suicide attempts or self-harm behaviour in the clinical record, and how these patients are followed up systematically in your service.
  • Consider ways of documenting and following up people who are impacted by the suicide of friends or family.
  • Ensure the environment and interactions in the service are culturally safe, warm and welcoming to encourage disclosure of suicidal plans if they are present.
  • Ask whether there are other members of the patient’s* extended family who they may want to be involved or not involved in their care, because there may be cultural kinship relationships important for decision making.
  • Find out about wellbeing and other support services for Aboriginal and Torres Strait Islander people in your region.
 
*Note that while acknowledging that some services may prefer the term ‘client’, this chapter uses the term ‘patient’. This is consistent with the rest of the National Guide and does not change any of the recommendations.

Background

There were very few reports of suicide among Aboriginal and Torres Strait Islander people prior to the 1960s. Suicide rates began increasing in the late 1980s12 and, in 2021, Aboriginal and Torres Strait Islander people died from suicide at a rate of 27.1 per 100,000 population.13 After adjusting for age, this is about twice the rate than for the non-Indigenous Australian population.14

The overall mortality rates from suicide in Aboriginal and Torres Strait Islander people are twice as high as for non-Indigenous Australians. Suicides among Aboriginal and Torres Strait Islander people occur at a much younger age, with the median age for Aboriginal and Torres Strait Islander people being 29.6 years, compared to 47 years for non-Indigenous Australians.14 Tragically, suicide is the leading cause of death among children aged between 5 and 17 years, accounting for 29.7% of deaths of Aboriginal and Torres Strait Islander children.13 Three-quarters of these were aged between 15 and 17 years.13

Given these tragically high rates of death by suicide, it is crucial to understand the causes in order to run effective prevention programs. The Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project (ATSISPEP)8 was conducted by Aboriginal and Torres Strait Islander researchers and mental health professionals from the University of Western Australia and has formed the foundation for the establishment of the Centre of Best Practice in Aboriginal & Torres Strait Islander Suicide Prevention (CBPATSISP). Based on numerous community consultations and round tables, and a review of the evidence, the ATSISPEP sets out a comprehensive summary of the evidence on suicide prevention in Aboriginal and Torres Strait Islander communities across Australia. Subsequently, the CBPATSISP has built on this evidence with development of guidelines, policy documents and resources (see Useful resources).

Although suicidal ideation and acts of self-harm do bring people into contact with health services, and are closely associated with mental health problems, the underlying issues are not predominantly medical. Important and often overlooked antecedents relate to historical and contemporary colonising policies and practices, forced removal from ancestral lands and the forced removal of children from families. The resulting, and continuing, intergenerational trauma and disempowerment results in a range of health problems and contributes to the increased rate of suicide and self-harm.15

Research from mainly remote Aboriginal communities suggests that suicide and suicidal behaviour are not well explained by biomedical concepts of mental health and are influenced by sociocultural phenomena specific to those communities.8 Therefore, suicide in Aboriginal and Torres Strait Islander communities needs health services and health professionals to understand the ongoing effects of colonisation, exclusion and disadvantage, and their health consequences, as well as the local context. This can be difficult for non-Indigenous Australian health professionals to put into practice and consequently makes it difficult to implement preventive measures because they tend to be based on biomedical models of care, which are often standardised and may not meet community expectations. This may adversely affect help-seeking behaviour such that well-intentioned suicide prevention strategies can actually do harm.16,17
Suicide prevention measures are only likely to succeed if they are developed and implemented by the local Aboriginal and Torres Strait Islander community. In fact, the ATSISPEP report recommends that suicide prevention projects in Australian Aboriginal and Torres Strait Islander communities that are not led by the community themselves should not proceed.8 This underscores the importance of health practitioners working closely with the local Aboriginal and Torres Strait Islander mental health workforce or SEWB teams and privileging the knowledge and experience of these people.

It is clear that all health professionals seeing Aboriginal and Torres Strait Islander patients are very likely to treat people who have personal experience of suicide, either in friends or family, or in thoughts or an attempt themselves. Clearly, then, health professionals have an obligation to ensure they maintain cultural competency, through ongoing training and feedback within their local communities.

Health professionals are also often influential locally in the development of programs and policies, especially where they have been working in the community for a while and have established trust and relationships, and so have an opportunity to advocate effectively that local Aboriginal and Torres Strait Islander community leadership is crucial for success in any suicide prevention program.

