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Volume 2: Exploring
the Suicide Prevention Research Continuum 2015 Suicide Prevention Australia
For more information contact Suicide Prevention Australia GPO Box 219, Sydney NSW 2001 P: 02 9262 1130 E: email@example.com W: www.suicidepreventionaust.org Suicide Prevention Australia acknowledges the funding provided under the Australian Government National Suicide Prevention Program.
We also thank the Ian Potter Foundation and the MLC Community Foundation for funding to support the National Coalition for Suicide Prevention.
Suggested citation: Transforming Suicide Prevention Research: A National Action Plan. Volume 2 Sydney 2015. Suicide Prevention Australia. Disclaimer: While Suicide Prevention Australia endeavours to provide reliable data and analysis and believes the material it presents is accurate, it will not be liable for any party acting on such information.
Any enquiries about or comments on this publication should be directed to Suicide Prevention Australia www.suicidepreventionaust.org.
This report was prepared on behalf of Suicide Prevention Australia by Susan Carrick and Associates. Photography kindly supplied by Solaradt Bungbrakearti following the 2015 National Suicide Prevention Conference.
About Suicide Prevention Australia
Suicide Prevention Australia Limited (SPA) is the national body for the suicide prevention sector. SPA is a not for profit organisation representing a broad-based membership of organisations and individuals with a commitment to suicide prevention. SPA works to prevent suicide by supporting its members to build a stronger suicide prevention sector; developing collaborative partnerships to raise awareness and undertake public education; and advocating for a better policy and funding environment.
A world without suicide Suicide Prevention Australia Suicide Prevention Australia delivers national leadership remembers those we have lost for the meaningful reduction of to suicide and acknowledges the suicide in Australia.
suffering suicide brings when it touches our lives. We are brought together by experience and unified by hope. Suicide Prevention Australia acknowledges the traditional owners of country throughout Australia, and their continuing connections to land, sea and community. We pay our respects to them and their cultures, and to elders both past and present.
EXPLORING THE RESEARCH CONTINUUM A series of essays across the suicide prevention research continuum 1. Involving Lived Experience in Suicide Research 2. Community Mental Health Promotion 3. Protective Factors that Ameliorate Risk Factors 4. Human Engagement 5. Vulnerable Populations 6. Clinical Trials for Suicidal Behaviour 7. Technology and Suicide Prevention 8. TeleWeb Support Services 9. Does Treating and Intervening with Psychiatric Disorders Prevent Suicide? 10. Evaluation and Suicide Prevention 4 Volume 2: Exploring the suicide prevention research continuum
There is scant understanding of the breadth and The inclusion of the essays is designed to give depth of suicide research. However there is strong context to the depth and breadth of the challenges agreement that to reduce the suicide burden faced by those who are seeking to draw on research in Australia the design and implementation of to deliver high quality, evidence based services to programs and services needs to be determined by a diverse and geographically dispersed population. the knowledge that comes from research. There The list of research areas is not exhaustive, and as is also agreement that greater emphasis needs to the implementation of this Research Action Plan be given to supporting research that assesses the evolves it is proposed over time to add further impact of program implementation.
essays including areas such as: This second volume of the National Research Action • Data methodological challenges Plan introduces a series of essays that explores the research continuum. Designed to stimulate discussion, each essay offers insights into the • Genetics and epigenetics status of current research and the possibilities for future directions of research across the suicide research continuum, both nationally and • Research capacity building.
internationally. In writing the essay each author The starting point is to understand the sought to provide: opportunities and challenges for enhancing the • A brief overview of current research and research environment. knowledge in the area; This then needs to be supported through the • The strengths and weaknesses of Australia's formation of effective partnerships that support research capacity in this area; and the eight actions in the Plan. To be successful these partnerships will have to be formed on the • Evidence gaps in research that need to be basis of a shared understanding and acceptance of addressed and for which Australia has the the importance of a coordinated and collaborative capacity to resolve.
approach to planning, funding, implementing and monitoring suicide prevention research. Volume 2: Exploring the suicide prevention research continuum 5 Involving lived
Dr Mic Eales
Ethics and research
To more fully understand and research how to The ethics procedure for researchers is a reduce and prevent people taking their own lives we demanding, rigorous and challenging process. It must first understand why and how individuals get can also be an invaluable experience that helps in to a point where they feel that suicide is their final the examining of the methodological underpinnings and only option.
of any research and can bring to light issues that The World Health Organisation (WHO) defines the researcher/s may have overlooked. That said, suicide as being ‘the act of deliberately killing ethics committees too are subject to their own oneself'. The experience of suicide, as it is lived misconceptions and prejudices around the issue of however, indicates a complexity far beyond suicide. It is for this reason that it would be helpful this concept. There is no other human health if ethics committees (and researchers) had access or philosophical issue as complex. The intense to some form of guidance when reviewing research psychological pain and trauma associated with applications relating to suicide. This could take the the act of suicide has lasting effects upon all who form of an advisory panel (a panel which would are affected. Few other issues are surrounded include researchers alongside individuals with a by as many myths, misconceptions, prejudice lived experience of suicide) that could respond to and discrimination as suicide. The cultural and issues or concerns raised by ethics committees.
socio-cultural intricacies of suicide only add to the mystery of how researchers are best able to Recommendations for
investigate and decipher this multi-multifaceted re-thinking
It is essential that researchers and suicidologists The voices of lived experience
re-conceptualise how we think about suicide and view the suicidal urge as a crisis of the self, rather People with a lived experience of suicide (SPA's broad than due to some notional, mental illness or mental definition) have unique insights that to date have health issue. The medicalisation of suicide fails to been under utilised by researchers. It is the voice of look more deeply into other causal possibilities for lived experience that challenges what researchers any particular individual.
think they know. Much insight can be gained by listening to and engaging with those with a lived To fully engage with suicide survivor's first-person experience of suicide, not as patients or consumers perspectives, narrative methods will need to play but as individuals with a unique experience (a certain an essential role. This applies in both the research expertise if you like) of the issue. The utter complexity and clinical realms.
of suicide, particularly for those who have never Recognition of a possible spiritual dimension experienced a suicidal crisis, can be extremely to the suicidal crisis needs to be embraced by difficult and perplexing to comprehend, however researchers and suicidologists. This also applies by developing empathetic and compassionate to acknowledging that significant cultural and relationships with individuals, researchers will socio-cultural factors may also be involved but help to enable the voices that have long remained remain hidden because of a lack of knowledge silent. Speaking about suicide, from whatever lived or understanding by researchers, (eg. the gap experience perspective is not easy and requires, between the Indigenous and non-Indigenous from researcher/s, much patience, respect and the communication is frequently occupied by establishment of a trusting relationship.
misunderstanding, mistrust and disappointment).
6 Volume 2: Exploring the suicide prevention research continuum Mental health laws require re-examination and a role that social media platforms can and do play in proper human rights analysis as to whether they our understanding of suicide and its prevention also help or hinder suicide prevention.
requires immediate attention by researchers.
Attitude and treatment responses carried out by first responders and/or whilst being treated in emergency departments require careful The traumatising nature for anyone affected by examination to determine how these affect an suicide or suicide attempt is profoundly complex. individual's recovery process. Researchers too The difficulty in understanding and researching the need to be mindful of their own fears, judgements issue of suicide cannot be overstated. and prejudices around the issue of suicide.
Research obviously needs to be of the highest Engagement with those who have attempted quality and based on the best evidence available, suicide is essential in discovering what provides but what are the criteria for what constitutes them with a hopeful future, what support networks meaningful evidence of research? The validity and and strategies have they established. Rather than use of any research into the issue of suicide will focusing on an individual's suicidality there are always be compromised unless we confront the lessons to be learnt about their ongoing recovery prejudice and discrimination that exists against suicide and suicidal people. Only through healthy, Researchers need to explore alternative research open and honest community conversations on opportunities and be willing to step outside of suicide will a healing conversation take place. conventional or more traditional research and These conversations begin through encouraging academic structures in order to more fully explore and promoting constructive dialogues between and represent the complex realities and emotional researchers and the voices of lived experience.
pain of the suicide phenomena. To understand and appreciate the trauma associated with suicide a multi- and, ideally, inter-disciplinary research approach is required. Only by fully appreciating the depth of pain in any suicidal experience can real understanding begin. Collaborative partnerships need to be established between researchers and individuals/groups with a lived experience of suicide. By providing a sense of ownership of the research, those with a lived experience of suicide may be more willing to participate. Research done in conjunction with individuals has far more chance of success and with real and meaningful outcomes than research conducted on them. Varying degrees of support will be required for those with a lived experience of suicide who decide to participate or indeed undertake their own research project. Collaborative partnerships also need to be established between researchers and mental health professionals and frontline workers to address the current disconnection between these sectors. Research projects ideally need to be reviewed by committees made up individuals (from varying backgrounds, experiences, genders and ages) with a lived experience of suicide. The CRESP consumer advisory committee is an example of what is possible. Technological advances are being developed at a ferocious rate. Immediate and ongoing research needs to be carried out regarding the pros and cons of the array of apps that are currently available alongside the development of new apps. The crucial Volume 2: Exploring the suicide prevention research continuum 7 Community
Robert J Donovan
a health promotion approach that included positive mental health components within the intervention5. Although mental health promotion (usually followed This intervention successfully reduced suicide in by ‘prevention and early intervention') is talked the intervention towns6 but, as in the USAF case, about more than a few decades ago, and there are a there was no evaluation of the relative contributions number of documents setting out ‘frameworks' for to this reduction of the various components. mental health promotion (e.g., the WHO's Promoting However, as an example of increasing attention to Mental Health: Concepts, Emerging Evidence, positive mental health as an integral component of Practice, Herrman et al, 2005; England's ‘No health suicide prevention, the latest Irish guide to suicide without mental health: implementation framework', prevention in the Community7 includes a substantial HM Government, 2012), the reality is that the Act- section on promoting positive mental health.
Belong-Commit campaign that originated in Western Australia is the only currently known comprehensive, Overall, although there are clear indications that community-wide mental health promotion increased mental health, and hence reductions in campaign. Most existing mental health programmes mental illness via prevention, would yield substantial target only specific groups or settings for primary social and economic returns, including suicide or secondary prevention, or, if community-wide, are reduction8, there is not only little research into concerned with stigma reduction or encouraging community mental health promotion in general, but (early) help-seeking rather than enhancing positive even less on the impact of promoting positive mental mental health. Hence it is unsurprising that there is health on suicide prevention. However, various little available research on community-wide mental research findings emerging from ongoing evaluation health promotion. of the Act-Belong-Commit campaign suggest that research in this area would yield valuable directions At the same time, most community-wide suicide for reducing the social and economic burden of prevention interventions have tended to emphasise mental illness and suicide.
components for secondary or tertiary prevention, including targeting depression as a major risk factor The Act-Belong-Commit campaign
for suicide1, rather than building positive mental health2,3. Nevertheless, the US Air Force intervention did include efforts to improve overall mental The Act-Belong-Commit Campaign is designed to health within the broader US Air Force community, build population mental health and prevent mental and this is considered to have contributed to the illness. The campaign targets individuals to engage intervention's success4, and an intensive community- in mentally healthy activities, while at the same based intervention across six towns in Japan adopted time supporting and encouraging organisations 1 Hegerl et al, 2006 2 Knox et al, 2003; 2010 3 Motohashi et al, 2004 4 Knox et al, 2004, 5 Motohashi et al, 2004 6 Motohashi et al, 2007 7 O'Sullivan et al, 2011, 8 Knapp et al, 2011 8 Volume 2: Exploring the suicide prevention research continuum that offer mentally healthy activities to promote belongingness and perceived burdensomeness. and increase participation in their activities. The The former refers to feelings of ‘social isolation, campaign utilises a mass media umbrella and alienation, and disconnection from valued social social franchising strategy to reach and influence networks', while the latter to ‘a belief that the self the population at large, and selected target is so incompetent as to be a burden or liability on groups, via partnerships with health services, local governments, schools, workplaces, community Given that Belong is about building and maintaining organisations, and sporting and recreational clubs9. connections with others, including community and The origins of and rationale for the campaign civic organisations and institutions, and that Commit are described in Donovan et al (2006). The three involves doing things that provide meaning and verbs ‘act', ‘belong', and ‘commit' not only provide purpose in life and feelings of efficacy, via taking a colloquial "‘A-B-C' for mental health", but also up causes and volunteering that helps society and represent the three major behavioural domains that other individuals, the Act-Belong-Commit campaign both the literature and people in general consider clearly builds and strengthens protective factors contribute to good mental health10. They are that reduce the risk of suicide. Interestingly, the articulated as follows: Japanese intervention included components to Act: Keep alert and engaged by keeping mentally,
eliminate the sense of psychological isolation and socially, spiritually, and physically active. promote a sense of purpose amongst the elderly15.
