Keynote Presentation
DR LEONARD LAMBETH
Chief Psychiatrist,
Dept. Health & Human Services Tasmania
Suicide Prevention– It’s Everyone’s Business
An Approach to Understanding &
Prevention
Assoc Prof. Len Lambeth
BSc(Med), MBBS, FRANZCP, DAvMed ,Cert Forens Behav Science, AFRACMA
Chief Psychiatrist, Mental Health, Alcohol and Drug Directorate
The Problem
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Every year in Australia, suicide takes the lives of around 2000 Australians
It is ahead of road traffic accidents and skin cancer as a cause of death
For those aged 15-24, it is the NUMBER ONE cause of death.
Suicide accounts for around 20% of all deaths in this age group and 25% for
males in this group.
National Context
• Suicide Prevention Australia is the national peak body for the suicide prevention
sector in Australia.
• Plays a role in providing policy advice to governments, community awareness and
public education, increased involvement in research and a future role in leading
Australia’s engagement internationally.
• LIFE Communications is a National Suicide Prevention Strategy project that aims to
improve access to suicide and self-harm prevention activities in Australia through
the promotion of the LIFE resources and website.
• Also aims to improve communication and networks between suicide prevention
stakeholders in Australia.
Starting Points
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Suicide is a rare event overall
Suicide and self-harm is not rare among psychiatric patients
Suicide is hard to predict with any specificity
It is very difficult to know and understand the thinking behind a suicidal act
What Drives People to Suicide?
• Understanding the person in the context of their unique environment is
essential if we are to have any understanding of the drivers behind suicide.
Some of the drivers include:
– Mental health problems
– Social disadvantage
– Adverse childhood experiences
– Physical health problems
– Adverse life events
– Legal problems
– Loneliness
A Personal Response
• “I believe that each case of suicide has its own unique
constellation of factors including, at its centre, the vital role of
idiosyncratically defined psychological pain, which itself is pushed
by a pattern of thwarted psychological needs that is special for
that particular person”.
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Schneidman, E., (2005) Suicide & Life-Threatening Behaviour. Vol 32 (1)
An Ancient View
“ Whensoever any affliction assails me, methinks I have the keys of
my prison in my own hand and no remedy presents itself so soon to
my heart as mine own sword.”
Biathanatos – a treatise about the moral implications of suicide. (John Donne – 1602)
Understanding Suicide
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Is understanding suicide achievable?
Is it always associated with mental illness or disorder?
Can we understand the underpinning emotions?
Can we delineate the diverse and multifaceted underpinnings?
Understanding Suicide
• Biological - decreased serotonin, excess noradrenaline
• Sociological – society’s influence on the individual (Durkheim); social
dependency/gender role/ marital status (Hassan)
• Psychological-psychodynamic (emotional states); cognitive (learned
behaviour); family systems (family conflict).
Psychache (Schneidman)
• Schneidman (1985) developed the concept of “Psychache” – losses
that can lead to intense emotional pain
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Rejection
Worthlessness
Hopelessness
Helplessness
Grief
Anger
Frustration
Shame
Isolation
Loneliness
Despair
failure
Suicide and Alcohol
35-80% of all suicidal behaviour is said to be alcohol
related.
Experiences of Suicide
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Increased tension
Unpleasant affect
Disorganised behaviour
Cognitive confusion
Inability to resolve conflict
Maladaptive problem solving
Perceptual distortion
Confusion and disorganisation
Agitation. Anger, worthlessness
Risk Factors
• Predisposing – historic, static
• Acute – current and dynamic
• Protective
Predisposing Risk factors
• Demographic - male, older age, ethnicity, marital status, economic,
employment
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Diagnosis of mental disorder
Previous suicidal behaviour
History of aversive life events
Dispositional –maladaptive personality characteristics, emotional
instability, poor resilience/coping skills
Acute Risk Factors
• Precipitant social stressors – loss of resources or status,
interpersonal discord, legal or financial difficulties
• Current mental state – hopelessness
• Current engagement/compliance with professional
support and treatment
Protective Factors
• Only a few have been identified
• Many are inversions of risk factors
• Those identified include:
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Positive coping strategies
Effective problem solving skills
General life satisfaction
Resilience
Suicide Prevention–
areas of focus
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Assessment and treatment of psychiatric disorders
Detection and treatment in primary care
Reducing access to lethal means
Reducing inequalities in disadvantaged groups
Increasing availability of psychological therapies
Suicide and Mental Disorder
While there is no doubt that the causes of suicide are multiple
and complex, we must be aware of the increased risk of suicide
associated with mental disorders:
• Borderline Personality Disorder – 45 times increased risk
• Depression - 20 times increased risk
• Bipolar Affective Disorder – 17 times increased risk
• Opioid use – 14 times increased risk
• Anorexia Nervosa – 31 times increased risk
• Alcohol misuse or dependence – 16 times increased risk
The conclusion?? – We MUST assess for underlying psychiatric
disorder
Identifying Psychiatric Disorder –
Benefits
• By identifying psychiatric disorders we can:
– Target evidence-based therapies aimed at preventing suicide and self-harm and wellbeing
– Examples include:
• DBT for BPD reduces self-harm and hospitalisation
• Clozapine and other second generation anti-psychotics reduce suicide in
Schizophrenia
• Lithium reduces suicide in Bipolar Affective Disorder
Suicide Prevention in
Populations
• Population based programs aimed at suicide prevention
must include:
– Public education
– Means prevention
– Improved assessment
– Improved treatment
– Targeted programs for specific populations
Suicide Prevention –
A Three Tiered Approach
• Reducing suicide in any population requires a focus in
the following three areas:
1. Capacity in communities
2. Recognition of those at risk
3. Post discharge and community-based care
Tasmanian Context
• Tasmanian Suicide Prevention Strategy 2010-2014 was launched in
December 2010.
