Last partial update: August 2016 - Please read disclaimer before proceeding

 

Introduction to suicide in Australia

Suicides and attempted suicides are tragedies that haunt families and communities for many years after they occur. In 2015, suicide was the cause of 2,500 deaths in Australia with most deaths occuring in males; a ratio of about 3.5 to 1.0. The overall rate has been dropped since the 1990s but may be stating to climb again and Australia has a higher rate of youth suicide than other developed countries overall. The rate is highest in the 25 to 45 year old male group.

The suicide rate in males is higher for several reasons; they are more action oriented and use more violent suicide methods, they abuse alcohol and other drugs more often, they often have poorer social networks, and they feel they should be more ‘in control’.

The method of suicide is changing with hanging increasing and firearms decreasing. Overall, about 47 per cent of deaths by suicide involve hanging and, in young people, hanging, strangulation and suffocation acount for about to 66% of suicides. (Firearms and poisoning account for about eight per cent and eleven per cent respectively.)

Attempted suicide: For each person who dies, many more attempt suicide and the number of hospitalizations resulting from suicide attempts far outweighs the actual numbrer of suicide deaths. There were about 20,000 hospital admissions for suicide attempts and self-harm injuries in 1997/1998 and, in contrast to suicide deaths, the rates for attempted suicide are far greater for females. The female to male ratio for hospitalisations for attempted suicide is about 2.5 to 1, with the highest rate of attempted suicide occurring in young women aged 15 to 19 years. It goes without saying that it is important to take ALL attempts at suicide very seriously.


Recent trends in suicide - The suicide rate is decreasing

Increasing suicide rates in the 1980s and 1990s prompted health authorities to initiate a large Australia-wide campaign to reduce this tragic death rate and luckily it has been very successful. Over recent years there has been a significant decline in the suicide rate with the overall rate dropping by about 15% between 1997 and 2002. This drop was fairly equal in men and women but occurred most markedly in the 15 to 24 year old group. (The rate in this group dropped by about 37%. In 2002, about 9 young people per 100,000 committed suicide in Australia, a 14% decline since 1886.)(As stated previously, while the offical rate had dropped significantly further by 2006, it is not known how much of this drop should be attributed to changes in statistic collection, specificaly the information supplied by coronors.) The reasons for the overall improvement are:

Unfortunately the reductions achieved were off a very high levels and the rates are still unacceptably high.

It is worth noting that suicide is significantly more common in young people after they have left school (until the age of about 25 years) than it is in school years.

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People at risk of suicide

Is trying to identify people most at risk of suicide helpful? Many say that, with the currently available risk assessment tools, it is not really possible to predict which people with mental health issues are more likely commit suicide. (About 50% of people who commit suicide do not come from a high risk groups.)

The public health viewpoint: For a long time health professionals have been trying to predict which people with mental illness are most at risk of committing suicide in the hope that they can better target scarce medical resources and reduce the incidence of suicide. From a public health perspective, it is important that our scarce health resouces are used optimally. Unfortunately it appears that using the currently available questionnaires and assessment tools has not been of great help in indentifying those who successfully complete suicide. (Hopefully better ones will be developed.)

The reasons are as follows. About 95% of those identified as being at high risk do not die from suicide and thus most of the treatment targeting these people doesn't reduce suicide rates. (This, of course, doesn't mean the treatment is wasted. The vast majority will be significantly helped.) Additionally, over half the people who do commit suicide do not come from the high risk group and thus don't benefit from increasing the treatment given to the high risk group. Also, some studies have shown that having one risk factor is just as predictive of suicide risk as have several factors. Finally, quite a number of people who are not seen by heatlth professionals prior to committing suicide.

For the above reasons, it is very difficult for health professionals who use currently available risk factor assessment to identify those people who will successfully complete suicide. Thus, many (not all) are now electing not to base treatment decisions on risk factor assessment. Additionally, it is felt that any additional funds provided to reduce suicide rates might achieve this aim better if they were spent more broadly amongst people with significant mental health issues (or perhaps on public educational programs); rather than just on those identified as being at high risk.