Evidence from population studies strongly suggests that improving access to primary healthcare services in general, and mental health services in particular, is associated with reduced suicide rates.18 This is particularly relevant for Aboriginal and Torres Strait Islander people who access health services less frequently than non-Indigenous Australian people prior to a suicide attempt.17 It is crucial, then, that all primary care services are accessible, affordable and are culturally safe places for Aboriginal and Torres Strait Islander people to attend to maximise the likelihood of attendance for those at risk.

There is also evidence that education of ‘gatekeepers’ can improve knowledge about suicidal behaviour. This is the training of specific key people in a community, including GPs, nurses and Aboriginal and Torres Strait Islander health practitioners, on effective responses to people with behaviours indicative of suicidal risk.8,19

Mental health first aid training is designed to equip people to have the knowledge, skills and confidence to respond to someone experiencing a mental health crisis. There is evidence of some improvement in participants’ mental health literacy, and their confidence and intention in helping a person with mental health problems.10 However, it is not clear that this improves observed, rather than self-reported, behaviours, and the impacts on the person being helped are unclear.20 Specific Aboriginal and Torres Strait Islander mental health first aid courses are accredited, and these would be the most appropriate for people working in Aboriginal and Torres Strait Islander communities.

In assessing the evidence for primary care practitioners about interventions to prevent Aboriginal and Torres Strait Islander suicides, it should be acknowledged that systematic reviews and randomised controlled trials are not suited as the predominant measures for evaluating complex interventions, such as suicide prevention programs.21 Evaluations of existing and new programs are crucial, but need to be based in the context of Aboriginal and Torres Strait Islander models of SEWB and models of healing. A practice-based evidence base will be built through the evaluation of programs and the narrative synthesis of research, evaluations and implementation understood in its community and cultural context.

Even within a paradigm of randomised controlled trials, much of the evidence regarding screening for suicide risk compares an intervention against treatment as usual. In an area as important as suicide, treatment as usual is often highly active treatment and, because suicide is a rare outcome, it is difficult to have trials sufficiently powered to detect an outcome. This makes randomised controlled trials have a tendency towards demonstrating ineffectiveness, but is not a reason for therapeutic nihilism.

Routine screening for suicide risk is not recommended because there is little evidence it reduces rates of intentional self-harm or suicide. The tools available for screening for suicidal ideation have not been assessed for cultural safety when working with Aboriginal and Torres Strait Islander peoples and communities. Notably, in a Delphi study to develop guidelines for psychosocial assessment of Aboriginal and Torres Strait Islander people with suicidal ideation or self-harm, there was a strong consensus against the use of such tools.2,3 No harms arising from the use of screening tests for suicide were identified in the U.S. Preventive Services Task Force systematic review.4 In an Aboriginal and/or Torres Strait Islander community setting, the harms are even less clear. However, there is a clear risk in using a tool that is culturally inappropriate that not only will it be ineffective in identifying those at risk of self-harm, but it could also affect help-seeking behaviour. 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. Clinicians must be alert to the possibility of suicide risk and be comfortable discussing this with patients. Suicidal ideation is common among patients with mental health problems, and the intensity of suicidal ideation is not related to the risk of suicide attempt. Many patients do not disclose suicidal plans to health professionals. In assessing risk of suicide, the following features are associated with higher risk:5,22

  • previous suicide attempt or non-suicidal self-injury
  • anxiety disorders
  • post-traumatic stress disorder, including complex trauma
  • complex and compounded loss, including loss of freedom/incarceration, loss of identity, bereavement and separation
  • sexual abuse history
  • drug use disorders.

Specific research in Aboriginal and Torres Strait Islander communities by Dr Tracey Westerman, a Nyamal psychologist, clarifies the risk of suicide.23 Impulsivity is one of the key risks for suicide. In the absence of specific coping mechanisms at the time of a specific trigger, such as a relationship breakdown, sometimes along with the use of alcohol or other drugs, suicide risk is higher. Also contributing to suicide risk is knowing someone who has died by suicide.

In some Aboriginal and Torres Strait Islander communities, the phenomenon of suicide clusters is described, where several people die by suicide in a short space of time. These are thought to be suicides copying the actions of another, often relating to hanging.12 Practitioners should be aware of this and consider the impact on other community members, and the response of the health service to those affected. The strategy of ‘postvention’ (ie intervening/intervention particularly for those affected by a recent suicide or suicide attempt) is an important opportunity to intervene effectively at a time where some people most need it24 (see Useful resources for information for health professionals). Postvention interventions can be directed to individuals or be community wide.25

The ATSISPEP report identified community-wide strategies effective at suicide prevention in Aboriginal and Torres Strait Islander communities.8 Crucial for success is that programs are led by those communities affected and address the problems they identify. This includes tackling poverty and the social determinants of health, as well as education and awareness raising that is appropriate for people’s literacy levels, important measures that are outside the scope of this guide. Community empowerment including local Elders and a cultural framework is also a component of successful programs. Local service delivery must be available, but again this has to be led by the community.26

Aboriginal and Torres Strait Islander people have been saying for a long time that connection to culture is protective of SEWB, and Aboriginal and Torres Strait Islander-led research is starting to demonstrate this in published literature.1 Although currently no specific cultural programs or activities can be recommended, programs led by local Aboriginal and Torres Strait Islander communities are likely to be beneficial in improving SEWB and reducing suicide rates.

