One hundred and forty articles were retrieved by the search, of which 39 focused on those groups at elevated risk of suicide, and 41 reported on the effectiveness of specific interventions or approaches to suicide prevention. Three articles reported on individual studies of interventions in Indigenous populations.
A further 33 articles were identified through hand searching of references, and targeting key authors in the area of suicide prevention.
3.1 High-risk groupsThis section summarises evidence obtained from the retrieved literature regarding those subgroups of the general population that are at elevated risk of suicide. It also considers high-risk groups that are specific to Australia.
3.1.1 MenSuicide is one of the leading causes of death among men, both here in Australia and around the world. The most recent Australian data show that men account for three quarters of all deaths by suicide,5 whilst in England suicide is the leading cause of death in men under 35 years.6 Young men are at especially high risk, with suicide being the second-leading cause of mortality (behind accidental death) for this group around the world7 and the greatest cause of premature mortality in Australia.5
3.1.2 YouthInternationally, youth suicide rates have gradually been increasing and young people are now at the highest risk of suicide in one third of all countries (both developed and developing). At least 100,000 adolescents die by suicide every year8 and, worldwide, suicide ranks in the top five causes of mortality among 15 to 19 year olds.9
In Australia, the most recent data available demonstrate that suicide is the leading cause of death among Australians aged between 15 and 24, accounting for between 22% and 24% of all deaths in this age group. In 2010 there were 113 suicide deaths among 15-19 year olds and 183 among those aged 20-24.
3.1.3 Older adultsSuicide rates are highest amongst the elderly population according to the World Health Organisation8 (WHO), and in Australia, suicide rates in older adults are at a similar level to those of young people.10 It has been suggested that the elderly are at risk of suicide due to a number of factors, including psychiatric illness (most notably depression), physical and functional impairment and the impact of stressful life events, including bereavement.11 Top of page
3.1.4 Culturally and linguistically diverse (CALD) populationsPeople who were born overseas make up around 25% of all suicides in Australia each year. Possible reasons for this may be that people from CALD communities do not seek help for mental health issues, or the information/support that is available may not be in their language. Furthermore, those who have experienced a traumatic event may be at higher risk for subsequent mental health issues such as depression or Post Traumatic Stress Disorder (PTSD) that in turn increase their risk of engaging in suicidal behavior.12
3.1.5 Indigenous populationsIn Australia, the suicide rate in the Aboriginal and Torres Strait Islander population is over two times higher when compared with non-Indigenous Australians. Between 2001 and 2010 there were 996 deaths by suicide among Indigenous Australians and although rates have been decreasing in recent years, suicide among Indigenous people remains disproportionately high relative to non-Indigenous Australians.13 This is particularly notable in young people: in Indigenous children younger than 15 years, the suicide rate was more than seven times higher than their non-Indigenous peers, and in the 15-24 age group, Indigenous youth had a suicide rate 3.6 times higher than that for non-Indigenous youth.14
Recent research using the Queensland Suicide Register suggests that Indigenous people who have died by suicide were less likely to have sought treatment for a psychiatric condition or be diagnosed with depression compared with non-Indigenous individuals who have also died by suicide.15 Other risk factors may be disproportionately high in Indigenous populations, including demographic isolation, substance abuse and imprisonment.16
3.1.6 Rural and remote populationsThere is some evidence to suggest a higher rate of suicide in rural and remote areas, when compared to metropolitan areas, especially amongst men.17,18 Potential explanations as to why this may be include greater access to firearms, lower socioeconomic circumstances, and higher levels of social isolation.19 Top of page
3.1.7 People with mental illnessThe relationship between mental illness and suicide is well established, with a systematic review of psychological autopsy studies estimating that 83% of suicide cases had a history of mental illness.20 In terms of attempted suicide, evidence suggests that more than 50% of those who attempted suicide had a previous mental illness.21 Suicide-related behavior is associated with a broad range of mental disorders, including major depressive disorder, bipolar disorder, anxiety disorders, schizophrenia, substance use disorders, anorexia nervosa, and borderline personality disorder.22,23,24,25,26,27,28 Previous suicide-related behaviour has also been found to be a strong predictor of subsequent suicide-related behaviour in those admitted for inpatient psychiatric treatment.29
With regard to young people specifically, suicidal youth are six times more likely to have a psychiatric disorder compared with non-suicidal youth30 and psychiatric issues present as early as eight years of age can be predictive of future suicidal behaviours.31
3.1.8 Those with substance-related disordersThe literature pertaining to both adults and adolescents indicates a strong association between substance misuse and suicide-related behavior,32,33 showing that those who misuse substances and those with substance use disorders are more likely to attempt, and die by, suicide. A recent review of psychological autopsy studies estimated that between 15 and 61% of those who died by suicide suffered from a substance use disorders.34 Additionally, substance use disorders commonly occur alongside mental illness (e.g. depression) and, given the link between mental illness and suicide risk, this further increases the risk.35
While the elevated risk of suicide in those who misuse substances is well established, the mechanisms that account for it are not. Likely explanations include proximal effects (e.g. effects of intoxication), distal effects (e.g. social isolation, family breakdowns) and common factors that predispose an individual to both substance misuse and suicide-related behaviour (e.g. mental illness).35
3.1.9 People who have previously engaged in suicide-related behavior (including suicide attempt, suicidal ideation and deliberate self-harm)People who have engaged in past suicide-related behavior are at significantly higher risk of future suicide-related behaviour, including death by suicide, even when other suicide risk factors are accounted for (e.g. mental illness, hopelessness).36 For example, among those with a mood disorder, rates of completed suicide are higher in those with a previous suicide attempt when compared to those with no suicide attempt history.37 While it is acknowledged that suicidal ideation does not necessarily translate into suicide attempt or completion, it does constitute a significant risk factor.38
Similarly, a previous episode of deliberate self-harm is an important risk factor for future suicide; those presenting to emergency departments for deliberate self-harm were significantly more likely to die by suicide than those in the general population, with suicide rates highest in the six months following the self-harm episode.39 Top of page
3.1.10 People with physical illnessThere is some evidence that people who are physically ill are at higher risk of suicide. For example, a systematic review by Catalan et al40 suggests that there is a high prevalence of suicide-related behaviour in people with HIV. Harris and Barraclough22 also note a number of physical illnesses that have been associated with suicidal behaviour, including HIV/AIDS, certain types of cancer (head and neck), neurological diseases and some autoimmune diseases.