Government-funded campaigns based on primary care (GP) initiatives, public relations campaigns and community facillitators have been found to be very effective in Europe (e.g. The Nuremburg Alliance Against Depression) and there is growing support for such campaigns to be developed in Australia. Some of the initiatives that have been shown to be effective are:

The individual patient viewpoint: The issue is different when looked at from the viewpoint of treating individual patients rather than from a public health viewpoint. As stated above, about half the suicides do come from this high risk group and much can be done to reduce their risk. And they do need to be watched carefully. Thus, most health professionals do feel that suicide risk assessments are worthwhile. The important thing is not to be given false reassurance by a lower risk rating. All people with mental health issues need optimal care from both their treating health professionals and their family and friends.

Another important consideration is that basing treatment decisions on risk level means that many people at high risk will be addmitted to psychiatric hospitals. Doing this has real mental health implications for the person being admitted.

People at greatest risk of suicide include:

Mental illness: People with mental illness are especially at risk, particularly those recently discharged from psychiatric units. Most people who attempt suicide, especially young people (about 90 per cent), have previous mental health problems, particularly depression. While suicide and depression are often linked together, it is important to note that ten per cent of people with schizophrenia commit suicide and forty per cent attempt suicide. This rate is up to twelve times that of the general population. Most of these suicides occur within the first ten years of their schizophrenia being diagnosed.

A particularly lethal combination is someone who is a male; has experienced a recent unfortunate 'life event'; has feelings of hopelessness; has a history of mental illness and / or alcohol abuse; and who is impulsive by nature.

 

Suicide 2

Source: Australian Institute of Health and Welfare 2000.


The figure above shows that suicide incidence increases with increasing isolation. (They are a few years old now but still relevant.) The reasons for this include isolation from people in general, reduced access to help for mental illness, poorer economic conditions in rural areas, increased access to firearms and the fact that Indigenous Australians mostly live in remote areas and they have suicide rates significantly higher than the general population. Young men in these locations are particularly at risk. Older farm managers also have a high incidence, with financial problems being a significant factor. The above partially explains why the rates are significantly higher in Tasmania (14.7 per 100,000 people) and the Northern Territory (13.0 per 100,000) and lowest in NSW (7.3 per 100,000), and Victoria (8.5 per 100,000). Interestingly, despite having a large rural community, Queensland also has a quite low rate (8.3 per 100,000).

Having said this, Australia is an urbanised society and most suicides therefore still occur in the cities.

Compared with other countries, Australia fares reasonably with respect to suicide incidence with an overall rate of 10.3 per 100,000 population. (Greece 3.2, Brazil 4.3, Italy 7.1, UK 7.0, Netherlands 9.3, Singapore 10.1, USA 11.0, NZ 11.7, Germany 13.0, Sweden 13.2, Cuba, 13.5, Switzerland 17.4, France 18.0, Finland 20.3, Japan 24.0, Russian Federation 34.3)

Modifiable risk factors

Perhaps the most important task in assessing a person's risk of suicide is determining whether they have risk factors that are modifiable. As stated above, it is very difficult to determine who will actually comit suicide and thus all people with mental health issues need optimum treatment if suicide rates are to be lowered. The first step in this process is determining what risks can be modified.

Alcohol: Alcohol use is probably the most important modifiable factor to address. About 20% of the illness caused by suicide and self harm is directly attributable to alcohol use.

Risk factors that can be modified are maked * in the table below.

 