There is limited evidence on psychosocial interventions for adults6 or young people7 with self-harm behaviour, although cognitive behavioural therapy approaches, dialectical behaviour therapy or mentalisation-based therapy may have some effect on reducing future self-harm.6 There is also some evidence that these interventions may work by enhancing effective contact with those who have suicidal ideation and that other services, such as telephone support or befriending services, may also have some positive impact.27 The Australian Indigenous suicide prevention policy concordance developed by CBPATSISP recommends connecting people with traditional healers where they are available (see Useful resources).

Chemoprophylaxis within the context of suicide prevention relates mainly to the use of pharmacological agents to optimise the management of mental health conditions that may prevent suicidal behaviour or deliberate self-harm. The goal of antidepressant medication is improvement in symptoms and functioning from anxiety or depression, rather than suicide prevention per se.

There is no evidence that antidepressants, antipsychotics, mood stabilisers or natural products reduce repetition of self-harm in adults.9

Consistent with this, there is no reliable evidence that pharmacological treatment is effective at preventing suicide or deliberate self-harm attempts in people with diagnosed personality disorders, bipolar disorder or schizophrenia.28–30 Although populations with higher rates of antidepressant prescribing have lower suicide rates, there is no evidence that individuals prescribed antidepressants are at less risk of suicide. Indeed, in some people, especially adolescents, suicidal ideation may be increased if selective serotonin reuptake inhibitor (SSRI) antidepressants are used.31

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.11 However, within an Aboriginal and Torres Strait Islander community context, this may not be as effective because many of these measures have already been taken, and the majority of suicides among Aboriginal and Torres Strait Islander peoples are by hanging.26

 
 
