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Success! The Australian National Suicide Prevention Strategy has worked… But what exactly made the difference?. Professor Graham Martin OAM MD, MBBS, FRANZCP, DPM. Two Cases. Suicide is increasing worldwide. Nearly 1 million people in 2007. Strategies work: Finland 1992.
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Success!The Australian National Suicide Prevention Strategy has worked…But what exactly made the difference? Professor Graham Martin OAM MD, MBBS, FRANZCP, DPM
Suicide is increasing worldwide Nearly 1 million people in 2007
21% of all male deaths under 35 years are suicide ABS, 2007 3303.0 SUICIDES AS A PROPORTION OF ALL DEATHS
Australian suicide rates in males (20-34 yrs) adjusted for misclassification Revised suicide rates under both scenarios did not significantly differ from recorded suicide rates based on 95% confidence intervals.
So…. • Big changes have occurred over 12 years • The changes in youth suicide could be described as dramatic (55% reduction) • They appear to be real, despite any possible misclassifications • It is tempting to suggest that the National Strategy ± state strategies may have had some impact
Morrell, Page & Taylor, 2007Social Science and Medicine, 747-75 “The recent sudden turnaround in Australian young male suicide trends and its extent appears to preclude explanations centering on slow-moving social indices traditionally associated with suicide, or on possible cohort effects. This sudden decrease has occurred mainly in non-impulsive means, and at the same time has broken a long-standing secular link between 20-24yrmale suicide and unemployment, lending plausibility to the case for the NYSPS having had an impact on young male suicide in Australia.”
Before moving on… • There are 2 issues within the rates which need • to be addressed: • Rural and Remote Status, and • Socio-economic Status
Australian suicide rates by urban-rural residence, 1979-2003 (rate per 100,000) Page A, Morrell S, Taylor R, Dudley M, Carter G. Further increases in rural suicide in young Australian adults: Secular trends 1979-2003. Soc Sci Med. 65(3): 442-53.
Australian suicide rates by low, middle & high SES, 1979-2003 (rate per 100,000) Page A, Morrell S, Taylor R, Carter G, Dudley M. Divergent trends in suicide by socio-economic status in Australia. Soc Psychiatry Psychiatr Epidemiol 2006;41(11):911-7.
% Children from each State/Territory in Bottom/Top Social Exclusion Deciles (ABS 2001 Census) Harding et al., 2006. NATSEM
The origins of suicide:Implications for suicide prevention • This brings us to the crucial issue of the origins of suicide. • On the one hand we know that suicide is a behaviour related to mental illness and occurring at the end point of despair • On the other hand, there are social and cultural conditions which contribute to the development of mental health problems and despair
Interventions which workGunnel & Frankel, 1994 • Support high risk through Suicide Prevention Centre (I) • Post-discharge contact with psychiatric inpatients (I) (3%) • Education for GPs (II) • Drug treatments and ECT (II) • Improved Prescribing (eg SSRIs) (III) (4%) • Suicide Prevention Centres (III) • Group treatment for depressed and suicidal (III) • Media restrictions on reporting (III) • Legislation of Drugs (eg Barbiturates) (III)
Mann et al, 2005 (consensus) • “National suicide prevention strategies have been proposed despite knowledge deficits about the effectiveness of some common key components • the most promising interventions are physician education, means restriction, and gatekeeper education. Many universal or targeted educational interventions are multifaceted, and it is not known which components produce the desired outcome”
Despite this we concluded… National Strategies are successful if they provide… • communication program to the whole population • education for relevant groups (‘gatekeepers’) • reduced access to means (bridges, firearms, etc) • a strategy on drugs and alcohol • a critical mass of clinical services with relevant and sufficient highly trained professionals • improved services managing suicidal people, as well as improved linkages with the community • proper evaluation with a formative approach • a strategy for Indigenous peoples