Belong: Develop a strong sense of belonging
by keeping up friendships, joining groups, and participating in community activities.
Commit: Do things that provide meaning and
Population-wide surveys are conducted annually to purpose in life like taking up challenges, supporting assess campaign impact. Although the campaign causes, and helping others. was originally conceived as a primary prevention campaign, many individuals currently or previously Overall, the Act-Belong-Commit programme experiencing a mental illness have reported that encourages people to be physically, spiritually, they have been inspired by the campaign to take socially and mentally active, particularly in ways that up activities they would not otherwise have done, increase their sense of belonging to the communities that have assisted their recovery or enhanced their in which they live, work, play and recover, and that quality of life. To quantify this anecdotal evidence, involve commitments to causes or challenges that general population campaign impact survey results provide meaning and purpose in their lives. The for 2013 and 2014 were analysed by experience of campaign is diffusing throughout Australia and mental illness (i.e., whether the respondent had ever internationally [see Koushede11 re launching the been diagnosed with a mental illness or had sought campaign in Denmark]. professional help for a mental health problem in the past 12 months). The Act-Belong-Commit campaign
In brief16, these data showed that those with a direct and Suicide Prevention
experience of mental illness were twice as likely as In a general sense, by building mental health, the rest of the sample to have tried to do something resilience and agency, the Act-Belong-Commit for their mental health as a result of their exposure framework has clear implications for suicide to the campaign, with actions consistent with the prevention at a primary prevention level. However, Act-Belong-Commit message. A slightly greater the implications are quite explicit in the context of proportion of those with mental illness experience also reported having talked about the campaign and 12 theory of suicide and the motivational moderators in O'Connor's mental health with family or friends. With respect 13 model of suicide. In both of these models, the desire or motivation to suicide to prompted reasons for doing something for their is driven by two major factors: low or ‘thwarted' mental health, it is noteworthy that just under half of 9 Donovan & Anwar-McHenry, 2015 10 Donovan et al, 2003, 2007; Donovan & Anwar-McHenry, 2014 12 Joiner's T.E., 2005, Ribero & Joiner, 2011 13 O'Connor, RC. 2011 14 Ribero & Joiner, 2011, p 171 15 Motohashi et al, 2007 16 see Donovan et al, under review Volume 2: Exploring the suicide prevention research continuum 9 those with a mental illness experience reported that • How can community mental health promotion they had tried to do something because they were programmes be strengthened to further impact ‘a bit depressed and felt that the action they took on stigma reduction and increased openness could help'. Of note is that in informal discussions in the community with respect to talking about with campaign personnel, individuals with a mental mental illness and about suicide? illness indicated that one of the major factors • How can the universal principles of the Act- facilitating their involvement with the campaign Belong-Commit campaign and other mental was that it did not target only people with a mental health promotion frameworks be further illness, but rather "it's a campaign for everyone". embedded into health professional training and That is, they can get involved with the campaign clinical practice, school, worksite, hospital and without their involvement being defined by their aged-care settings? Other results of note are that substantial majorities of both those reporting a mental illness experience and the rest of the sample believe that the campaign has reduced stigma and made people more open about mental illness. Given the current high reported prevalence of depression around the globe and its relationship to suicide17, and given that stigmatisation inhibits early help-seeking18, the above data suggest that community mental health promotion campaigns can potentially have a major impact on suicide prevention.
Implications for suicide prevention
Given these encouraging results from evaluation
of the impact of the Act-Belong-Commit mental
health promotion campaign on suicide risk
and protective factors, it is likely a systematic
research programme into the following would have
substantial social and economic benefits:
• What factors facilitate and what factors inhibit the extent to which community-wide mental health promotion campaigns not only enhance people's quality of life, but build resilience and provide a strong protective effect against vulnerability to suicide? • What factors have a positive impact on the population at large versus specific sub-groups – and especially those with mental health problems or are at risk of suicide? • How can recreation, sporting and arts organisations become more involved in building mental health and resilience, and hence contributing to suicide prevention? • How can community-wide mental health promotion campaigns best complement clinical interventions with those at risk of - or recovering from - a mental illness or suicide attempt? 17 Nock et al, 2008 18 Corrigan, 2004; Sartorius, 2007 10 Volume 2: Exploring the suicide prevention research continuum engagement
A great many valuable strategies to prevent suicide
Lifeline support programme and capacity for those have been developed in efforts both in Australia at risk (to call and talk to an understanding person in and internationally. Nevertheless, the numbers ways that can shift them from such intent). Actions of suicide deaths remain high, and occur in many of engagement, as at "the Gap" in Sydney, talking different groups in the population. Some, such people out of their intent, strategies such as "LiFE", as the experiences of Aboriginal and Torres Strait "ACT", Act-Belong-Commit, R U OK? and many Islander people, are at a very concerning level. And others all add to positive engagement.
there is growing concern about such deaths of young A critical issue in all of the above, including the people, adolescents and even younger children long-standing models such as Lifeline, is the as evidenced by the 2015 annual report from the human engagement and its associated strength and Australian Human Rights Commission Children's support, including for those who are vulnerable. These themes need to also address the concept of The depth and extent of research in this field resilience: the strengths that can be mobilised in contributes both opportunities for prevention, and the face of adversity which can also contribute to the intervention when the person is near to intent. Much capacity to endure.
research has focused of mental health problems It is suggested in this brief paper that the core associated with heightened risk, for instance severe elements we need to assess and work with should depression, but there have not been adequate studies of large numbers (population data) to answer some of these questions systematically and over • Human engagement in any assessment process time. While mental illnesses and mental health • Building a relationship with those vulnerable problems are frequently implicated, it is often difficult to confirm that the act is directly linked • Exploring their "family", relationships and the to the diagnosis except, perhaps, when a person degree of "emptiness" in their lives with psychotic illness acts on the "voices" or other • The sense of worth, of being valued, having an delusional beliefs.
identity as a person Another complex issue is the relationship to self- • The capacity for "agency", to act with "success" harming behaviours, particularly those repetitive or some positive achievement patterns in adolescents in which repetitive "cutting" • "Love" actually – The need for love, affectional may indicate non-fatal self-harm, rather than suicide, is the primary intention. • The experiences of loss & grief, as an inevitable Patterns of attempted suicide by children reflect the component of human experience emptiness and despair of their lives. In attempting to address "suicide" and its prevention, numerous excellent initiatives have undoubtedly been helpful for some. These include Volume 2: Exploring the suicide prevention research continuum 11 Dark times, dark places, dark
Direction for research
Progressing this field is critical to bring together Assessing someone's vulnerabilities to suicide with all the evidence of what has been effective: which other negative elements requires an assessment strategies, and how, or which people (and the of their current perception of their lives, what is short and longer term outcomes). "Big data" on problematic, what has happened, and what do they multifaceted and large scale studies can potentially see for the future, as they view it. The loss of one's capacity for hope, any sense of worthlessness and I would suggest however that the human of not being wanted are clearly "dark" experiences. engagement, the understanding of, and caring for, They may be brief, but if continuing, are likely to those who are in "dark", distressing and despairing breed other negative trajectories, including suicidal states of being, need assessment and care. This thoughts and actions. Shame related to perceived may or may not relate to mental health problems or or real actions can lead to self-degradation and a mental illness. It may occur at almost any age, and wish to die, the more so if "no one cares". Anger and the concerned family, clinician, friend or other, may impulsive action can also drive suicidal intent – "I'll need to help with the steps to regain a hold on life show them – they'll be sorry" – "if I kill myself".
and living and to become engaged in the complex, The meaning and reality of death is also a rewarding, difficulties and challenges of these component of vulnerability. While it is assumed that human engagements.
adults will fully comprehend this reality of death and its finality, it is often hard to envisage "not being here". Many people may still hold the sense of continuity, and this may also occur for those who would take their ow n lives, perhaps with intent to "join" a deceased loved one. Adolescents have also often contemplated such acts as almost consistent with living. Debate about children's capacity to understand the reality and finality of death leads to a view that they cannot "know" death, but the despair, desperation and attempts make it clear that they have a "level of reality" in their intent and action.
Ultimately, perhaps the darkest of affects is profound despair, and if suicide is to be prevented this affect must be assessed, understood and managed as an element of risk.
"Living is For Everyone" is a valuable model, but when people feel it is not for them, the clinical challenge is understanding why, and then what they may be able to do to deal with this and what assistance others can give, so they may be able to accept life and living.
12 Volume 2: Exploring the suicide prevention research continuum Vulnerable
It is well recognised that many vulnerable groups experience significant barriers to care, including a lack of
culturally safe and effective services, exacerbating their risk of suicidal behaviour. These groups include:
• Aboriginal and Torres Strait Islander people • Lesbian, gay, bisexual, transgender and intersex (LGBTI) people • Older Australians • Culturally and linguistically diverse populations • Refugees and asylum seekers • Rural and remote populations Available data is inadequate for the accurate assessment of both how many individuals fall into some vulnerable groups, and how much suicidal behaviour happens among these populations. For example, national data is not centrally or routinely collected on who identify as lesbian, gay, bisexual, transgender, intersex or other sexuality and gender diverse people (LGBTI).1 Volume 2: Exploring the suicide prevention research continuum 13 Aboriginal and
Professor Pat Dudgeon
And Dr Tom Calma AO2
other Australians because there are specific cultural, historical, and political considerations Suicide among Aboriginal and Torres Strait that contribute to its higher prevalence, and that Islander peoples occurs at double the rate of other require the rethinking of conventional models and Australians. Self-harm rates are also much higher.3 Because of this, Aboriginal and Torres Strait Islander peoples are a priority group for suicide prevention The most common risk-factors for suicide reported research efforts. in data-based, analytical descriptive studies specific to Aboriginal and Torres Strait Islander populations Among Aboriginal and Torres Strait Islander children were mental illness, alcohol abuse and a prior and young people, the rate of suicide over 2001 -2010 history of self-harm10.
was six times as high as the national average.4 Males between 25 and 29 years of age, and female 20 to 24 But these risk factors are themselves likely to be years olds were at the highest risk of suicide.5 The symptomatic of deeper problems. Overall, Aboriginal 2004 Western Australian Aboriginal Child Health and Torres Strait Islander peoples report such life Survey reported that about 15 per cent of Aboriginal stressors at 1.4 times the rate of non-Indigenous 12 – 17 years old in the survey had seriously thought people.11 These flow from the cumulative effects of about suicide in the 12-months. About 6.5 per cent exposure to negative historical determinants flowing had attempted suicide. 6 from colonisation, negative social determinants, and deep and entrenched poverty. This is compounded by There are also communities that are at particular racism and exposure to violence. risk of suicide and suicide clusters. In small Aboriginal and Torres Strait Islander communities Trauma and psychological distress is reported at where many people are related, and where many high levels as a result. In national health surveys, people face similar histories and challenges, high or very high psychological distress levels in the impact of suicide clusters is widespread and Aboriginal and Torres Strait Islander peoples are reported at three times the non-Indigenous rate.12 Research is needed into the prevalence of trauma Aboriginal and Torres Strait Islander suicide among Aboriginal and Torres Strait Islander peoples. has been described as ‘different' to that of What studies exist suggest it is high.13 2 Co-Chairs of the Commonwealth's Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention Advisory Group (ATSIMHSPAG)3 Steering Committee for the Review of Government Service Provision 2011, Overcoming Indigenous Disadvantage: Key Indicators 2011, Productivity Commission, Canberra, p.7.62 4 Australian Bureau of Statistics, Suicides, Australia, 2010, ABS cat. no. 3309.0, 24/07/12, www.abs.gov.au/ausstats/abs@.nsf/Products/3309.0 5 Australian Bureau of Statistics, Suicides, Australia, 2010, ABS cat. no. 3309.0, 24/07/12, http://www.abs.gov.au/ausstats/abs@.nsf/Products/3 6 Zubrick SR, Silburn SR, Lawrence DM, Mitrou FG, Dalby RB, Blair EM et al. (2005). The Western Australian Aboriginal Child Health Survey. Volume 2: The social and emotional wellbeing of Aboriginal children and young people. Perth: Curtin University of Technology and Telethon Institute for Child Health Research.
7 Georgatos G, ‘More confirmation of what everyone knows – WA's suicide prevention inadequate', The Stringer, 8/5/14, http://thestringer.com.