Suicide risk factors

General risk factors for people of all ages

  • Being male
  • Previous suicide attempt or episode of self-harm, especially if recent
    The risk of suicide is obviously greater in someone who has previously attempted suicide and this increased risk can last as long as ten years after the initial attempt. (About 40% of people who commit suicide have previously attempted suicide.) Thus, these people need careful watching for a long time and this is obviously aready done. The fact that the rate of subsequent completed suicide is still 40% is testament to how hard it is to successfully treat people with severe chonic mental health issues. Their treating health professionals and family and friends need real support when treatment fails.
    Over 50% of people who self-harm at some stage also attempt suicide. (While many people who self-harm do not wish to die, some of them will 'accidentally die' from their self-harm. ) Feelings of hopelessness commonly occur in both 'suiciders' and 'self-harmers'.
  • Mental health disorders*
    Well over 50% of people who commit suicide have a mental health disorder; and 41% have been in hospital for a mental health problem within the previous year. People are especially at risk immediately after discharge from a psychiatric unit, particularly if they were an involuntary admission, or after psychiatric assessment in an emmergency department. (The risk level in these people is up to 200 times that of the general population immediately after discharge and is still 30 times at 12 months after discharge!!) Community support needs to be planned prior to their discharge.
    Depression (60%) and substance abuse are the most common mental illnesses associated with suicide. People in the early stages of treatment for depression are still at risk and carers need to be 'on the lookout' until the patient's mental state improves. People with schizophrenia and anorexia nervosa are also at higher risk. A person with both drug use and mental illness problems is particularly at risk. Having said this, most people with a mental illness do not attempt suicide. Better recognition and effective treatment of these conditions would significantly reduce suicide incidence but, as stated previously, effective recognition is difficult to do. Improving social networks and ensuring the person lives in a caring and safe environment also reduce risk.
  • Recent significant loss / negative life event
    For example, the death of a partner or divorce / relationship breakup / unemployent. (People involved in difficult separations are at increased risk.) People who commit suicide have an incidence of such events that is four times greater than the general population. Financial problems are more commoly a factor in male suicides. The relatives of people who commit suicide are at significantly increased risk.
  • Impulsive personality type
    Substance abuse (especially alcohol) increases likelihood of impulsivity.
    Many young people who attempt suicide made the decision in the previous hour, especially where alcohol is involved.
  • Friends / family who have attempted suicide, especially if done recently.
  • Other personality traits including aggression, anti-social behaviour, low self-esteem, poor social skills.
  • Childhood / family adversity (especially abuse)
  • Time spent in prison
  • Living in a rural / remote area*
  • Social isolation*
  • Ease of access to guns*
  • Social disadvantage*
  • Sexual identity issues*
  • Alcohol use* Prior alcohol use is associated with many completed and attempted suicides. The combination of mental health disorder and alcohol use is particularly dangerous and people with significant mental health issues should consider not drinking at all and be encouraged to do so (and assisted) by their health professionals and their family and friends. Alcohol use is the most important modifiable risk factor to addess in suicide prevention strategy.

Risk factors that are especially important in adolescents

  • Severe and disabling mood disorder*
  • Recent relationship breakup
  • Impulsivity, particularly when it involves engaging in risky or self-destructive behaviour.
  • Being male
  • Lack of support from family / friends or social isolation

Risk factors that are especially common in older people

  • Being unmarried
  • Recent relocation
  • Suffering from chronic physical illness, especially where pain is difficult to control.

*Modifiable risk factors

 

Tipping points

Some potent risk factors commonly act to precipitate a suicide event. It is important to watch out for these occurring in people who have other risk factors. Many are adverse life events.

  • Relationship ending
  • Feared or unplanned pregnancy
  • Death or suicide of a friend or relative
  • Trouble at school or with the police
  • Argument at home / family conflict
  • Being abused, bullied or assaulted (including sexual asault)
  • Loss of status or respect
  • Debilitating physical illness or accident
  • Suicide of someone famous or media report about a suicide

Alcohol use in association with any of the above events increases risk dramatically.

 

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Preventing suicide

1. Reducing the incidence and effect of depression

Depression is the most common risk factor for suicide and also causes a huge amount of disability in the general community. Reducing its influence can have a significant effect on reducing suicide risk. This can be done in several ways.

From a public health viewpoint, health authorities aim to identify 'at risk' groups in the communiy and instigate programs that aim to help reduce risk in these groups. Such groups include people with mental illness, people who have a history of suicide attempt, people in custody, remote indigenous communities and socially or geographically isolated older men.

2. Be observant for:

a. Risk factors for suicide in family members and friends

Most people who commit suicide have several suicide risk factors. Identifying such people early on and helping them seek treatment will reduce their risk of suicide greatly. This requires:

  • Learning the risk factors for suicide so that at-risk people can be identified
  • Ensuring other family members are educated regarding suicide risk factors: This is helpful in all 'families', especially those where a person has been identified as being at increased risk of suicide.

Important risk factors and factors that can be a crucial factor in causing a person to commit suicide, termed 'Tipping points', are listed above. Many are negative life events.