  1. Lovett R, Brinckley MM, Phillips B, et al. Marrathalpu mayingku ngiya kiyi. Minyawaa ngiyani yata punmalaka; wangaaypu kirrampili kara Aust Aborig Stud 2020;2020(2):8–30. [Ngiyampaa title]; In the beginning it was our people’s law. What makes us well; to never be sick. Cohort profile of Mayi Kuwayu: The National Study of Aboriginal and Torres Strait Islander Wellbeing [English title].
  2. Leckning B, Hirvonen T, Armstrong G, et al. Developing best practice guidelines for the psychosocial assessment of Aboriginal and Torres Strait Islander people presenting to hospital with self-harm and suicidal thoughts. Aust N Z J Psychiatry 2020;54(9):874–82. doi: 10.1177/0004867420924082.
  3. Leckning B, Ringbauer A, Robinson G, Carey TA, Hirvonen T, Armstrong G. Guidelines for best practice psychosocial assessment of Aboriginal and Torres Strait Islander people presenting to hospital with self-harm and suicidal thoughts. Menzies School of Health Research, 2019 [Accessed 28 May 2024].
  4. Viswanathan M, Wallace I, Middleton JC, et al. Screening for depression, anxiety, and suicide risk in children and adolescents: An evidence review for the U.S. Preventive Services Task Force (Evidence Synthesis no. 221). Agency for Healthcare Research and Quality (US), 2022 [Accessed 28 May 2024].
  5. May AM, Klonsky ED. What distinguishes suicide attempters from suicide ideators? A meta-analysis of potential factors. Clin Psychol Sci Prac 2016;23(1):5–20. doi: 10.1111/cpsp.12136.
  6. Witt KG, Hetrick SE, Rajaram G, et al. Psychosocial interventions for self-harm in adults. Cochrane Database Syst Rev 2021;4(4):CD013668. doi: 10.1002/14651858.cd013668.pub2.
  7. Witt KG, Hetrick SE, Rajaram G, et al. Interventions for self-harm in children and adolescents. Cochrane Database Syst Rev 2021;3(3):CD013667. doi: 10.1002/14651858.cd013667.pub2.
  8. Dudgeon P, Milroy J, Calma T, et al. Solutions that work: What the evidence and our people tell us. Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project report. School of Indigenous Studies (University of Western Australia) and the Commonwealth Department of Prime Minister and Cabinet, 2016 [Accessed 28 May 2024].
  9. Witt KG, Hetrick SE, Rajaram G, et al. Pharmacological interventions for self-harm in adults. Cochrane Database Syst Rev 2021;1(1):CD013669. doi: 10.1002/14651858.cd013669.pub2.
  10. Morgan AJ, Ross A, Reavley NJ. Systematic review and meta-analysis of mental health first aid training: Effects on knowledge, stigma, and helping behaviour. PLoS One 2018;13(5):e0197102. doi: 10.1371/journal.pone.0197102.
  11. Zalsman G, Hawton K, Wasserman D, et al. Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry 2016;3(7):646–59. doi: 10.1016/S2215-0366(16)30030-X.
  12. Hunter E, Harvey D. Indigenous suicide in Australia, New Zealand, Canada, and the United States. Emerg Med (Fremantle) 2002;14(1):14–23. doi: 10.1046/j.1442-2026.2002.00281.x.
  13. Australian Bureau of Statistics (ABS). Intentional self-harm deaths (suicide) in Aboriginal and Torres Strait Islander people. ABS, 2022 [Accessed 28 May 2024].
  14. Australian Institute of Health and Welfare (AIHW). Deaths by suicide amongst Indigenous Australians. AIHW, 2023 [Accessed 24 May 2023].
  15. Dudgeon P, Calma T, Holland C. The context and causes of the suicide of Indigenous people in Australia. J Indig Wellbeing 2017;2(2):5–15.
  16. Isaacs AN, Pyett P, Oakley-Browne MA, Gruis H, Waples-Crowe P. Barriers and facilitators to the utilization of adult mental health services by Australia’s Indigenous people: Seeking a way forward. Int J Ment Health Nurs 2010;19(2):75–82. doi: 10.1111/j.1447-0349.2009.00647.x.
  17. 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 2012;34(2):185–91. doi: 10.1016/j.genhosppsych.2011.10.009.
  18. Campo JV. Youth suicide prevention: Does access to care matter? Curr Opin Pediatr 2009;21(5):628–34. doi: 10.1097/MOP.0b013e32833069bd.
  19. Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: A systematic review. JAMA 2005;294(16):2064–74. doi: 10.1001/jama.294.16.2064.
  20. El-Den S, Chen TF, Moles RJ, O’Reilly C. Assessing mental health first aid skills using simulated patients. Am J Pharm Educ 2018;82(2):6222. doi: 10.5688/ajpe6222.
  21. Dudgeon P, Bray A, Ring I, McPhee R. Beyond evidence-deficit narratives in Indigenous suicide prevention. Australian Institute of Health and Welfare, 2021. doi: 10.25816/7evx-x848.
  22. Barker J, Oakes-Rogers S, Lince K, et al. Can clinician’s risk assessments distinguish those who disclose suicidal ideation from those who attempt suicide? Death Stud 2024;48(2):129–39. doi: 10.1080/07481187.2023.2192532.
  23. Westerman T, Sheridan L. Whole of community suicide prevention forums for Aboriginal Australians. Aust Psychol 2020;55(4):363–74. doi: 10.1111/ap.12470.
  24. Hunter E. ‘You didn’t tell us what to do’: Trauma2 and critical incident responses in remote Indigenous settings. Australas Psychiatry 2017;25(3):290–92. doi: 10.1177/1039856217690065.
  25. Couzos S, Murray R. Aboriginal primary health care: An evidence-based approach. Oxford University Press, 2008.
  26. Dudgeon P, Milroy J, Calma T, et al. ATSISPEP suicide prevention in Indigenous communities – literature review. ATSISPEP, 2017 [Accessed 24 May 2023].
  27. Goldney RD. Suicide prevention: A pragmatic review of recent studies. Crisis 2005;26(3):128–40. doi: 10.1027/0227-5910.26.3.128.
  28. Cardish RJ. Psychopharmacologic management of suicidality in personality disorders. Can J Psychiatry 2007;52(6 Suppl 1):115S–27S.
  29. De Hert M, Correll CU, 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. doi: 10.1016/j.schres.2009.12.029.
  30. Ernst CL, Goldberg JF. Antisuicide properties of psychotropic drugs: A critical review. Harv Rev Psychiatry 2004;12(1):14–41. doi: 10.1080/10673220490425924.
  31. Schneeweiss S, Patrick AR, Solomon DH, 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. doi: 10.1001/archgenpsychiatry.2010.39.




 

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