8 Tatz C, Aboriginal Suicide is Different: Aboriginal Youth Suicide in New South Wales, the Australian Capital Territory and New Zealand: Towards a Model of Explanation and Alleviation, A Report to the Criminology Research Council on CRC Project 25/96–7, Sydney 1999 9 Clifford et al. 201410 Ibid11 Australian Bureau of Statistics, ‘Family stressors' Australian Aboriginal and Torres Strait Islander Health Survey: First Results, Australia, 2012-13, ABS cat. no. 4727.0.55.001, 27/11/13, 12 Australian Bureau of Statistics, ‘Psychological Distress' Australian Aboriginal and Torres Strait Islander Health Survey, First Results, 2012, ABS cat. no. 4727.0.55.001, 13, 27/11/13, www.abs.gov.au/ausstats/abs@.nsf/Lookup/9F3C9BDE98B3C5F1CA257C2F00145721?opendocument [Verified 15/7/14] 13 Heffernen E, Andersen K, Dev A, et al., Prevalence of mental illness among Aboriginal and Torres Strait Islander people in Queensland prisons. Med J Aust 2012; 197 (1): 37-41. 14 Volume 2: Exploring the suicide prevention research continuum The greater burden of stress and trauma is another. Services should be delivered through compounded by generally lower access to health Aboriginal Community Controlled Health Services services and mental health services than in the where possible.19 general population, particularly in remote areas. And For the family and community members of people also lower access to culturally safe and competent who suicide, culturally safe and competent post- services where services otherwise might exist.
vention and support services can also play a critical When asked, Aboriginal and Torres Strait Islander role in preventing further suicide.
mental health leaders, experts and stakeholders recommend that a broad preventative approach is required in addition to interventions for people who are self-harming or at risk of suicide. In particular, The findings from a recent rapid evidence review they support strengthening social and emotional found there is a lack of evidence from published wellbeing and culturally-based approaches as a way studies on the most effective intervention strategies of strengthening Indigenous identity and building for preventing suicide in Aboriginal and Torres resilience against the impact of life stressors. Strait Islander people, but community prevention programmes currently have the most evidence Aboriginal and Torres Strait Islander concepts of for reducing actual rates of suicide or suicide social and emotional wellbeing include physical behaviours among Aboriginal and Torres Strait and mental health, and an individual's relationships Islander people20 to family, community, land, waters and ancestors, as well as acknowledging the importance of Poor understanding of Aboriginal and Torres Strait employment, housing and education to wellbeing.14 Islander social and emotional wellbeing and how The effectiveness of culturally based approaches to it relates to mental health and suicide prevention suicide prevention is a particularly promising line has posed problems to policy-makers.21 A dedicated Aboriginal and Torres Strait Islander suicide prevention of research. Studies among Canada's Indigenous research agenda must build on a broader one - peoples suggest the importance of cultural focused on developing the evidence base for social and continuity as a suicide prevention measure.15 And emotional wellbeing and culturally based interventions. work in Australia by the National Empowerment Project has highlighted the high level of demand From a clinical and service model perspective, in communities for culturally appropriate, locally many questions require research: What are the best based and relevant programs that strengthen social service models in the health and mental health and emotional wellbeing.16 Such approaches require sector and for Aboriginal and Torres Strait Islander engagement and partnerships with communities. family and youth support services to prevent suicide? Cultural healers and healing methods and working What are the workforce needs? What is the role of with Elders have also proved important in community- schools, family support services, and other services? generated approaches to suicide to date. 17 How effective are existing clinical diagnostic models to gauge suicide risk among Aboriginal and Torres Also important are prevention strategies to address Strait Islander peoples? What is the appropriate role the needs of high-risk groups within the Aboriginal of cultural and clinical approaches, and how should and Torres Strait Islander population and particularly cultural healers and culturally based methods of healing be incorporated into programs and services? For those at immediate risk of suicide, culturally safe, non triggering management, treatment and support is particularly important. Training Aboriginal There is a need for further research in Aboriginal and Torres Strait Islander people to provide such and Torres Strait Islander suicide prevention and services is one way to achieve this; ensuring non- Aboriginal and Torres Strait Islander people should Indigenous workers are culturally competent is lead this. The Aboriginal and Torres Strait Islander 14 Gee G, Dudgeon P, Schultz C, Hart A, and Kelly K, ‘Social and Emotional Wellbeing and Mental Health: An Aboriginal Perspective'. Chapter 4, In Dudgeon, Milroy and Walker (eds.) Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice – Revised Edition, Commonwealth of Australia, Canberra, 2014, pp.62-63.
15 Chandler, M. J. & Lalonde, C. E. (2008). Cultural Continuity as a Protective Factor against Suicide in First Nations Youth. Horizons --A Special Issue on Aboriginal Youth, Hope or Heartbreak: Aboriginal Youth and Canada's Future. 10(1), 68-72.
16 Chandler, M. J. & Lalonde, C. E. (1998). Cultural continuity as a hedge against suicide in Canada's First Nations. Transcultural Psychiatry, 35, 17 Dudgeon P, Cox A, Kelly K, et al., Voices of the Peoples: The National Empowerment Project, Summary Report 2014 (in print).
18 See, for example, Culture is Life Campaign, The Elders' Report into Preventing Indigenous Self-harm & Youth Suicide, 2015. Available online 19 Ibid20 See for example: Department of Health and Ageing, Operational Guidelines for the Access to Allied Psychological Services Aboriginal and Torres Strait Islander Suicide Prevention Services (unpublished) Canberra, DOHA, 2012.
21 Clifford et al. 2014 Volume 2: Exploring the suicide prevention research continuum 15 Suicide Prevention Evaluation Project is an important example of such leadership in action. Launched in 2014, it will be the first formal evaluation of Aboriginal and Torres Strait Islander suicide prevention programmes and services nationwide. In particular, it promises to inform the implementation of the National Aboriginal and Torres Strait Islander Suicide Prevention Strategy in 2015.
Participatory action research (PAR) should be promoted among researchers working in Aboriginal and Torres Strait Islander communities. This proceeds through repeated cycles, in which researchers and communities start with the identification of priority issues, originate action, learn about this action and proceed to a new "research and action cycle". This process is a continuous one that empowers Aboriginal and Torres Strait Islander perspectives. Participants in PAR projects continuously reflect on their learning from the actions and proceed to initiate new actions on the spot – potentially bringing immediate benefit.22 There are also established ethical guidelines for research in Aboriginal and Torres Strait Islander communities that researchers must observe. 23 Overall, there is a need for dedicated national Aboriginal and Torres Strait Islander suicide prevention research agenda, led by Aboriginal and Torres Strait islander people, and that is able to work with the differences between them and other Australians that shape both suicide and suicide prevention. Building on cultural strengths to prevent suicide is a particularly promising line of enquiry.
22 Gee G, Dudgeon P, Schultz C, Hart A, and Kelly K, ‘Social and Emotional Wellbeing and Mental Health: An Aboriginal Perspective'. Chapter 4, In Dudgeon, Milroy and Walker (eds) Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice – Revised Edition, Commonwealth of Australia, Canberra, 2014, pp.56-57.
23 See National Medical and Health Research Council, Values and Ethics: Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Health Research, 2003, Commonwealth of Australia, Canberra, 2003.
16 Volume 2: Exploring the suicide prevention research continuum Pictured: Tracy McCown and Julie Turner Volume 2: Exploring the suicide prevention research continuum 17 People of LGBTI
Mr Atari Metcalf
Overview of current research and
Encouragingly, there is emerging evidence for knowledge in the area
the protective role of school-based policies and practices that recognise sexual and gender diversity The prevalence of suicidal behaviours amongst in reducing suicidal ideation and attempts in lesbian, gay, bisexual, transgender and intersex young people. Furthermore, same-sex attracted (LGBTI) people in Australia is disproportionately and gender diverse (SSAGD) young people show higher than observed amongst non-LGBTI people. reduced rates of suicidal behaviour when they are The lifetime prevalence of attempted suicide supported by their families, compared to those with amongst Australians identifying as homosexual or experiences of family rejection28. bisexual is two and seven times higher, respectively, than heterosexual identified Australians (Appendix Strengths and weaknesses of
1), while 50% of transgender Australians have Australia's research capacity in
attempted suicide at least once in their lives26. There this area
is a lack of Australian data on suicide in intersex people but there is growing international evidence In Australia, the majority of data on the health and indicating that intersex people also experience wellbeing of LGBTI populations comes from LGBTI disproportionately high rates of suicidal ideation community surveys that are limited by selective and attempts. Despite these disparities, there has sampling techniques. Furthermore, few LGBTI been a dearth of policy attention, research focus community surveys have included questions on and resourcing of preventive interventions targeting intersex status, while collection (or public reporting) these LGBTI populations to date.
of LGBTI data in national representative population surveys has also been limited.29 Estimating reliable Australian and international studies consistently suicide mortality statistics for LGBTI populations report an association between experiences of also remains challenging as sexual orientation, homophobic and transphobic discrimination, intersex status and gender diversity, unlike other harassment and violence, and suicidal behaviours characteristics, are not necessarily publicly known, in LGBTI populations. Paradoxically, LGBTI people or readily identifiable through existing coronial exhibit high levels of resiliency in community health processes. Accordingly, much of the Australian surveys27. This observation suggests that while research to date has focused on non-fatal suicidal important, the promotion of resiliency in isolation of addressing wider social determinants of mental health may be insufficient for preventing suicide Evidence gaps
in LGBTI populations. Moreover, it reinforces The gaps in current data leave us with many that suicide is a multidimensional and complex unanswered questions about suicide risk for these public health problem that demands an equally communities. In particular, there is relatively little multidisciplinary research response in order to research into how other population characteristics, effectively develop and target appropriate preventive such as Aboriginality, religious beliefs, geographic isolation, socioeconomic status and cultural 26 Couch et al. 200727 Leonard et al., 201228 Hillier et al., 201029 Irlam, 2013 18 Volume 2: Exploring the suicide prevention research continuum background might intersect with being same sex attracted, intersex and/or transgender, and the subsequent influence these may have on suicide risk. More nuanced examination of suicidal behaviours within and between different LGBTI populations is therefore needed, along with exploring how discrimination and other established risk/protective factors may interact or moderate one another to increase or reduce suicide risk.
Additionally, there are few published intervention studies focusing on LGBTI populations to date, resulting in limited evidence to guide prevention policy and practice. This is compounded by the lack of regular and consistent monitoring of both suicide deaths and non-fatal suicidal behaviours, making it impossible to track progress towards reducing suicide in LGBTI populations. Notwithstanding the paucity in LGBTI suicide mortality data, studies conducted in countries where same sex relationships are legally recognised have leveraged relationship registry data in order to compare suicide death rates among individuals in same-sex relationships with those in heterosexual relationships (for example, see Mathy 201130 ). As such registries and associated data become available in Australia, opportunities may arise to adapt similar approaches.
30 Mathy et al., 2011 Volume 2: Exploring the suicide prevention research continuum 19 Regional, rural
Ms Sue Carrick
communities), are more likely than their urban counterparts to engage in risky health People living in regional, rural and remote areas of behaviours, including consuming alcohol at Australia make up 30 per cent of the population, but levels that place them at risk of harm over do not receive anywhere near 30 per cent of funding their lifetime (24% and 21% compared with the and services for mental health31. general population 19%)36.
In general, people in regional, rural and remote • These factors can lead to depression and may areas face higher levels of socio-economic, contribute to the higher levels of suicide in rural environmental, behavioural and physical health risks and remote areas of Australia. At higher risk associated with suicide and mental ill-health than are males, young people, Aboriginal and Torres those who live in major cities. While there is no clear Strait Islander people and farmers37.
evidence that the prevalence or severity of mental illness is any greater in regional and rural areas, or Interactions between area of residence, social and that geography alone affects a perceived need for other factors, and health outcomes, are known to specific types of mental health services by people be complex and that there is no single stereotypical with a lifetime mental health disorder, this data community experience of mental health in regional, may be unreliable32. A high prevalence of suicide rural or remote Australia38. Research suggests, and mental illness and suicide has been identified, however, that Australians living in rural areas however, as a key challenge for these areas, in generally have higher levels of social cohesiveness— addition to concerns about stigma and anonymity for example, higher rates of participation in acting as barriers to seeking help for mental health volunteer work and feelings of safety in their • Outer regional areas record the highest prevalence of persistent and deep exclusion in Australia, and rural and remote areas often have The Review concluded there are high levels of unmet poorer education, literacy, income, employment mental health needs in rural Australia40, noting that and housing opportunities34 than the general the availability of specialised mental health care in hospitals and health services is significantly worse in • The National Rural Health Alliance suggests more remote areas of Australia than in major cities41. these areas also are often affected more Fewer mental health specialists are available when severely by natural disasters; these areas may people need to access assistance for any mental also be more socially isolated35.
health concerns, and people generally need to travel over greater distances to deliver or receive care42. As • Regional and remote Australians, particularly a result, promotion, prevention, early diagnosis and men (excluding very remote areas and intervention services that could address suicide and discrete Aboriginal and Torres Strait Islander 31 NMHCR 2014 p9732 NMHCR 2014 p9533 Ibid34 Ibid35 Ibid36 ABS. Australian Health Survey (AHS), 201237 NMHCR 201438 AIHW 2014, NMHCR 201439 AIHW 201440 NMHCR 201441 Ibid 20 Volume 2: Exploring the suicide prevention research continuum mental illness are hampered and delayed, which can result in serious crises.