3.1.11 People bereaved by suicideIn terms of the risk of future suicidal behavior in those bereaved by suicide, a recent meta-analysis has found that children whose parents die by suicide are more likely to die by suicide themselves,41 and the suicide of a spouse has also been shown to increase the risk of suicide in the surviving spouse.42 Furthermore, those bereaved by suicide often exhibit higher rates of mental illness compared with those who have not been affected by suicide, which in turn elevates their risk for future suicide-related behaviour. For example, children of a parent who has died by suicide were found to have higher rates of alcohol and substance use, as well as depression, when compared with children whose parents had died of a sudden natural death.43 Longitudinal research has also found that children bereaved by the suicide of a parent demonstrate a greater number of anxiety symptoms during the first two years of bereavement compared with children whose parents died of other causes.44 The loss of a relative to suicide can often elicit complex grief reactions, which include prolonged mourning, and increased depression and anxiety,45 all of which may increase the risk of suicide in the future.
3.1.12 PrisonersInternational data, while acknowledging variation between countries, indicate that rates of suicide among those incarcerated are at least three times higher than rates found in the general population.46 In addition, those on forensic wards show the highest rates of attempted suicide, compared with other inpatient settings.47
Particularly vulnerable groups among prisoners include those with mental illness, history of substance abuse, suicidal ideation and history of suicide attempt.48 Recent release from prison is also a risk factor associated with suicide; international and Australian data show that suicide rates among the recently released are higher than 'in prison' rates (possibly reflecting access to means) as well as general population rates. These studies also indicate a timing effect, where risk appears heightened in the time period directly following release.49,50
3.1.13 Lesbian, gay, bisexual, transgender and intersex (LGBTI) populationsReliable information regarding rates of suicide in LGBTI populations is lacking, possibly reflecting the routine absence of reporting of sexual attraction, orientation or identity following suicide.51 However, a number of international studies have investigated suicide-related behaviour in LGBTI populations. Findings indicate that LGBTI populations experience both suicidal ideation and engage in suicide attempts at higher rates than non-LGBTI populations.51,52,53,54 Given that ideation and attempt are themselves risk factors for suicide, it is reasonable to assume that LGBTI populations are also at increased risk of suicide. Top of page
3.2 InterventionsWhile there is significant evidence pertaining to suicide rates and risk factors, less evidence exists regarding the effectiveness of specific interventions.55,56 Evidence about suicide prevention interventions obtained from the Stage 2 Literature Review falls into three contexts:
- Multifaceted interventions spanning universal, selective and indicated approaches (‘broad-spectrum’ interventions)
- Single intervention types
- Specific interventions delivered in Indigenous populations.
3.2.1 Broad-spectrum interventionsThe literature search retrieved four well-conducted reviews examining interventions that spanned the full spectrum of universal, selective and indicated approaches. The earliest of these studies was conducted by Mann and colleagues,57 who examined 93 studies published between 1966 and June 2005, in order to identify the effectiveness of specific suicide prevention interventions. The interventions examined in this review were:
- Restricting access to means of suicide
- Guidelines for media reporting of suicide
- Awareness and education programs targeting the general public, general practitioners (GPs) and 'gatekeepers'
- Screening programs
- Treatment interventions, including medication for the treatment of mental disorders, psychotherapy and follow-up care after a suicide attempt.
Based on the outcomes assessed and the quality of evidence, the authors concluded that overall the most promising interventions were GP education programs focusing upon better detection and treatment of depression, restricting access to means of suicide and gatekeeper training. These are discussed in more detail in the next section.
