Recommendations: Prevention of suicide
Preventive intervention type
Who is at risk?
What should be done?
Level/ strength of evidence
|Screening for suicide risk is not routinely recommended
|People with any one of the following:
- past history of intentional self-harm
- history of mood disorders and other mental health problems
- hazardous alcohol consumption or misuse of other drugs
- close to someone who has recently died by suicide (postvention)
|Consider asking about past and current suicidal ideation and intent as part of a comprehensive medical history (Box 5)
|37, 38, 40
|No specific behavioural interventions are recommended for the prevention of suicide
|People with a history of self-harm or suicide attempts
People who have close friends or family who have died by suicide
|Provide support and referral to social and emotional wellbeing services (particularly access to Aboriginal mental health workers) and other locally available community support groups
|Medication is not recommended for the prevention of suicide beyond a clinically indicated use for diagnosed conditions (eg major mental illness)
|Advocate for communitybased strategies to remove access to lethal methods of self-harm, both in the community and the household
|Advocate for communityled health-promotion programs that holistically address the multifactorial nature of cultural, social and emotional wellbeing (eg sports events, caring for country programs, healthy lifestyle festivals)
|Provide education so that primary healthcare professionals can recognise and respond to psychosocial distress and depression
|Take steps to enhance access to mental health and drug and alcohol services, and social and emotional wellbeing services, through integration with primary healthcare services
Box 5. Ways of asking about suicide
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
There were very few reports of suicide among Aboriginal and Torres Strait Islander peoples prior to the 1960s. Suicide rates began increasing in the late 1980s31 and now Aboriginal and Torres Strait Islander peoples die from suicide at a rate of 23 per 100,000.11 After adjusting for age, this is twice the rate of the non-Indigenous population.11 Hospitalisation for intentional self-harm is at least 2.5 times higher for Aboriginal and Torres Strait Islander people than for non-Indigenous Australians. The overall mortality rates from suicide in Aboriginal and Torres Strait Islander peoples are also twice as high as for non-Indigenous Australians, and are almost entirely among young Aboriginal and Torres Strait Islander people.5
Given these high rates of death by suicide, it is crucial to understand the causes and to run effective prevention programs. The Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project (ATSISPEP)6 was carried out by Aboriginal and Torres Strait Islander researchers and mental health professionals from the University of Western Australia. Based on numerous community consultations and roundtables, and a review of the evidence, it sets out a comprehensive summary of the evidence on suicide prevention in Aboriginal and Torres Strait Islander communities across Australia. While 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 problems are not predominantly medical. Important and often overlooked antecedents relate to historical and contemporary colonising policies and practices, forced removal from ancestral lands, and forced removal of children from families. The resulting, and indeed continuing, intergenerational trauma and disempowerment results in a range of health problems, and contributes to the increased rate of suicide and self-harm.32
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.6 Suicide in Aboriginal and Torres Strait Islander communities therefore needs health services and health professionals to understand the ongoing effects of colonisation, exclusion and disadvantage, and their health consequences. This can be difficult for non-Indigenous health professionals to put into practice and, consequently, makes it difficult to implement preventive measures as they tend to be based on biomedical models of care and may not meet community expectations. This may adversely affect help-seeking behaviour such that well-intentioned suicide prevention strategies can actually do harm.33,34 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 Indigenous communities that are not led by the community themselves should not proceed. This underscores the importance of health practitioners working closely with the local Aboriginal and Torres Strait Islander mental health workforce or social and emotional wellbeing teams, and privileging the knowledge and experience of these people.
It is clear that all health professionals consulting 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, 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.35 This is particularly relevant for Aboriginal and Torres Strait Islander peoples, who access health services less frequently than non-Indigenous people prior to a suicide attempt.36 It is crucial, then, that all primary care services are accessible and affordable, and are culturally safe places for Aboriginal and Torres Strait Islander peoples 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 general practitioners, nurses and Aboriginal and Torres Strait Islander health practitioners on effective responses to people with behaviours indicative of
Routine screening for suicide risk is not recommended as there is little evidence it reduces rates of intentional self-harm or suicide.38 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. The tools examined by the USPSTF39 had low positive predictive values – 33% being the highest – meaning many false positive screening test results. The performance of these tools in adolescents was even worse, which would particularly limit their effectiveness in Aboriginal and Torres Strait Islander communities, even if they were culturally appropriate. No harms arising from the use of screening tests for suicide were identified in the USPSTF systematic review. In an Aboriginal and/or Torres Strait Islander community setting, the harms are even less clear. There is a clear risk, however, 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 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. This is especially true for people with a history of:37
- intentional self-harm
- mood disorders and other mental health illnesses, such as schizophrenia
- hazardous alcohol consumption or misuse of other drugs.
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.31 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’ – intervening/intervention particularly for those affected by a recent suicide or suicide attempt – is important at a time when some people will most need it.40 (Refer to ‘Resources’ for useful information for health professionals.) Postvention interventions can be directed to individuals or be community-wide.41
The ATSISPEP report identified community-wide strategies effective at suicide prevention in Aboriginal and Torres Strait Islander communities. 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, education and awareness raising with programs that do not depend on literacy. Community empowerment, including local Elders and a cultural framework, are also components of successful programs. Local service delivery must be available; but again, this must be led by the community.42
There is currently no evidence demonstrating a favourable effect of behavioural interventions for people with suicidal ideation or suicidal behaviour, though there are some promising results for cognitive behavioural therapy or interpersonal therapy for those at risk. However, these studies had high withdrawal rates, which may affect the ability to generalise the findings.43 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.44
Within the context of suicide prevention, chemoprophylaxis 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. Populations with higher rates of antidepressant prescribing have lower suicide rates, but 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 antidepressants are used.45 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.46–48 The lack of evidence of effect may be limited by the quality of the trials conducted to date. As suicide is a rare event, randomised trials may not be sufficiently powered to detect statistically significant reductions in suicide rates.
There is evidence that certain environmental measures are effective in reducing suicide rates. Interventions 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. However, within an Aboriginal and Torres Strait Islander community context, this may not be as effective, as many of these measures have already been taken, and the majority of suicides among Aboriginal and Torres Strait Islander peoples are by hanging.42