There are already a number of suicide prevention activities and interventions for populations living in rural areas of Australia, although Kõlves et al43 identified that few had an evaluation of their outcomes. Overall, the authors found that: • More activities are based in the provision of recommendations than active interventions for suicide prevention for rural populations; • The majority of programmes address the issue of suicide prevention indirectly (e.g. via strengthening community networks); • Indirect suicide prevention approaches in rural areas often address variables on a collective level, such as community attitudes towards help-seeking or farmers' attitudes towards health; • Only a few programmes report on any results of their activities; and, • There are very few programmes where an evaluation of outcomes is available. Further, most evaluations are not conducted in parallel with a ‘control group', which makes it difficult to account for other possible environmental or individual factors that brought about the noted changes.
The authors conclude that these factors make it difficult to assess whether interventions in rural areas actually made a difference in terms of a reduction in suicide.
Recommendations for research
There is a need to conduct further research:
• on the determinants of mental health in regional, rural and remote Australia and effective service delivery models44 • into the past and continuing impacts of natural disasters, such as droughts and floods45; • to better understand the relationship between access to appropriate and high-quality physical and mental healthcare within the rural help-seeking paradigm46; and • better evaluate existing rural suicide prevention strategies in order to ensure their efficacy and validity, as well as to ensure there are no regions or groups overlooked.47 42 Ibid 43 Kõlves et a. 201244 NMHCR 201445 Kõlves et al. 201246 Ibid Volume 2: Exploring the suicide prevention research continuum 21 Other vulnerable
limited research on suicidal behaviour among women of trans experience, women with intersex Men are three times more likely to die by suicide characteristics, feminine spectrum people who than women, but are less likely to seek help for do not identify as women or men, and those with depression or anxiety. Linkage of Medicare Benefits culturally specific genders beyond the woman/man Schedule (MBS) and Census data for 2011 shows that during that year, 8.7 per cent of Australian females accessed any MBS-subsidised mental Given the large swing in the size of the health health-related service, compared with 5.6 per cent of burden towards women when suicide mortality men48. We know that men living in rural and remote and morbidity are combined it would seem areas are both particularly likely to take their own both reasonable and sensible to focus also on life and unlikely to seek professional help. Barriers understanding and preventing women's suicidal to help-seeking among men have been identified as behavior.50 Taken together, the numbers of women being partly related to the perceived role of men in who think about suicide, plan their suicide, attempt Australian society. Services targeted at men, such as suicide and die by suicide is considerable and has The Older Men's Network in Queensland, use men's a large impact on public health in Australia and interests and contributions to the community as vehicles for talking about mental health and making For more in-depth discussion on this topic see SPA use of peer support49.
discussion paper: Suicide and Suicidal Behaviour in Women – Issues and Prevention. A Discussion Despite there being higher numbers of men Older Australians
who suicide each year research consistently demonstrates that women have higher rates of A life course approach to mental health is not just suicidal behaviour, i.e. ideation, planning and about early intervention for young people, but also suicide attempts compared to men. Gender plays a relates to an early intervention ethos for health and significant role in suicide and suicidal behaviours. wellbeing needs at all stages of life. Older people Gender differences have been reported in relation to face particular difficulties with mental health related suicide methods, risk and protective factors, causal to age discrimination, bereavement, social isolation, factors, the very nature of suicidal behaviour and increasing susceptibility to chronic disease and the how it is manifested. However, our knowledge of transition from work to retirement. The fact that a these differences remains incomplete, particularly person grows older is not sufficient reason to accept so for reported gender differences in those who that mental ill-health is a necessary consequence of attempt suicide, and also within different age groups. old age. Nor should it be acceptable that admission Research has not contributed much to our to a residential aged care facility is reason enough understanding of suicide and suicidal behaviour to use chemical restraints to manage older people's in women nor consciously informed prevention of suicide in this population. There is also very 48 NMHCR 201449 NMHCR 201450 Chaudron & Caine 200451 Suicide Prevention Australia 2015 22 Volume 2: Exploring the suicide prevention research continuum Refugees and asylum seekers
Refugees and asylum seekers are often highly
vulnerable to suicidal behaviour, having both
experienced trauma and having had their social
support networks disabled. There is clear evidence
that detention in closed environments for longer
than six months has a significant, negative impact
on mental health53. However, data needs to be made
available to allow a clear and accurate picture of the
extent of suicidal behaviours occurring among those
in detention and to determine, based on evidence if
available, what interventions are likely to be effective 54.
Culturally and linguistically
People who have an experience of immigration to
Australia (even without having fled traumatic home
circumstances as refugees) have specific mental
health experiences and needs which must be
accounted for if support is to be effective. Not only do
experiences of migration often create or exacerbate
mental distress, but people can find the response
of Australian mental health supports inappropriate
to their needs. They can also face problems of
seclusion and restraint in the mental health system
because of issues such as language barriers and
culturally different approaches to mental health and
52 NMHCR 2014 p 10753 Commonwealth Ombudsman (2013)54 NMHCR 2014 p 10755 NMHCR 2014 p 107 Volume 2: Exploring the suicide prevention research continuum 23 Clinical trials
Professor Greg Carter
5. In Australia, clinical endpoints would rely on ABS and coronial data, which has a 2-3 year lag time There are three main forms of suicidal behaviour to provide the primary outcome data.
that are relevant to a clinical trials approach. In a clinical trials context, these should be thought of as clinical endpoints of the trial, with the specification of primary and secondary outcomes as appropriate to the specific circumstances of a given trial.
As an example, consider a high risk population These three suicidal behaviours are: like hospital treated DSH, which after 1 year has a suicide rate of 1% and after 10 years has a suicide rate of 7%56. We have used the Pocock formula of: n 2. Non-fatal suicidal behaviour – variously called deliberate self-harm (DSH), self-harm (SH), suicide attempt (SA), parasuicide, etc.
(https://www.sealedenvelope.com/power/binary-superiority/) to calculate simple sample sizes for a 3. Suicidal ideation significance level (alpha) of .05 and power (1-beta) of .90, in the examples below.
To test an intervention that "worked" over 1 year There are multiple and serious limitations that need to try to demonstrate a reduction from 1% to say to considered if suicide death is a clinical endpoint of 0.5% suicides (a 50% relative risk reduction), would require 619 per group (1238 total).
Suicide is a low prevalence outcome, even in high To test an intervention that "worked" over 10 years risk populations (hospital treated DSH and recently (say 1 year treatment and 9 years follow-up) to try to discharged psychiatric inpatients), which has several demonstrate a reduction from 7% to 3.5% suicides (a implications for clinical trials.
50% relative risk reduction), would require 849 per group (1698 total).
1. Sample sizes need to be very large and would usually require multi-site trials in order to be Of course a 50% relative risk reduction is not adequately powered.
very realistic in the world of medicine for a 2. Trial duration, including treatment and follow-up binary outcome. Taking the 10 year example and phase, would need to be very long to maximise anticipating a more realistic 10% relative risk the prevalence of this outcome.
reduction from 7% to 6.3% suicides after 10 years, would require 26627 per group (53254 in total).
3. Long duration of treatment phase can be costly.
4. Long duration of follow-up, after the completion of the treatment phase, has implications for interpretation of the trial as to plausibility of a sustained long term benefit after treatment concludes. 56 Carroll et al 2014 24 Volume 2: Exploring the suicide prevention research continuum There are other limitations, including an absence Selecting the correct or appropriate metric (or of any strong candidate therapies for psychological combination) for studying repetition of DSH is also or pharmacological intervention to evaluate. There an issue that has not been adequately resolved. is a greater possibility that service organisation The traditional approach has been to use the interventions might have more likelihood of success, binary outcome of any DSH event, which may be and this possibility has been demonstrated in an appropriate but difficult because of the short time observational study in the UK57. These service- between repeat events for some patients and the based interventions could be usefully evaluated long history of events for others. For other chronic using a stepped wedge design58 (a special form and relapsing conditions (e.g. headache), other of randomised controlled trial), which has not metrics have been used, like a reduction in number previously been used in suicide prevention studies. or severity of events or a reduction, which may be There is a lack of familiarity with this study design worth consideration in non-fatal suicidal behaviours. amongst suicide researchers and the related ethics This approach has been used in studies of non- committees. These deficits can be overcome by fatal suicidal behaviours62. For chronic relapsing training and trial supervision by a bio-statistician conditions, it is sometimes suitable to use a survival familiar with the study design and its analysis.
analysis with time to next episode as the appropriate metric. This has been occasionally used for non-fatal Non-fatal suicidal behaviours
Hospital treated deliberate self-harm (DSH) or Using institutional data for the measurement of suicide attempt (SA) is perhaps the best recognised hospital treated DSH or SA is an accepted way and most studied form of non-fatal suicidal to measure repeated DSH or SA as an outcome, behaviour. DSH is common and costly with one-year however these institutional data are known to be repetition rates of 15% and a strong association with serious underestimates. This occurs for several later suicidal death reasons, including only recording admitted patients, 59 This form of suicidal behaviour has been the subject of multiple intervention and inaccurate coding of the reason for admission studies and remains an important focus for suicide by administration staff. As an alternative approach, prevention research activities. However, there are direct contact with trial participants during follow- several strengths and limitations that need to be up, to obtain direct patient report for the occurrence of non-fatal suicidal behaviours, is difficult but possible. Where this method is used to determine There has been considerable success in the these clinical endpoints, it is important to either development of interventions to reduce repetition account for missing data in an intention-to-treat of DSH for sub-populations, especially for analysis or to provide a sensitivity analysis to allow Borderline Personality Disorder populations, for study dropouts63.
although there have been much fewer successful trials of unselected DSH populations, using either pharmacological or psychological interventions60. There are a number of other candidate interventions There is considerable disagreement about the including psychological, pharmacological and brief appropriate use of suicidal ideation as an outcome, contact interventions that are worthy of evaluation.
and the appropriate metric to use for non-fatal There have been serious quality problems with the suicidal behaviours: occurrence, frequency or design and analysis of existing randomised clinical severity of ideation, or time to next episode of trials RCT studies of DSH and these limitations suicidal ideation. Perhaps the greatest value of using have already been clearly articulated: "investigators suicidal ideation as a clinical endpoint would be in should perform power calculations to determine the restricting use to particular clinical populations of number of subjects necessary to detect clinically relevance, e.g. depression and borderline personality important effects, provide information on method of randomisation and interventions, use standard There has been a recent systematic review of measures of outcome, and focus on homogeneous instruments to measure this clinical endpoint64 subgroups of patients. Improving the methodology of which will be useful in organising future studies to future studies in this field will be essential if sound use an agreed common outcome measure so that evidence is to be obtained which can inform effective comparisons across studies can be more easily service provision for deliberate self-harm patients"61.
made and so that meta-analyses of pooled data is more valid.