Beautrais and colleagues58 looked more specifically at effective strategies in New Zealand. Like the study by Mann et al, this review identified three interventions for which 'strong' evidence pertaining to their effectiveness exists: training for medical practitioners, means restriction and gatekeeper education. Top of page
The more recent study by Feltz-Cornelis and colleagues59 reviewed findings from systematic reviews investigating the effectiveness of interventions for the prevention of suicide, with the aim of identifying evidence-based components that could be included within multilevel suicide prevention strategies. The authors concluded that at least three types of interventions have evidence for their effectiveness. These include training GPs to recognise and treat depression and suicidality, means restriction and improving access to care for at-risk groups (e.g. gatekeeper training and follow up of high-risk groups). These findings reflect those of both Mann et al57 and Beautrais et al.58
Finally, the study by Nordentoft60 reviewed the available literature around suicide prevention, using the universal, selective and indicated prevention model to classify findings. The author described intervention strategies at each level within the prevention model and, where intervention evidence was lacking, identified risk factors as potential intervention targets.
At the universal level, means restriction was identified as an effective intervention (although levels of evidence were not presented). At the selective level, a lack of evidence for prevention strategies was outlined, however high-risk groups (e.g. those with mental illness, substance misusers, homeless people and prisoners) were identified and potential interventions targeting these groups were alluded to (e.g. education/training strategies for those involved in diagnosis and treatment). At the indicated level, follow up after suicide attempt was noted as an effective strategy for preventing subsequent attempts. Psychological and pharmacological interventions were also described, however no firm conclusions about their effectiveness were presented.
3.2.2 Single intervention typesIn addition to the reviews described above, 13 other papers were identified that systematically reviewed one particular type of intervention. Six of these described universal approaches, of which three reviews examined the effectiveness of restricting access to means of suicide,61,62,63 two described school-based education and awareness programs,64,65 and one reviewed media reporting of suicide.66 Three described selective approaches,11,67,68 two described indicated approaches,69,70 and two described postvention approaches.71,72
In addition, six studies were identified that reviewed interventions for a specific at-risk group; of these four reviewed interventions targeting young people,56,65,73,74 one assessed interventions for the elderly,11 and one assessed suicide prevention approaches for military veterans.67 Top of page
These individual intervention types are discussed further in the next section.
3.2.3 Interventions in Aboriginal and Torres Strait Islander populationsThree articles retrieved by the current search reported on individual studies of interventions in Indigenous populations. One of these reported on a series of health promotion and awareness-raising initiatives in a rural community in South Australia.75 The other two reported on aspects of gatekeeper training programs conducted in New South Wales and Central Australia respectively.76,78
The first article reported on the development of a series of mental health promotion-type activities that targeted Indigenous communities in rural South Australia.75 Components of the program focused upon raising awareness of suicide among community members, assisting community members to identify and support people at risk of suicide, delivery of the Applied Suicide Intervention Skills Training (ASIST) program,77 self-esteem and resilience-building initiatives and leadership and community identity initiatives. The program was subject to a process evaluation, which led the authors to draw conclusions regarding the importance of placing interventions in a relevant sociopolitical context, local relevance, and sustainability. It also enabled them to make a series of 'good practice' recommendations for future projects. However, the article did not report on the actual impacts of the program on any suicide-related outcomes, therefore its ability to provide information regarding the effectiveness of programs such as this on Indigenous suicide rates is limited.
Of the gatekeeper training studies, the first by Capp and colleagues78 reported on a series of community gatekeeper training workshops delivered to Aboriginal community members in New South Wales. The workshops aimed to increase the ability of members of the Aboriginal community to identify and support people at risk of suicide, as well as facilitate access to relevant services. Workshop participants included community members, students and Aboriginal workers from health, education and youth work backgrounds. The authors report that the program led to an increase in participants’ knowledge about suicide, greater confidence in identification of people who are suicidal, and high levels of intentions to provide help, suggesting that gatekeeper training may also be an effective approach among Indigenous communities. That said, as with the other studies reported above, their impact on actual suicide-related behaviour is untested. It must also be noted that this is only one small study that was conducted in a specific area in New South Wales, and the results may not be generalisable to other Indigenous communities across Australia. Further, no follow-up assessment was conducted, and whether or not the changes demonstrated over the course of the workshop were sustained over time is therefore unknown. Top of page
The second study76 employed qualitative techniques to evaluate a training resource specifically developed for use in suicide prevention workshops targeting central Australian Indigenous communities. The training resource, 'Suicide Story' consists of a DVD that covers a range of topics relevant to many suicide intervention training tools, but also elements specific to Indigenous suicide; it incorporates film, animation, artwork, music and interviews. The aim was to provide a culturally-sensitive approach to increase understanding about suicide, as well as improve gate keepers' skills in working with people at risk. The resource is to be used by skilled trainers in the context of a three and a half day suicide prevention workshop. The development, implementation and evaluation of the resource was underpinned by the philosophy of 'cultural safety', which recognises that the delivery of suicide prevention programs needs to reflect the diversity that exists between Indigenous and non-Indigenous populations, as well as the differences within Indigenous groups, highlighting the need for locally and culturally-specific approaches to suicide prevention. The authors report that the DVD increased trainees' knowledge and confidence to respond to someone at risk of suicide, and that applying the principles of 'cultural safety' in the context of suicide prevention can "lead to initiatives that are more informed, more applicable, and ultimately more effective" (p1).