All people with significant mental health problems are at risk: It is important to remember that half of suicides occur in people at low risk who may have only one risk factor. (Some studies have shown that the risk is the same whether you have one or several significant risk factors.) Thus, all people with significant mental illness should be receive appropriate care for suicide risk, whether they are deenmed to be at low or high risk.

Negative life events: Negative live events are important sucide risk factors and are especially important to watch out for in friends / relatives who already have suicide risk factors, such as a history of depression. Assessing the appropriateness of responses to life events that cause significant stress can help predict suicide likelihood.

Important life events include recent losses, such as loss of an important person through death or separation, the recent suicide of a friend or relative, or breaking up with a boyfriend/girlfriend. A 'normal' grief-depressive reaction to a relationship breakup typically lasts up to several weeks. If the reaction lasts longer than this then underlying depression should be suspected. Feared or confirmed pregnancy, trouble at school or with the police, family conflict or domestic violence, being a victim of sexual or other abuse (present or past), and drug abuse can also precipitate suicide.

The risk of suicide is obviously greater in someone who has previously attempted suicide and this increased risk can last as long as ten years after the initial attempt. Thus, these people need careful watching for a long time.

b. Warning signs for suicide in family members and friends, especially those with risk factors

There are important warning signs (abnormal behaviours) that people at significant risk of suicide often display. These are listed in the box below and are important to look for in all people but especially in those with risk factors for suicide. Their presence should not be ignored.

Important suicide warning signs

  • Expressing a wish to die or making preparations to die
    For example, making wills or other final arrangements, giving away prized possessions.
    Statements showing suicidal ideas or thoughts such as “I wish I was dead”, “no one cares if I live or die”, “does it hurt to die?”. Death or suicide themes dominating written or creative work in adolescents are especially important and need to taken seriously.
    Planning / researching self-harm, especially when thought has been given as to how effective the plan might be.
  • Feeling of despair and hopelessness
    Adolescents lack the ‘life-experiences’ that show them that problems usually do resolve themselves with time and are especially vulnerable to these feelings. They often say / feel that they are letting parents / friends down. They may also say that they feel trapped and that there is no way out of their predicament. Unexplained consistent crying can be a sign of dispair.
  • Recent onset or increase in alcohol (or other drug) use: This is mostly a sign for males. (It is factor in roughly 30% of male suicides.)
  • Withdrawing from friends or family
  • Uncharacteristic behaviour, including risk taking that is out of character or poor judgement
  • Aggitation / anxiety / dramatic changes in mood / anger. Aggitation is a very important sign, especially in someone with feelings of dispair.
  • Abnormal sleep patterns; too much or too little
  • Sudden calmness or even happiness following a period of significant distress associated with depression. This can indicate that the decision to commit suicide has been made.
  • Giving away personal possessions.
  • Feeling trapped - ike there is no way out
  • Decline in school performance or attendance


3. Restricting access to means of suicide

Restricting access to firearms and medications is a sensible precaution in all households whether or not there is a person at risk of suicide present.

4. Education regarding suicide risk

This is beneficial for certain groups at increased risk including the following.

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Helping at-risk people

1. Initiating help - This is a task that always needs to be done.

Assessing whether people are at risk of attempting suicide and what help they need are not an easy tasks, even for experienced health professionals. If you are at all concerned that a person is at risk of committing suicide, you should always act on these concerns immediately as the management of an 'at risk' person is a medical emmergency. Do not delay acting in the hope the person's symptoms will go away or that you might be over-reacting to the situation. It is always best to ensure the person you are worried about is safe and gets assessed by a competent health professional.

Here is some advice regarding things you can do that will help.

All people at risk will need urgent professional medical assessment / help. The first step in this process will almost always involve someone talking to the person about accessing help. (There are circumstances when this is not appropriate, such as when there is a risk of the person being violent. Here the police may need to be initially involved.) How a person goes about getting the person to talk about the problem will depend on how he or she feels about dealing with it. Some people will feel comfortable talking with the person without initial guidance; others will want to discuss 'how to approach the topic of discussing suicide' with a health professional (i.e. get help) first; and others will not wish to be involved directly themselves (and act by getting another person to help). Some advice regarding talking to people who are 'at risk' is provided in the boxed section below.