57 While et al 191758 Brown C, Lilford R 200659 Carroll et al 201460 Hawton et al 200061 Arensman et al 200162 Carter et al 200563 Hassanian-Moghaddam 201164 Christensen et al 2014 Volume 2: Exploring the suicide prevention research continuum 25 Technology
Associate Professor Jane Burns, Ms Emma Birrell, Dr Michelle Blanchard On the positive side, mental health and its importance in Australia as a significant public In 1995, youth suicide was a leading cause of health concern has gained traction due to the work death in young people second only to motor of organisations like beyondblue: The National vehicle accident65. This national tragedy provoked Depression Initiative. We have the foundations for a a crisis workshop in Canberra, at which 70 suicide strong evidence-based youth mental health system prevention specialists coalesced in a show of with the roll-out of Headspace and the Orygen EPPIC national solidarity to determine gaps in evidence and model. Australia is the world leader in the use of make recommendations to address those gaps. This innovative e-health platforms to promote wellbeing workshop was jointly supported by NHMRC and the and deliver mental health services69, with (growing) Department of Health66 and explicitly made the point evidence that technologies can be used to improve of ensuring that ‘Here for Life', the youth suicide mental health and wellbeing70. prevention strategy, was informed by the evidence. Since that review almost 20 years ago, suicide is Strengths and weaknesses -
now the leading cause of death in young people and where Australia is now
young men continue to be at greater risk of suicide than their female peers67. While we have seen a lot of The role of technology in the lives of Australians
activity in Australia during the intervening years, and Technology continues to cement its place in the lives some positive steps taken, much of the commentary of Australians, and has had a dramatic impact on in that NHMRC review remains relevant today.
how we learn, work and play. Australian statistics In 2014, WHO released a report on suicide prevention indicate that almost all home internet connections efforts worldwide, showing a significant increase are broadband, and as of May 2014, 12.07 million across the globe by Governments that are committed people used a smart phone71. The rapid development to an agenda of decreasing suicide rates68. Despite of internet-enabled devices, such as smart phones this concerted effort, with 28 countries worldwide and tablets, also saw 68% of Australians accessing known to have national suicide prevention strategies, the internet via three or more devices in the six we are yet to see an ongoing and sustained reduction months preceding May 201472. in suicide rates. Significantly, the WHO report fails to include any discussion at all about the role of Young people, technology and suicide prevention
technologies as a setting in which people engage, interact and spend time. It fails to speculate on Suicide is recognised as a substantial public health either the positive potential of technologies or the problem, with adolescence identified as a period negative risk of contagion, other than to make when the risk of suicide is heightened73. While a passing mention of the potential risk of cyber Australia has seen significant mental health reform, it is a stark reality that traditional modes of service delivery are failing to reach young people; one study 65 ABS, 199766 Patton and Burns, 199967 Burns et al., 201368 WHO, 201469 Christensen and Petrie, 2013, Griffiths, 2013, Proudfoot, 201370 Cuijpers et al., 2008, Griffiths et al., 2010, Burns et al., 2010, Burns and Birrell, 201471 Australian Communications and Media Authority, 201472 Ibid 26 Volume 2: Exploring the suicide prevention research continuum suggests that as many as 80% of young people still care; allowing young users a flexible and accessible do not seek help for their mental health difficulties74. source of support that does not compromise the An integral part of suicide prevention is the therapeutic relationship86. The service gaps left by development and uptake of mental health promotion, traditional modes of information, care and treatment prevention and early intervention services, however delivery can be filled by e-mental health platforms 87 young people face numerous barriers to receiving , that place the power back in the hands of the care, for example: a lack of youth friendly services young people using the service and enable them to access the care they need at a time and place that 75, geographical location and isolation76, stigma associated with mental illness suits them. Technology also allows for customised 77, and complex state and federal funding models support services to be provided to groups that are typically difficult to engage, such as young men88.
With internet usage almost at saturation point Young people are engaging with technologies
amongst young people89, the online setting serves more than ever before, which can be attributed as an ideal mechanism to "rapidly engage young to the proliferation of mobile devices, improved people"90. Furthermore, it has demonstrated the accessibility and faster internet speeds79. The online capacity to engage young people who may not space is an environment where young people feel otherwise seek help via traditional means . The safe, secure, and in control. Service providers, online space is ideally placed to play an integral mental health professionals and policy makers role in the provision of mental health care and have grappled, however, with the way young people support, particularly as the utilisation of Internet, as use social media and social networking services a source of reliable health information, continues to (SNS) like Facebook. As a result, they have failed to capitalise on new and emerging technologies as a valuable tool Online platforms for mental health information 80. The use of SNS by young people has been shown to improve social connectedness, provision and service delivery allow young assist in delivering educational goals, provide people (and those that care for them) to educate support in identity formation and foster a sense of themselves, and establish support connections, to be accessed online or offline; the two spheres can 81, in contrast to the negative discourse often perpetuated by traditional media coexist93. There is a substantial opportunity for the sector to capitalise on the high technological literacy Social media is evolving quickly, often faster than of young people, to invest in and create services the research that might help us understand its that are designed to appeal to this digitally aware role in suicide prevention. A 2014 study outlined the increased use of social media by individuals and organisations that are active in the suicide prevention space, and the benefits that come from this practice83 In the study, individuals expressed The most common rationale for online support positive sentiment about being able to share their has been an economic justification: it is cheaper experiences with others in a safe and supportive to deliver services online. This paper argues for a environment84. Organisations were found to be using reframing of that rationale and purports that an social media primarily as a tool for promotion and integrated service is optimal for mental health networking.85. With this wide uptake of social media, outcomes. While there will always be a need for face- the Young and Well Cooperative Research Centre to-face services for those who are severely unwell (Young and Well CRC) is the driving collaboration and those with complex needs, best practice would between young people, researchers and technology- dictate this approach is supplemented by around- focused companies like Google, Twitter and the-clock support provided through technologies. Facebook to work alongside each other to fast track While technology can be used as an adjunct to the research that will help us understand more clinical care, it is becoming clear that there are a about its role in suicide prevention.
number of conditions that can be effectively self-managed, and that technology provides a low-cost The increased engagement of mental health vehicle to achieve this. In addition, because of its professionals with social media would see this online reach, the incremental cost per person of receiving space serve as a meaningful adjunct to traditional this care reduces.
73 De Silva et al., 2013, Harrington et al., 199674 Burgess et al., 200975 Australian Youth Affairs Coalition, 201076 Medibank Health Solutions and Nous Group, 201377 Ibid78 Ibid79 Burns and Birrell, 201480 Blanchard et al., 201281 Collin et al., 201182 Third et al., 2011 Volume 2: Exploring the suicide prevention research continuum 27 This paper argues for a greater focus on the disorders. Notwithstanding, if technologies are used effectively as part of a comprehensive and integrated mental health system, they have the • United efforts across promotion, prevention, potential to reach a large number of people to early intervention, treatment and relapse treat high prevalence disorders like anxiety and prevention: In other areas of health, such as depression at lower cost, thereby freeing up cancer, or cardiovascular disease, there is professionals and services to focus on those with little or no debate about the significant role more complex needs. The current offering online of promotion, prevention, early intervention, has evolved in parallel with the offline service treatment and relapse prevention. Across the offering and there is little or no integration preventive interventions framework, each across or between services. This is a missed component is seen as a critical element to opportunity and one that should be addressed comprehensively address the complexity of illness. Indeed, back in 1994, the Institute of Medicine wrote a seminal piece on how this • Addressing disparities in access: Bridging framework could be used in mental disorders. the gap in disparities to access to care, The document has been the backbone to much specifically for young men, young people who of the mental health policy that has shaped are indigenous, and young people who live organisations like beyondblue. Despite this, with a chronic illness or disability is still one the message that the elements that make up of our greatest challenges, despite 20 years of the spectrum are bigger than the sum of their investment. Technologies have been lauded as parts, has been lost. In cancer care, people our greatest opportunity but despite a plethora expect to receive the best possible evidence- of online offerings, the reality is that these based treatment available and there is little services are predominately accessed by women. or no argument about the role that smoking Some online services report ratios of 70:30 but cessation, diet and exercise play. In cancer most are sitting at around 80:20. This challenge care, health professionals urge the community was identified in the Young and Well CRC's report to look for early warning signs and they act Game On: Exploring the Impact of Technologies immediately to intervene. As a result, there has on Young Men's Mental Health and Wellbeing, been a substantial drop in morbidity and death with clear recommendations made about how associated with certain cancers. However, this services might adapt technologies to provide is not the case for mental health. As the sector an offering more closely aligned to the needs of becomes more sophisticated, it is clear that young men (Burns et al., 2013).
thought leaders must unite in one common voice • Measuring impact: In 2000, a paper in the – we can no longer argue that one approach is Australian New Zealand Journal of Psychiatry better than the other. In youth mental health, we was published with the following quote: still fail to provide support to over 70% of young ‘Economic evaluation of both clinical services people. This is due in part to the inadequacy and preventive interventions remains a complex of federal/state service models and a lack of and largely unexplored area. An important support in certain communities, particularly consideration is that the costs and consequences regional, rural and remote communities. It also of intervention (or failure to intervene) are reflects fragmentation and the challenges facing borne not simply by mental health services, a sector that has been driven by competitive but by other government (e.g. education and grant funding and attempts to secure a piece of social services) and non-government sectors. the pie that is simply too small to begin with.
Accurate cost–benefit evaluations require • Integrated service offering: Rather than being long-term follow up, and, in relation to youth viewed as a cheaper option, the role of new and suicide specifically, continued tracing through emerging technologies in driving system reform the period of high risk in young adulthood (Burns should be viewed as an important enhancement and Patton, 2000).' Strong leadership will ensure of interventions promoting wellness, as well that measuring impact is a core element of as the prevention of disorder, the delivery of every service, whether online or offline. This online mental health services, and as an adjunct leadership must come from the Boards and to support face-to-face services for those Executives of all service providers and, critically, who require professional care. Technologies they must be held accountable. An external cannot simply replace therapy, particularly evaluation is not good enough. Government must for young people with complex, severe and seriously invest in determining the effectiveness enduring mental health problems such as of services both on their own and as part of a major depression, drug and alcohol addictions, complex system. Effectiveness in mental health eating disorders, psychosis and personality service delivery needs to move beyond – ‘did 28 Volume 2: Exploring the suicide prevention research continuum the person like the service? do they trust it? and would they recommend it to a friend?' Evidence of impact is the following – ‘did this person get the right treatment? at the right time? and did they recover?' If not, why not, and how is their illness being managed? Our current system is not set up to follow people over time. As a result, they fall through the cracks, repeat their stories multiple times, and service delivery is inefficient. We simply must get better at providing a coordinated, wraparound system. The only way to do that is to get agreement from service providers to collectively unite in a common goal, and build standards that allow that to happen without the organisations involved losing their brand integrity. Prior to the 2013 election, the Coalition committed to invest in Project Synergy, a technological solution that allows data to be captured and stored across multiple services, led by the Young and Well CRC. A consultation with the sector is currently underway to determine the next steps for this initiative. An ongoing challenge is uncertainty and concern that a solution like this will take away from service autonomy. This is being addressed.
These recommendations merge contemporary understanding of how innovative technologies may be used to promote mental health, outlined in the "National Mental Health Commission's Review of Mental Health Services and Programmes" (http://www.mentalhealthcommission.gov.au/our-reports/review-of-mental-health-programmes-and-services.aspx), with the proposed benefits of such methods as illustrated in Young and Well CRC's "Advice on Innovative Technologies in e-Mental Health" (http://www.youngandwellcrc.org.au/knowledge-hub/publications/advice-on-innovative-technologies-in-e-mental-health/). With particular attention on reducing suicide rates and attempts and promoting mental health and wellbeing, engaging online affords a unique avenue for service delivery and timely and effective intervention.
Volume 2: Exploring the suicide prevention research continuum 29 TeleWeb support
Mr Alan Woodward
telephone crisis line and up to half of the visitors to a chat service may be suicidal at the time of • TeleWeb Support services provide accessible, contact98. These findings have been replicated in immediate and private forms of connection with the operational data of many Australian TeleWeb people seeking help and they play an important Support services.
role in suicide prevention, with emerging research findings suggesting that these services TeleWeb Support services provide an opportunity can engage people who otherwise would not to directly and immediately engage with a person contact conventional service systems, and that experiencing suicidal crisis and interrupt the state reductions in suicidal states can occur through of crisis so that immediate safety and wellbeing these support services. This is increasingly being can be secured. This process of engagement with recognised in Australia and internationally. a person may be seen as a first step towards a de-escalation of the state of crisis. This is explored by • However, neither research on the effectiveness authors such as Slaikeu (1983) and Kalafat (2002)99. of TeleWeb Support services nor the general Australian research on TeleWeb Support service establishment of evidence-based standards and impact has also shown effectiveness in reducing the features to define quality in service have kept suicidal state of contacts during a service session.100 pace with the propagation of these services. Further, a theme emerging from authors such as Greater investment in research on TeleWeb Kalafat, Baldwin and Brockopp is that a collaborative Support services may help unlock the key approach with a caller in crisis - which includes factors in their effectiveness and guide strategic active problem solving and mobilisation of internal development of the services and the operational and external resources - is necessary to take standards for their success.
advantage of the opportunity for growth and change • In particular, research needs to find innovative presented by crises.
yet ethical ways to engage with the consumers of Crisis intervention is identified as one of ten key these services and ensure the lived experience suicide prevention strategies in the World Health perspective is factored into the design, Organisation Report on Suicide 2014. Many national evaluation and ongoing performance monitoring suicide prevention strategies highlight crisis of these services.
intervention services as integral to their approach in reducing lives lost to suicide. TeleWeb Support Suicide crisis intervention and
services, operating out of normal hours, and using TeleWeb support services
immediate, low cost and private means of service contact (telephone and online) play a valuable Various research studies on telephone crisis lines contribution as a ‘safety net' service to provide crisis in USA and Canada94,95,96 and Australia97 have intervention when the person in crisis needs it most.