• The Minister recently approved an extension of the Strategy until
December 2015.
• The Tasmanian Suicide Prevention Committee provides high level
strategic advice and leadership in suicide prevention activities in
Tasmania, with a focus on implementing the strategy.
• The Tasmanian Suicide Prevention Community Network is hosted by
Relationships Australia (Tasmania) and funded by the Directorate to
enable key stakeholders and service provides to work collaboratively
across the state to address suicide prevention.
Suicide in Tasmania - 2012
• Tasmanian age-standardised suicide death rate – 14.1/100,000
• NT – 18.1; WA – 13.5; QLD - 13.0
• 70 deaths by suicide in Tasmania in 2012 (33 from transport
accidents)
• 56 male deaths and 14 female deaths
• The female suicide rate is the highest among all states and
territories and higher than the national average of 5.1/100,000
• The male suicide rate is the second highest in Australia.
• Most suicides occur in the areas of greater population, but
males have a higher rate of suicide in rural areas.
Approaches to Prevention
The elements of the approach to suicide prevention in Tasmania include a
range of initiatives under the current strategy. The following are some new
initiatives aimed at further developing and enhancing our approach:
1. Assisting communities with the implementation of community action plans to
prevent suicide.
2. Establishing early intervention referral pathways following suicidal behaviour
or self-harm
3. Delivering suicide prevention awareness training to persons in key
occupations.
Approaches to Prevention cont.
4. Ensuring Tasmanian researchers can access in-depth analysis of Tasmanian
suicides to better target prevention strategies.
5. Developing a targeted Youth Suicide Prevention Strategy for Tasmania with
the Youth network of Tasmania
6. Analysis of suicide “hotspots” to mitigate risk at places of repeated suicides.
7. Ensuring that clinical risk categorisation processes are developed to aid in
the early identification of those at high risk and to inform plans for the
management of those at high risk.
Community Action Plans
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In line with current directions
Working through organisations such as Relationships Australia
Aimed at enhancing social connectedness of community members
Enabling communities to respond appropriately to people showing signs of
distress, mental ill health or suicidal intent
• Providing access to available support services
Early Intervention Referral
• Establishing referral pathways for early intervention is vital to both prevent
the behaviour and to deal with the underlying causes.
• Not everyone who attempts or considers suicide requires hospitalisation, but
all require professional assessment, support and follow up.
• Models aimed at ensuring effective follow-up for patients following an
episode of self-harm or a suicide attempt to support discharge to early
intervention and other support services need to be developed and
implemented in DEMs and public mental health in-patient settings.
Suicide Prevention
Awareness Training
• We wish to identify the suicide prevention training needs within Tasmania and
commission training providers to deliver suicide prevention training to key
occupations and sectors.
• This training will target a number of important “gatekeepers” – people in
positions to become aware of those in distress including:
• GPs, Sporting bodies (coaches etc), churches, hairdressers, refuges, any services
directed at those suffering with problems, OH&S representatives.
Research
• More research is needed to allow in-depth analysis of Tasmanian suicides to better
target prevention strategies.
• The Directorate is working closely with the Tasmanian Coroner to establish a new
Tasmanian Suicide Register which will provide researchers with vital data upon
which to base recommendations for prevention strategies.This would be a valuable
tool in prevention giving us niche data in an accurate and timely manner.
• Such a register will attempt to capture an individual’s story prior to suicide including
the factors unique to their environment and gather information such as service
contacts in the time leading up to the person’s death.
Youth Suicide
Prevention Strategy
• A youth suicide prevention strategy will aim at building resilience in youth and
encouraging and developing help seeking behaviours.
• The strategy is being developed in partnership with the Youth Network of
Tasmania (YNoT).
• Success in this endeavour is very strongly aligned to the ability to consider
and include the views of the youths themselves.
• Throughout Australia, suicide remains the leading cause of death within the
15-24 year old age bracket.
• A statewide forum to discuss youth suicide will be held in Launceston on 20
March 2015.
Youth Suicide
Prevention Strategy cont.
• Youth suicide prevention strategies include:
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Developing internal positive coping strategies
Assistive social supports
Assisting in the development of self esteem
Social support and connectedness
Accessing professional support for assistance
Removing access to means of suicide
Suicide “Hotspots”
• Research has demonstrated that there are a number of specific, accessible and
usually public sites that are frequently used as a location for suicide – these become
known as so called “hot-spots”.
• Hot-spots include tall structures (bridges, cliffs), railway tracks and isolated locations
(rural car parks) which offer direct means for suicide or seclusion that prevents
intervention.
• Establishing a cross-agency group including representatives from Health, Police,
Ambulance, the Coroner and the Department of Infrastructure will enable any “hotspots” in Tasmania to be identified and options for mitigating suicide at such places
developed.
Clinical Risk
Categorisation
• This provides clinicians with a formulation that a person is at high, moderate,
low or no foreseeable risk of an outcome – in this context – suicide.
• The risk judgement is based upon a structured, transparent clinical process.
• It leads to the development of a management plan based upon the
formulation and enables monitoring of the risk and the effects of the
management plan.
Clinical Risk
Categorisation
• All clinicians involved in the care of people with mental health problems should be
aware that assessment of risk is a required skill.
• While suicide prevention is the concern of the whole community, clinicians have an
ongoing role in the management and monitoring of identified risk.
• Risk assessment involves an examination of both static and dynamic factors
including gender, age, previous history, current mental state, social situation,
impulsivity, treatment availability – all in the context of the person and their
environment.
Questions