Rose’s Theorem A large number of people at small risk may give rise to more cases of disease than a small number of cases at high risk A population strategy of prevention is necessary where risk is widely diffused through the whole population. Rose, Geoffrey, The strategy of preventive medicine. Oxford University Press, 1992
Population-based Approach Mortality threshold Move population risk Population Low High Suicide risk
A Model of PreventionNIH - Patricia Mrazek & Robert Haggerty, 1994 Mental Health Promotion
NYSPS Projects 1995–1999 • 70+ Projects funded, covering: • Primary prevention and cultural change • Early Intervention • Crisis Intervention • Treatment, support and postvention • Access to Means/Injury prevention • $31m+ (over 4 years) • National Advisory Council Valuing Young Lives, Penny Mitchell, Australian Institute of Family Studies, 2000
Major Achievements NYSPS 95-99Universal, Selective and Indicated • Process Indicators are available for: • Professional training (eg in parenting programs) • Gatekeeper training (eg KYA & GPs - 7% or 3500) • Curricula for schools • Media Resource Kit • Training for Telephone Counsellors • Crisis/Hospital Emergency Departments • Community Development projects Valuing Young Lives, Penny Mitchell, Australian Institute of Family Studies, 2000
Major Achievements NYSPS 95-99Universal, Selective and Indicated • Impact Indicators • Clinical programs (“some evidence”) • Population level impacts (“no evidence exists”) • Outcome Indicators (only a few available) • Clinical programs • 3 programs in mental health services • 1 program in Accident & Emergency • Parenting programs • Telephone counselling services • Programs for marginalised youth Valuing Young Lives, Penny Mitchell, Australian Institute of Family Studies, 2000 The Evaluation Experience, Jonine Penrose-Wall et al., NYSPS Evaluation Working Group, 2000
Longevity • Many, if not most, of the smaller programs simply completed their course, were not refunded, and their long term impact at a local level is unknown • A few programs acted as springboards for larger, better programs • Some of the larger programs have lasted to the present day and continue to have impact at a national level
Media Guidelines • Achieving the Balance (Suicide Prevention Australia, 1998) negotiated widely with Media to provide clear, relevant advice. • Then, a new National Media & Mental • Health Committee commissioned: • major literature review • 1-year prospective research • revised guidelines • www.MindFrame-Media.info
Firearm Deaths since 1996 In the 18 years before the 1996 gun law reforms, there were 13 mass shootings in Australia, and none in the 10.5 years afterwards. Declines in firearm-related deaths before the law reforms accelerated after the reforms for total firearm deaths (p 0.04), firearm suicides (p 0.007) and firearm homicides (p = 0.15), but not for unintentional firearm deaths, which increased. No evidence of substitution effect for suicides or homicides was observed. S Chapman, P Alpers, K Agho, M Jones, Injury Prevention 2006;12:365–372
Antidepressant prescribing for young people (1995 - Number) Total: 47,086 ABS, 1999
Medication prescribing for young peopleNHS Survey 2005 704,200 young people used psychotropics • 41,548 (5.9%) Citalopram • 25,351 (3.6%) Paroxetine • 51,407 (7.3%) Sertraline • 11,972 (1.7%) Other SSRI • 20,422 (2.9%) Venlafaxine • 12,676 (1.8%) Tricyclics • 12,676 (1.8%) Other Antidepressant • 10.1% Anxiolytics • 83.5% other including 69.2% Vitamins and Minerals Table 15, page 36 Ausstats 2005 = 18.5% 130,277 Total SSRI prescriptions
Suicide reduced yet problems persist • No change in rates of depression between 1995 and 2005 (ABS: Mental & Behavioural Problems, 2005) • More children <17 years were homeless and sought help through Supported Accommodation Assistance Program (SAAP) (AIHW) • Reported cases of child abuse rose from 91,734 to 115,471 during the period 1995/6-2000/1 • Number of children placed in out of home care rose from 14,078 to 18,241 during the period 1997 - 2001