established that up to one third of callers to a 94 Litman, R.E. (1970, 1995). 95 Sudak, H.S., Hall, S.R. & Sawyer, J.B. (1970, 1995). 96 Mishara et al 200797 Perkins D. and Fanaian, M. (2004)98 Lifeline Australia and Net Balance (2014) 99 Kalafat, J. (2002a). 100 King, R., Nurcombe, B., Bickman, L., Hides, L & Reid, W. (2003). 30 Volume 2: Exploring the suicide prevention research continuum Continuity of care and follow-up
Mental health promotion and
using TeleWeb support services
TeleWeb support services
Follow up support for suicidal persons – and their Research on the profile of callers to telephone carers and families – can also be provided effectively helplines reveals many have underlying mental through TeleWeb means and several services in health issues. One Australian study found anxiety Australia perform follow up support, ranging from and depression over-represented in the profile non-clinical emotional support to more structured of callers101. Closer studies of the callers have established that many are experiencing levels of The rationale for follow up using TeleWeb Support psychological distress that are sufficiently high at services has several facets: the time of the call to warrant clinical diagnosis if they were to visit a mental health specialist.102 The - Reach people who do not access professional operational data of many TeleWeb Support services services following a suicide attempt or suicidal confirms high proportions – perhaps 35% of their crisis, but continue to have suicidal thoughts and callers – self report diagnosed mental health issues. intentions. TeleWeb Support services may be able to attract and follow up contact with suicidal There is a direct link between the contribution persons – and provide accessible support for of TeleWeb Support services on mental health their carers – in ways that conventional services promotion and prevention and suicide prevention: mental health and suicide prevention are inter-related. TeleWeb Support services assist in providing - Enable greater use of safety and action plans those who contact them with increased awareness of following initial contact to a crisis intervention mental health issues and information about mental service. A follow-up service might encourage health professional services that they can access. these individuals to follow through with the A few research studies in US and Australia have action plan that was established or help them generated encouraging results showing more than develop a more suitable one.
half of those who receive referrals to mental health - Provide greater support for those individuals services actually take action on these referrals after at high risk of re-attempting suicide, namely the call to the crisis lines. 103, 104,105 those who are discharged from hospital or acute care facilities. As there can be delays in getting an appointment with community mental health Despite the proliferation of TeleWeb Support services services, contact with a TeleWeb Support service in Australia and internationally, there has been may be a more rapid form of community follow- remarkably little research related to their purpose or effectiveness. This has started to change, with - Address emotional support and psycho-social several research studies and evaluations of the needs for people who have experienced suicidal effectiveness of telephone helplines and online or crisis or attempted suicide. TeleWeb Support mobile services emerging in the past decade. services which utilise non-clinical crisis support Research priorities in Australia include the processes are able to directly address this need.
Australians are particularly astute, as a population, Consumer expectations and preferences
in the adoption of technology and it seems highly congruent to consider TeleWeb Support services To a large extent it remains a mystery why suicidal as potentially highly effective outlets for enhanced persons contact TeleWeb Support services – despite continuity of care and outreach for suicide prevention the research evidence which shows that they do. It in this country, as is occurring in Europe, UK and the is often suggested that TeleWeb Support services attract suicidal persons because of the ease of contact, their relative privacy and the safety of 101 Burgess, N et al (2008) Mental Health Profile of Callers to a Telephone Counselling Service. Journal of Telemedicine and Telecare; No. 14 pp 102 Perkins, D., Fanaian, M. (2004). Who calls Lifeline: Baseline study of callers and their needs. CEPHRIS: Centre for Equity and Primary Health Care Research in the Illawarra and Shoalhaven, University of New South Wales.
103 Turley, B., Zubrick, S., Silburn, S, Rolf, A, Thomas, & Pullen, L. (2000a) Lifeline Australia Youth Suicide Prevention Project. Final Evaluation 104 Gould, M.S.; Munfakh, J; Kleinman, M; & Lake, A (2012). National Suicide Prevention Lifeline: Enhancing Mental Health Care for Suicidal Individuals and Other People in Crisis. Suicide and Life-threatening Behavior, 42 (1),22-35.
105 Lifeline Australia and Net Balance (2014) Social Return on Investment study of Lifeline Online Crisis Support Chat Service Volume 2: Exploring the suicide prevention research continuum 31 the confidential environment in which to disclose What value – befriending?
suicidality without fear of negative responses. There do not seem to be any published research studies The befriending processes of listening and support to confirm these reasons, especially from the offered by some TeleWeb Support services may consumer's perspective. be seen to offer a vulnerable individual a sense of compassion and (re)-engagement with others that Are crisis oriented TeleWeb support services
in itself presents options of a more hopeful future. The application of recent models to TeleWeb Support A core feature of crisis-oriented TeleWeb Support services offers the opportunity to reinterpret the services is that they are accessible, usually through importance of non-clinical emotional support as a low cost telephone or online contact, and often means of engaging with vulnerable individuals and available when other services are not, i.e. weekends, challenging the trajectories of their psychological after hours. Accessibility, however, goes further than experiences with a view to increasing the protective cheap phone calls and easy to remember contact factors at play and decreasing the influence of negative and destructive thoughts and perceptions. However, very little research has been conducted in Operational performance of in terms of call/contact Australia or internationally using these theoretical answer rate and queue waiting times are measures paradigms to test the efficacy of crisis lines.
of accessibility for consumers. There appears to be, however, no research published on the required While there appear to be positive impacts for those levels of performance – and on the impact on contacting TeleWeb Support services in terms of consumers where deficient operating performance their continued help-seeking and immediate relief results in poor access.
from distress, this aspect of non-clinical befriending style services deserves much closer attention. Such The promotion of a TeleWeb Support service in research may also build the case for closer formal the community is another facet of access. This interaction between non-clinical support services can influence the extent to which it is regarded as and professional health and community services.
welcoming for all people, regardless of background, culture, religious belief and socio-economic status. Frequent callers to crisis lines
While some services specialise in their appeal for particular groups, those that present themselves It is the case that some contacts to TeleWeb Support as generalist services need to ensure that they services make use of the service on a continuing or are actually regarded as such by the communities frequent basis. An additional perspective into the that they seek to serve. Those that are targeting social support role performed by TeleWeb Support particular groups need to know if they are actually services, is that of chronic support needs and reaching those groups. Few studies have addressed chronic suicidality which may exist for a group of this for TeleWeb Support services in Australia.
callers. However, questions arise regarding whether or not unlimited and unregulated access to TeleWeb Promotion of TeleWeb support services
Support services prompts dependent behaviours or possibly avoidance of engagement with professional There is some research evidence to show that active promotion of TeleWeb Support services generates contact activity. Operational data from several Within the broader mental health system, the Australian services suggests contextual factors such frequent contacts to TeleWeb Support services as a high profile suicide reported in the media, or appear to have unmet needs which are being deliberate marketing and promotional campaigns, partially, and perhaps not effectively, met through can generate increased contacts. frequent contact to a telephone or online service. There is also potential for the TeleWeb Support A recent Australian study by Melbourne University services to contribute to a more ‘joined up' model of involving four major TeleWeb Support services mental health service and care for these individuals. found that male call patterns have increased in Research trials on improved models of coordinated recent years, along with specific findings regarding or integrated service are warranted.
increased contacts when the services are promoted alongside positive stories on mental health recovery. Links to hospital and health services
What is not clear, however, in Australia is whether or not consumers prefer particular ‘brands' or types It is sobering to note that there are no known of TeleWeb Support services, despite the service research studies on the impact of crisis intervention providers maintaining such an emphasis on brand through TeleWeb Support services initiating promotion and product distinction.
emergency interventions with police and hospitals for suicidal persons who are identified as being in life threatening states or situations. It is not 32 Volume 2: Exploring the suicide prevention research continuum established whether or not these individuals expect, TeleWeb support and theories on suicidal
or benefit from, such interventional referral to hospital and mental health services. Impacts on families and carers are also unknown.
A challenge for TeleWeb Support services is to establish and measure the outcomes that they The limits and nature of crisis intervention for generate for their consumers and the impact overall TeleWeb Support remains a difficult and complicated that they achieve towards suicide prevention.
issue. In particular, while some research on suicide safety planning has been undertaken by Stanley and Traditional principles around befriending and others, there has not been in Australia any common emotional support have tended to dominate practice approach established or service standards relevant knowledge, based on the values of ‘unconditional to safety planning. positive regard' for the help seeker and the provision of a non-judgemental and empathic response It is likely that the ability of TeleWeb Support services to their situation. Although this form of support to address the issue entirely themselves will be continues to constitute the bulk of what many lessened as research in this field further prompts TeleWeb Support services provide to their callers, reviews of existing practices and the intersection of there has not been a lot of in depth research to build the hospital and health system with suicide crisis the evidence for it, to determine what the ‘process' intervention services. Trials of models of service or model of support consists of, what ‘difference this between TeleWeb Support services and hospital makes' or ‘outcomes' this creates for callers, or its and health systems may offer insights into how effectiveness in achieving its primary aim of reducing crisis intervention can be viewed in a more collaborative way.
Future research studies on the outcomes and impacts of TeleWeb Support services could usefully TeleWeb Support service worker techniques
align to the emerging theories on suicidal behaviour In 2007, research by Brian Mishara and others such as the Interpersonal Theory on Suicidal revealed that, from a study involving listening to Behaviour by Thomas Joiner and others, or the more than 1,000 calls to a US helpline, there were Motivational-Volitional Theory by Rory O'Connor and great variations in the service delivery to callers others, to provide a more theory-based framework across individual crisis line workers as well as through which evaluation of this aspect of TeleWeb across different crisis centres106. The variations Support services could occur. These theories offer did not appear to reflect the policy or practice a bridge between the operational and process orientations of the crisis centres. Critically, the considerations of the services and the achievement crisis line workers failed to identify suicidal callers of intended positive outcomes for consumers. on numerous occasions and, on some occasions, even when correctly identifying suicidality, failed to implement crisis intervention actions to secure the safety of the caller.
This study placed a spotlight on the adequacy of quality assurance and supervision controls in TeleWeb Support services. There are, however, no worldwide standards on quality assurance in TeleWeb Support services and most Australian services operate internal review systems rather than externally conducted or validated measures of process integrity and quality assurance. In particular, there are limited studies – although some are now emerging in Australia and overseas – on the critical factors in worker performance that should be measured and monitored for service effectiveness.
Volume 2: Exploring the suicide prevention research continuum 33 Does treating and
Dr Michael Dudley
substance abuse disorders, bipolar disorder and schizophrenia) and are also more strongly Notwithstanding controversy about this issue, there associated with multiple psychiatric disorders. 111 is a strong connection between mental disorders and suicidal behaviours, both fatal and non-fatal.
A previous review of suicide research priorities highlighted the dearth of focus on interventions.112 In Western settings and high-income countries, Disparate research across several domains has where most research historically has been focused, confirmed that various interventions and strategies mental disorders are said to be present in up to can prevent suicide. 113 90% of people who die by suicide, and in the other 10% without distinct diagnoses, their mental health Within the field of effective interventions to prevent indicators are similar to others dying by suicide.107 suicide, there is a question regarding whether The relationship between mental illness and suicide treating or intervening with psychiatric disorders is historically durable. 108 affects suicide and/or suicide attempt. This question is of major importance when considering However, most people suffering high prevalence the impacts and costs of psychiatric disorders, disorders such as depression, substance use the benefits of treating psychiatric disorders, and disorders and antisocial behaviours will not display when marshalling evidence for comprehensive suicidal behaviour. In recent years, re-examinations approaches and national programmes to prevent of the relationship have raised questions about, for suicide. However to our knowledge, there is less example, the reliability of the psychological autopsy research regarding the extent to which treatments method on which many estimates depend,109 and and interventions for psychiatric disorders may frequencies of mental disorders have been noted to contribute to suicide prevention and no systematic be lower in non-Western and Aboriginal and Torres review of this topic. Strait Islander settings. Socio-cultural research and political debate has turned on the importance Suicide Prevention Australia has assembled a of sociocultural aspects of suicide, the objection of National Coalition for Suicide Prevention, which some key service user organisations to the emphasis aims to reduce suicide in Australia by 50% in 10 on psychiatric illness, the dominance of what are years. In the context of mounting such a national seen as medical approaches to suicide prevention, strategy to reduce suicide and suicide attempts, it and the exclusion of the voices of those with lived was decided to undertake an exploratory survey to identify strengths and limitations of research in this area, to outline questions needing answers, and to These latter important observations and arguments specifically outline Australia's research capacity with require different responses, but do not remove regard to this area. the important connection of psychiatric illness for suicide and suicide attempt in a very sizeable This preliminary survey addressed the question of proportion of cases. Suicide and suicide attempts treatment and interventions in relation to suicide- have particularly strong relationships with certain related outcomes. It was principally concerned with psychiatric disorders which carry far greater risks identifying treatments and interventions where these than the general population (e.g. affective disorders, were the principal focus of the study and the focus was on their effectiveness (see below, in Results). 107 World Suicide Report, 2014, p40108 Goldney, 2007109 Hjelmeland et al, 2012110 Webb, 2013111 World Suicide Report, 2014, p40112 Robinson et al, 2008113 Mann et al, 2005; Christensen et al, 2015 34 Volume 2: Exploring the suicide prevention research continuum The survey focussed on self-harm, suicidal behaviours and suicide, not (at this stage) on suicidal Three were excluded because they were in other ideation. It also did not encompass the question of languages.116 One (Leor et al, 2013) was excluded whether health promotion or preventing psychiatric because it referred to suicide bombings. There are disorders demonstrably prevents suicide. also case reports that were discarded117.