Options available regarding getting help

  1. Emmergency help. In emmergency situations, help can always be accessd by ringing 000 or by going to the casualty department at your local hospital. If you are worried that the person is at immediate risk, you should not leave the person alone. Ringing an emmergency 24-hour help service, such as Lifeline and Kids Help Line, is a good option when a person is insure how to best deal with a difficult situation. (See 'Further information' below for contact details.)
  2. Professional help. There are many people in the community who can provide professional advice and help. They include: GPs, psychologists, social workers, counsellors, staff at your local hospital or community health centre, ministers of religion, school counsellors, the police and emmergency 24-hour telephone counselling services, such as Lifeline and Kids Help Line. Ongoing medical help needs to be sought from suitably qualified health professionals skilled at treating people who are at-risk of suicide. A relative or friend should accompany the person on their first visit to the health professional and on later visits when appropriate.
  3. Help from family and friends: Helping people at-risk of suicide is never an easy task and can often be a long-term commitment. To ensure that helpers are not over whelmed and stay healthy themselves, it is important that the job of supporting the person is shared, wherever possible, between numerous friends and family members. However, this can only happen if other friends and relatives know there is a problem and thus it is important to discuss the issue with them. This will hopefully be with the agreement of the at-risk person. However, sometimes this needs to occur without their permission. (See comment below.) In most cases, the first person to contact should be the person who would normally provide long-term care for the person (if that is not you). When the person at-risk is an adolescent, this would usually be a parent or carer.

Note: At risk people will often ask the people they confide in not to inform others. This is not a reason for not seeking help and it is important not to promise to keep secret any threat of self-harm.

Discussing the topic of suicide / self harm

If you are worried that a friend or relative might be at risk or attempting suicide, someone needs to talk to them about the subject of suicide. If you feel unable to do this (and it is not an easy task), find another person who feels comfortable doing it or get them to talk to a person at Lifeline etc. The best way to really find out how a person is feeling is to ask.

When self-harm/suicide is discussed, address the issues seriously with the person and suggest that the person receives help as soon as possible. Discussing suicide is likely to reduce the risk of a suicide attempt, not increase it.

When talking to people about self-harm / suicide, be honest about concerns and feelings and try to discuss them calmly. Allow the person time to talk about their feelings / situation and avoid offering too much advice, being judgemental or trivializing the person’s concerns. If the person is evasive / denies suicide intent and you are still worried, go with your gut feeling and seek help anyway.

Try to emphasise that the person's situation is NOT HOPELESS and that he or she has a well-recognised, common and very treatable illness. If their feelings are in response to a crisis, it is worthwhile mentioning that many people respond in this way or feel like this under such circumstances and that there are many options regarding finding a solution to their problem. Hopelessness is a very distressing and serious symptom that needs to be overcome quickly. Presenting alternatives to suicide and affirming the self-worth of a person can assist them to feel less alone and hopeless.

Deciding whether a person is at-risk: Leave it to the professionals. As mentioned above, deciding whether a person is 'at risk' of attempting suicide is not always easy, even for health profesionals, and it is not something that you should attempt to do. Always play it safe and get the person professionally assessed by a health professional as soon as possible. If you are worried enough to think about suicide as a possibility, then it is highly likely the person needs assessment and treatment. Having said this, some specific information can be sought to help determine how serious the problem is; including information about the following.

  • Suicide planning: Ask about whether they have thought about how they would commit suicide AND whether they have taken steps to organise a suicide attempt. Do they already have the means to attempt committing suicide? Have they organised a possible date? People with a well thought out plan and the means to implement their plan are particularly at risk.
  • Their feelings about their support network: What support do they feel they have to fall back on? Who do they trust? (Family, friends, teachers?)
  • How hopeless do they feel the situation is. Dispair is a serious risk-factor, especially when accompanied by aggitation.

2. Ensure that the person is not left alone: This usually means someone staying with them while they are acute risk. (This is especially important if the person has been consuming alcohol.) This may mean staying overnight or even longer and thus may require the help of several family members / friends. Where this is not possible, it may be necessary to take the person to casualty at the local hospital. People rarely attempt suicide when in the company of others.