At this stage, seven studies that considered suicidal ideation alone were excluded. Garlow studied Medline and PubMed searches were conducted from the impact of fluoxetine on suicide ideations in 1/1/2008-31/12/2015 as follows: outpatients with minor depressive disorder.118 1. (suicide or ‘suicide attempt' or ‘self*harm').m_ The ascertainment of suicidal ideation using validated questionnaires in primary care settings where psychiatric case review, psychotropic 2. (treatment or intervention or management).m_ medications, and specialty mental health referral are also available, can help facilitate discussions 3. (depressi* or anxi* or substance or drug or about suicidality, flag psychiatric complexity and alcohol or cannabis or hallucinogen or stimulant treatment-resistance, and prompt assertive follow- or sedative or hypnotic or opi* or inhalant or up and treatment.119 Isotretinoin therapy for acne tobacco or smok* or schizophren* or bipolar or contrary to product warnings results in improvement psychosis or psychotic or neurodevelopment* or of depression and was not associated with suicidal autis* or attention or neurocognitive or dementia ideation.120 Also Diamond had a mixed focus on or Alzheimer or personality or trauma or eating ideation and attempts and Mewton and Andrews or anorexia or bulimia or disruptive or impulse or addressed the impact of CBT for depression on suicidal ideation.121 Christensen studied whether web-based Cognitive Behaviour Therapy (iCBT) with and without telephone support reduces In this preliminary survey, titles and abstracts suicide ideation in callers to a helpline compared of articles from these two databases only were with treatment as usual (TAU).122 They found that though suicide ideation declines over 12 months with and without intervention, and higher baseline suicidal behaviour decreased the odds of suicidal ideation remitting post-intervention, that change in 83 studies were located. depression over the course of the interventions was associated with improvement in suicide ideation. Nine were discarded because there was no Watts found that suicidal ideation was common treatment / intervention component or it was (54%) among primary care patients prescribed iCBT incidental to the study's primary purpose (which treatment for depression but dropped to 30% post- was not intervention-focussed).114 Defining whether treatment despite minimal clinician contact and studies were part of an intervention was sometimes the absence of an intervention focused on suicidal difficult. For example, Mrnak-Meyer et al studied ideation.123 This reduction in suicidal ideation was predictors of suicide-related hospitalisation among evident regardless of sex and age. U.S. veterans receiving treatment for comorbid depression and substance dependence, finding that The remaining reports (after these foregoing negative mood regulation expectancies were the were eliminated) concerned a number of different only significant predictor of hospitalisation during psychiatric disorders. These included clinical 6-months of outpatient treatment, and that history of depression and treatment-resistant depression, a suicide attempt was the only significant predictor substance misuse, borderline personality disorder, of hospitalisation during the one-year follow-up bipolar disorder, and first episode psychosis, early period.115 It was decided to exclude this because it psychosis and schizophrenia. There were also considered the predictors rather than effectiveness studies of sexual trauma, and severe, chronic and of an intervention. The criterion used was as noted complex psychiatric illness. above (treatments and interventions were the No studies were located that focussed on the principal focus of the study and the focus was on impacts on self-harm and suicidal behaviours 114 Mrnak-Meyer et al 2011114 Munizza et al, 2010; Schneider et al, 2011; Cho, 2012114 Sloan et al, 2014; Fabregas et al 2009 114 Garlow et al 2013114 Bauer et al, 2013114 Nevorolova and Dvorokova 2013114 Diamond et al 2013 and Mewton and Andrews 2015114 Christensen et al 2013114 Watts et al (2012) Volume 2: Exploring the suicide prevention research continuum 35 on treatments or interventions with disorders of Discussion
neurodevelopment, attention, neurocognition, personality, trauma, eating, disruptive behaviours, The present review begins with the presumption impulsivity or conduct. of a strong connection of psychiatric disorders to suicide and suicide attempts, a strong need The remaining reports studied a number of to address suicidal vulnerability in people with interventions. These included education and psychiatric disorders, and a research priority for training, screening, treatments of psychiatric suicide intervention research compared with further disorders (broadly considered), hospitalisation, research on areas of suicide risk that have been psychotherapies (e.g. CBT, dialectical behaviour therapy and supportive psychotherapy informed by collaborative assessment and management The limitations of this preliminary survey are of suicidality), medications (new generation several. The survey only considered title and antidepressants, lithium, other mood stabilisers, abstract, and for last seven years: broadening the antipsychotic drugs, and sedative-hypnotics), search to include the whole article and over a longer management protocols and quality of care and/ period may have elicited more material. It limited or adherence to treatment standards, community- the number of databases to two key ones. It did not based interventions. One study considered the consider unpublished or grey literature. impact of smoking cessation. The survey at this point did not consider suicidal Nearly all studies had concerns that overlapped in a ideation, only suicidal behaviours or self-harm: it is number of these areas. possible that more studies would be identified were suicidal ideation included. Different populations were the subjects of the research, notably veterans, older people, youth The review did not study the extent to which studies and those treated for substance use disorders or of the treatment of psychiatric disorders review participating in specialised early psychosis (EP) the status of suicidal thinking and behaviours. To treatment programmes. Among professional groups, address this would entail surveying the broader substance disorder treatment providers and primary field of research on the treatment of psychiatric care physicians were the focus of treatment.
disorders (especially disorders where risks are reliably identified as high such as affective disorders, Several studies reported on the design phase of substance abuse disorders, personality disorders and conduct disorders) and considering the status of Five studies among the 83 involved Australian suicidal thinking and behaviours in those studies. research groups. They addressed the treatment of However the review confirms the possibility of substance use with comorbid suicide risk using CBT identifying and implementing effective strategies 124; the impact of a specialised early psychosis (EP) (treatments and interventions) to prevent suicide treatment programme for younger people on risk among those with psychiatric disorders. of suicide125; the characteristics of suicide attempts during treatment for first episode psychosis (FEP)126 It is of interest that much of the research appears to and the quality of care in bipolar suicide cases.127 retrospectively investigate the relationship between psychiatric treatments and inadvertent suicide- There was approximately equal attention to suicide related outcomes. Much less research constitutes attempts, suicide and both. tests of treatments or interventions with psychiatric There was a preponderance of specific biological disorders as potential avenues of suicide prevention, interventions (9 studies) over psychotherapeutic with suicidal behaviours as primary outcomes of the studies (5). There was almost no attention to the social and cultural components of effective The review found that the identified studies psychiatric treatment or intervention to prevent encompassed various treatments and interventions including education and training, screening, treatments of psychiatric disorders (broadly considered), hospitalisation, psychotherapies, medications, management protocols and quality of care and/or adherence to treatment standards, and 124 Morley et al, 2013125 Harris et al, 2008126 Fedyszyn et al, 2011127 2012; Keks et al, 2009128 Robinson et al, 2008 36 Volume 2: Exploring the suicide prevention research continuum community-based interventions. There is a relative dearth of material about psychotherapies, and particularly about community-based treatments or interventions with psychiatric disorders. They have targetted a range of psychiatric disorders, including depression, substance abuse, psychosis, and bipolar disorder, but also have not included impacts on self-harm and suicidal behaviours on treatments or interventions with disorders of neurodevelopment, attention, neurocognition, personality, trauma, eating, disruptive behaviours, impulsivity or conduct. There was a fairly even weighting between studies considering suicide and suicide attempt. Few studies considered psychotherapies and other questioned aspects of some well-accepted treatments (e.g. distress tolerance), for example with borderline personality disorder.129 There is some diversity of focus in the populations that have been considered – e.g. veterans130, older people,130 youth.132 There is a dearth of material about the treatment of psychiatric disorders as a suicide prevention measure in a range of other populations (e.g. Aboriginal and Torres Strait Islander, refugee/asylum-seeker, migrant, forensic/custodial). There was a preponderance of biological interventions (9 studies) over psychotherapeutic studies (5). The review found very little attention to the social and cultural components of effective psychiatric treatment / intervention to prevent suicide. As already noted, the need for treatment and intervention research in psychiatric disorders to consider suicidal behaviour and self-harm as outcomes is important when considering the impacts, costs and benefits of treating psychiatric disorders, and when accruing evidence for comprehensive approaches and national programs to prevent suicide. The coverage of this domain is patchy, with some notable gaps. A plan for how this area can be systematically researched needs to be devised.
A fuller literature review should undertake this task of also including suicidal ideation, a longer timeframe and also for sake of completeness to include other relevant databases (e.g. Embase, Cinahl, Cochrane, Google Scholar, Scopus, Web of Science). In addition, the brief was not taken to be the potential of health promotion and prevention of psychiatric disorders as preventative of suicidal behaviours: this seems a potential separate subject for future research.
129 Marchand, 2014130 Webster et al, 2012, Smith et al, 2011, Valenstein et al, 2012, Pfeiffer et al, 2013131 Oyama et al, 2008132 Henry et al, 2012; Diamond et al, 2012; Ramchand et al 2008, Vitiello et al, 2009 Volume 2: Exploring the suicide prevention research continuum 37 Evaluation
Mr Alan Woodward
"…only two prevention strategies where there was evidence of effectiveness: educating physicians • Suicide is a major health and social issue in to detect, diagnose and manage depression and which the knowledge and evidence base is restricting access to lethal methods of suicide." not what it could be in Australia. Evaluation of services, interventions and programmes A Senate Inquiry into Suicide in Australia in 2010 is necessary to broaden the knowledge and identified deficiencies in the evaluation of past evidence base beyond epidemiological data or activity and programmes: clinical measures to discover more about what New research should focus on the efficacy of suicide works and why – and where investments by prevention interventions and results should be governments, private and community parties widely available to practitioners and others. should be prioritised, informing strategy and policy as well as improvements in actual service Commentary to the Inquiry included: and programme effectiveness.
Professor Jane Pirkis from the University of • Evaluation of suicide prevention strategies Melbourne outlined research undertaken which and programmes is fraught with complexity reviewed the 156 projects funded under the original and challenge. However, some approaches to NSPS. While the organisations which received evaluation will support better conduct and use of funding for these projects were contractually evaluation in suicide prevention. In particular, the obligated to evaluate ‘…in practice the evaluations creation of an evaluation framework at a national were methodologically too weak to contribute much level, including outcomes statements and to the evidence base regarding what works and what measures, will enable alignment of evaluation doesn't work in suicide prevention'.8 activities at programme and services level.
Similarly the Australian Institute for Suicide • Australian expertise in evaluation is highly Research and Prevention highlighted that despite regarded internationally, but is not generally a broad range of programmes funded by the harnessed in the development of evaluation Commonwealth and States only 60 per cent included methods for suicide prevention. Impact an effectiveness evaluation component and none of measurement is a growing field that is highly those evaluated the impact of the interventions on relevant to effectiveness and outcomes the actual suicide rate.
evaluation for suicide prevention – a strategic The Senate Inquiry therefore addressed both the link with impact measurement experts should be need for evaluation and the utilisation of evaluation. fostered in Australia.
It focused particularly on the need for evaluation of specific interventions for the prevention of suicide, i.e. building knowledge on ‘what works'. The current knowledge of what works in suicide In recommendations 35, 38 and 39, the Inquiry prevention is quite limited. Or to speak in terms of identified three levels at which evaluation of suicide evidence, a 2005 review by Mann et al of research prevention can occur: and evaluation on suicide prevention published in the i. Policy evaluation – how effective are the policy Journal of the American Medical Association found priorities in the National Suicide Prevention ii. Programme evaluation – what works and what doesn't in projects designed to impact on suicide prevention? 38 Volume 2: Exploring the suicide prevention research continuum iii. Intervention evaluation – what clinical and non- Socio-economic factors also apply, e. g: greater clinical interventions are efficacious? suicide rate during economic downturn and race/ The Federal Government's response to the Senate ethnicity (Goldsmith et al 2002); women experiencing Inquiry in 2010 included a commitment to evaluation domestic violence are 4.5 times more likely to of the National Suicide Prevention Strategy. In engage in suicidal behaviour (WHO 2013).