3. Reducing risk in their environment

4. Assessing and reducing risk to others: Some people contemplating suicide may also have thoughts about harming others, especially the parents of young children. If you feel others are at risk, seek professional help immediately (see list of sources of help above) and, where possible, provide support while help is coming and during treatment. This may mean contacting the police in acute situations.

5. Help during AND after hospitalisation: In an acute situation it is likely that the at risk person will be admitted to hospital. It is helpful to have friends / relatives stay with the distressed person (when permitted) for one to two days until improvement occurs. This is imperative if for some reason the person at risk can not get access to hospital treatment e.g. isolated people. The immediate period after discharge from a psychiatric unit is a high-risk time for suicide attempts. It is important that adequate support for the person is organised before the person is discharged.

6. Ongoing support

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Further information on mental illness

Mental health resources

Mental Health Branch of the Department of Health and Aged Care  www.mentalhealth.gov.au
This site provides information about crisis supports and contacts, general mental health information, mental health information brochures / publications about specific topics such as depression, anxiety, information about suicide prevention etc.
Ph 1800 066 247

Beyond Blue: The National Depression Initiative https://www.youthbeyondblue.com/?&gclid=CICs69Tvgc4CFQiVvQodF-0MFA

ybblue (Beyond Blue’s youth program)  www.ybblue.com.au
Beyond Blue’s youth program (Self harm at ybblue (https://www.youthbeyondblue.com/understand-what's-going-on/self-harm-and-self-injury

Black dog institute www.blackdoginstitute.org.au
Provides information for clinicians and patient education.

Moodgym   www.moodgym.anu.edu.au
An interactive program of CBT, more aimed at depression, developed by the Centre for Mental Health Research at the Australian National University.)

Reachout www.reachout.com.au
A resource for young people with depression.

Lifeline www.lifeline.org.au  Ph 13 1114
Lifeline provides an immediate counseling service for all people)

Kids Help Line www.kidshelp.com.au
A national 24 hour counseling service for children and young people)
Ph 1800 551 800

CRUfAD, The Clinical Research Unit for Anxiety and Depression www.crufad.com 
CRUfAD is a group of researchers and clinicians concerned with anxiety and depression. It is a joint facility of St Vincent's Hospital Ltd and the University of New South Wales in Sydney, Australia. The self-help section of the web site has useful information about both anxiety and depression for the general public.

Anxiety Panic Hub www.panicattacks.com.au
A consumer web site with a focus on meditation / mindfulness.

Mindmatters  http://www.mindmatters.edu.au
A program that introduces mental health education to secondary schools.

A helpful Australian Government web site:
Children of Parents with a Mental Illness ('COPMI') (An Australian Government web site.)
http://www.copmi.net.au/

 

Further reading on mental health topics

Rowe L, Bennett D and Tong B. I just want you to be happy. Preventing and tackling teenage depression, Allen and Unwin 2009.

Rapee, R., Spence, S., Cobham, V. and Wignall, A. Helping your anxious child. A step by step guide for parents. New Harbinger, 2000.

Macquarie University Child and Adolescent Anxiety Unit
This unit runs 12 week courses for anxious children in the 6 to 12 year age group.
www.psy.mq.edu.au/muaru.

Rapee, R.M. (2001). Overcoming shyness and social phobia: A step by step guide. Sydney: Lifestyle Press.
Deals with social phobias and shyness

Wells, A. (1997) Cognitive therapy of anxiety disorders; a practice manual and conceptual guide. Chichester. John Wiley and Sons, 1997.
  
Beating the blues by Susan Tanner and Jillian Ball. Published by Susan Tanner and Jillian Ball. Distributed by Tower books.
A good book for issues dealing with the treatment of depression.

Don’t panic. Overcoming anxieties, phobias and tensions by Andrew Page. Published by Liberty One Media.
Deals with panic disorders, phobias and anxiety.

Aisbett, B. Living with it; a suvivor’s guide to panic attacks. Pymble, NSW. HarperCollinsPublishers, 1993.

Aisbett, B.Taming the black dog. Pymble, NSW. HarperCollinsPublishers, 2000.

Calrk, S. After suicide: help for the bereaved. Melbourne. Hill of Content Publishing Company Pty Ltd, 1995.

   

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