2014, the Evaluation Report on the National Suicide A major difficulty therefore in the evaluation of what Prevention Programme was released publicly works and what does not for suicide prevention is and recorded difficulties in obtaining data on the that the links between particular interventions and effectiveness of the 47 projects funded under the a reduction in lives lost are hard to establish clearly. programme, and in many cases, limited data on cost Several factors come into play: - the link between Programme and service activity Another issue in Australia has been that to saving lives is hard to establish – so many evaluation reports prepared on projects on suicide factors are involved in a person's suicidality and prevention have not been widely available; a few actions to take their life Non-Government Organisations have released - Programme and services may have clear publicly evaluation findings for their services and objectives, but it is difficult to measure beyond programmes, e.g. StandBy Economic Evaluation, outputs and immediate impact Mates in Construction, LivingWorks and Lifeline Online Crisis Chat service. However, evaluations are - data gathering is complicated – suicidal persons not universally made public, there is no single and are highly vulnerable and ethical considerations coordinated repository of these evaluation reports, apply when collecting data and feedback for and there is no nationally structured action to synthesise and share the knowledge obtained.
Deaths by suicide remain a relatively uncommon In USA, evaluation findings on suicide prevention and infrequent phenomena, from a population strategies and programmes is available through health perspective, so it is difficult to identify the Suicide Prevention Resource Centre, a federally significant changes in suicide rates or numbers of funded body with the purpose of supporting deaths to generate findings on the effectiveness of community and state government suicide prevention. suicide prevention strategies. Similarly, it is hard to Evaluation reports have also been made available in apply measures of impact and change that can be Europe through the EU mechanisms for coordinated reliably attributed to particular suicide prevention suicide prevention. In the UK, evaluations of the programmes or services on a large scale basis. Scottish and English suicide prevention strategies The ‘evaluation' of particular interventions, or have been made available publically. clinical treatments for suicidal behaviour cannot easily be established through Randomised Challenges and impediments - the
Controlled Trials – suicide is such a complicated complexity of suicide
behaviour it is difficult to establish a control group that is not affected by multiple factors in the "Every suicide is a different story; every suicide is individuals concerned, and it is often difficult to recruit sufficient numbers to conduct these research methods. David Knesper, University of Michigan Depression
Finally, it can be difficult to engage suicidal persons in research – there are practical safety issues Increasingly, it is being recognised that suicidal as well as ethical issues. This does not mean it behaviour and deaths by suicide may be fuelled by a is impossible, nor that the lived experience of multitude of inter-relating factors including: individuals, families, carers and communities • Biological – family risk, brain chemistry, gender, should not be sought, but for conventional research physiological problems methods and ethics processes there have been challenges in the past. Accordingly, most of the • Predisposing – psychiatric disorders, substance research on suicide prevention has been undertaken abuse, personality profile, severe illness without direct data from those who may access the • Proximal – experiences of hopelessness, various programmes or services being considered – aloneness, impulsiveness third party interpretations of consumer satisfaction, engagement and outcomes are often presented only. • Immediate Triggers – public humiliation, access to weapons or means of death, severe defeat, major loss.
Volume 2: Exploring the suicide prevention research continuum 39 Evaluation theory and practice –
activities; this approach is well suited to the design what can it offer?
of evaluations for suicide prevention which by definition is complicated and operating across Evaluation is concerned with forming judgements various services, organisations, contexts and people. and assigning value to particular actions or Outcomes hierarchies are very useful for mapping programmes – against pre-established statements the relationships between intended high level and of purpose and intended results. Typically evaluation population-based results to programme activities questions are either process oriented – did the and services, and their utilisation by target activity operate as intended, or outcome oriented – audiences. Outcome hierarchies enable clarity what happened to those affected and did anything and the opportunity to test the ‘logic' of particular change as a result of the activity? More attention in assumptions and linkages across a programme. recent times has been devoted to impact evaluation – Data collection and measurement can then be what difference did the activity make, and for whom? applied at various levels of the outcomes hierarchy. Evaluation is a key tool to guide policy makers, The Bennett's Hierarchy for example helps break programme managers, donors and financial down the complexity and the linkages between supporters of suicide prevention in identifying elements of a programme.
priorities, likely ‘best buy's and to review the success of particular strategies and suicide prevention An example of the use of programme logic mapping for the evaluation of suicide prevention gatekeeper training has been prepared by US Evaluator Phil Programme design and programme evaluation
Rogers, showing the basic structure of a programme evaluation framework for gatekeeper training.
For suicide prevention, a programme conceptualisation of strategies, activities and The process components include the inputs or services using logic tools can assist greatly in resources required to conduct the training, the clarifying the purpose, processes and intended actual delivery of the training to required standards results – or impact – of particular activities. and in ways that meet content and pedagogical Programme logic frameworks support mapping design specifications, and then a clearly identified of the complex inter-linkages between various output: persons trained satisfactorily. The outcomes components include short, intermediate and long 40 Volume 2: Exploring the suicide prevention research continuum term outcomes that can have measures attached service delivery measures. It provides a useful way to them. This recognises that some outcomes of capturing ‘real life' translations of programme are identifiable immediately at the time of the objectives on the ground and is ideally suited to gatekeeper training, such as the knowledge gained, complex programme environments where the skills developed and attitude changes of the potential for implementation gaps in delivery is a participants. More far reaching outcomes, especially major consideration in evaluations.
those relating to behaviour change, are identified in the intermediate and long term classifications. Together, this mapping of the ‘logic' between inputs, activities, outputs and outcomes can inform the design of evaluation and the collection of data related to evaluation questions for this programme.
What is needed, at a national level, is an overall programme framework that establishes high level outcomes across priority areas for suicide prevention that can be used to align individual programme and service evaluations and assess their contribution to policy level strategic plans. An example of this is found in the US Rand Corporation Suicide Prevention Framework, which guides organisations, programme managers and service providers in the construction of programme logic maps to support evaluation of suicide prevention activities. In Australia, no formally distributed national evaluation framework for the National Suicide Prevention Strategy has yet been available. Social context and evaluation
Pawson and Tilley's seminal work, Realistic Evaluation (1997), suggests an approach grounded In 2009 a group of commentators including Niner, working towards a closer understanding of what Pirkis, Dudley and others published in the Australian causes change – within participants and more eJournal for the Advancement of Mental Health: broadly in a social context. Key assumptions of Realistic Evaluation include: Many felt that evaluation efforts should employ mixed methods, should be multidisciplinary and • Social programmes are an attempt to address an should be relevant to the Australian context. They existing social problem – that is, to create some also argued that there was scope for increasing the level of social change utility of research findings by communicating them • Programmes ‘work' by enabling participants to in a manner that would enable them to be utilised by make different choices policy-makers, planners and practitioners.
• Making and sustaining different choices requires Qualitative information has great relevance to the a change in participants' reasoning and/or the evaluation of suicide prevention programmes as resources they have available to them. This is it captures the attributes of people engaged in known as a programme ‘mechanism' programmes – target audiences – and allows for greater data collection on the immediate impact of • Programmes ‘work' in different ways for the intervention services. Evaluators have to become better at qualitative data capture and analysis and • The contexts in which programmes operate this has a place – mixed method data collection in make a difference to the outcomes they achieve suicide prevention.
• Context + Mechanism = Outcome One approach that would have application for suicide prevention is known as Most Significant Change, • Good understandings about ‘what works for a method which brings forward the qualitative whom, in what contexts, and how' are portable experiences and perspectives of those for whom Realist evaluation offers suicide prevention a method a programme is offered, or targeted. Drawing to analyse the contextual factors across communities on evaluation insights gained from international or different target groups for particular programmes development programmes, Most Significant Change or interventions. It enables analysis to address focuses on what happened, to whom and why the individual or social factors that may affect the rather than data against predetermined clinical or Volume 2: Exploring the suicide prevention research continuum 41 fidelity with which programmes are delivered, or the drivers and risks nationally. Economic analysis variations in service provision from the recipient's on cost-benefit returns of particular strategies, perspective that may result in different outcomes for and social return on investment methods should different people at different times.
be incorporated into policy level evaluation.
The various evaluation methods and application of 4. Consumer informed evaluation is a necessary evaluation theory to programme logic, evaluation change in direction. The experience of being design and the conduct of evaluations including suicidal, and of caring for suicidal persons, must change in Australia for the National Strategy data collection and analysis, have much to offer to be seen as effective. This reflects the reality Australian suicide prevention. A harnessing of that suicide attempts are individually-generated the body of knowledge from evaluation experts through a mix of complicated factors. The and applying this to the challenges of evaluation ‘system' of response accordingly needs to be for suicide prevention programmes, services and flexible and workable to adapt to the individual community activities, may provide a means through and intervene to prevent further development which greater conduct and utilisation of evaluation of suicidal activity. The system also needs to respond to the social dimension of suicide – friends / family members, social groups, sub What to do? – directions for
cultures, people in similar locations – so that evaluation and suicide prevention
targeted suicide prevention is engaging with those who are surrounded by suicidal people. 1. Useful and appropriate evaluation requires those The attention on mental health service provision commissioning and conducting evaluations to in suicide prevention is well justified; as with possess a level of skill to know what method the broader reform of mental health, so too relates to what evaluation purpose and context. with the health services evaluation should there Invest in evaluation education and training. be attention to consumer experiences of the Produce a guide on what evaluation methods services, consumer preferences for how these work for what purpose. services are offered / provided, and monitoring of the utilisation and adherence to programmes 2. Set outcome measures nationally that relate to and treatments relevant to mental health and strategy and priority. These measures should suicide prevention.
then support a logic mapping to key programme such as education / training, mental health 5. Social change factors in evaluation will generate services, crisis intervention, psychiatric early knowledge on the extent to which social intervention, removal of access to means, etc. determinants of suicide are being addressed The National Research Action Plan should adequately. Suicide is not evenly spread in then be aligned to the evaluation framework Australia: particular social groups are more nationally so that knowledge and evidence gaps vulnerable, e.g. Aboriginal and Torres Strait are addressed, i.e. so evaluation requirements Islander populations especially those in remote inform data collection and research priorities.
areas, farmers and rural residents, Lesbian, Gay, Bisexual, Transgender and Intersex people, 3. Policy level evaluation of the National Suicide people experiencing domestic violence. The Prevention Strategy needs to be established case for participatory evaluation with those with the whole sector - not just an evaluation affected by a social order in suicide prevention framework for the National Suicide Prevention is that the solutions to suicide may be generated Programme (NSPP) The evaluation purpose, collaboratively - and that they are unlikely to priorities and appropriate methods will flow be generated without the involvement of those from this. At one level, reduced deaths by suicide experiencing the social dislocation that is to be is the intended outcome measure. This could addressed. Community-based suicide prevention become more sophisticated by checking for in particular could be focused more on the reduced deaths in particular population cohorts. social determinants of suicide prevention and Also, greater attention to reduced suicide action to achieve social change at a community attempts and re-attempts will place a focus on level, rather than having community networks decreasing suicidal behaviour and improving attempting to replicate the existing community early detection and prevention. Moreover, the and health system or take up a ‘vigilante' outlook effectiveness of the NSPP is contingent on more on suicide prevention in an attempt to stop than it can control (economic downturns) so a set of evaluation measures needs to be agreed on that will examine the choice of strategies and 6. Social Impact Measurement should feature in the the relative mix of strategies, within a public evaluation approach to suicide prevention. These health framework that assesses the current methods combine traditional research data with 42 Volume 2: Exploring the suicide prevention research continuum evaluation methods and economic appraisal of value. Most importantly, social impact measurement is concerned with social change and development - measuring what difference is made in a programme or service. This is critical for policy stakeholders to make informed choices on suicide prevention strategies and programmes, but also for funding bodies who will be interested in ‘return on investment'.
7. Utilise the existing expertise in evaluation. Australia has some of the leading evaluation experts in the world, yet these individuals are not engaged in advising on the evaluation of suicide prevention strategies or programmes. There needs to be a deliberate process of engagement and utilisation of experts within Australia to develop and provide support for evaluation methods that are relevant to suicide prevention. Similarly, the potential to educate and build skills in evaluation through the relevant professional body, the Australasian Evaluation Society should be explored.
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A Comparative Study on Facially Expressed Emotions in Response to Basic Tastes Wender L. P. Bredie, Hui Shan Grace Tan & Karin Wendin Chemosensory Perception ISSN 1936-5802Chem. Percept.DOI 10.1007/s12078-014-9163-6 Your article is protected by copyright and all rights are held exclusively by European
Journal of Surgery & Transplantation Science Bringing Excellence in Open Access *Corresponding authorIoannis Liapakis, OpsisClinical Plastic and Reconstructive Surgery, 48 Anogion St., 71304, Therissos, Lipofiling and Modified Heraklion-Crete, Greece, Tel: 30-69-32934051; Email: Submitted: 11 May 2016 "Kligman's formula" for the