Social Determinants - Understanding their Relevance to Suicide Prevention Initiatives

Suicide Prevention - Understanding the Impact of Social Determinants

A summation of risk factors, the pathway to suicide and protective factors

Authors: Adjunct Professor John Mendoza and Marion Wands, ConNetica Directors

Some thoughts to ponder in relation to how we view and address suicide prevention initiatives.

 Once we recognize that suicide is not exclusively a “scientific problem” we will be in a much better position to recognize its moral, political and cultural dimensions and develop prevention approaches that reflect this complexity.

 Professor Jennifer White, Vancouver Island, BC Canada, 2011

While a suicide attempt is a moment in time, it is part of an episode of living (and maybe dying). The episode continues after the attempt. Put another way, attempting suicide is a punctuation mark; it is not the story!

Eric D. Caine, MD – “Looking beyond ‘Risk Factors’ in the evaluation of people who are seriously suicidal”. Plenary presentation, IASP World Congress, Beijing, September 2011 

If you always do what you’ve always done, you always get what you’ve always gotten.

Jessie Potter featured speaker at opening of the 7th Annual Woman to Woman conference 1932. 

Although there have been many advances in understanding suicide risk in recent decades, our ability to predict suicide is no better now than it was 50 years ago. There are many potential explanations for this lack of progress, but the absence, until recently, of comprehensive theoretical models that predict the emergence of suicidal ideation distinct from the transition between suicidal ideation and suicide attempts/suicide is key to this lack of progress. 


Professors Rory O’Connor & Olivia Kirtley, 2018

1       Suicide and Suicide Prevention Knowledge - Key Points

Introduction to Suicide and Intentional Self Harm 

1.     Suicide is a preventable cause of death.

2.     Suicide is a complex, multifaceted and dynamic phenomenon.

3.     Suicide is a response to overwhelming conditions, both personal and contextual. 

4.     Suicide prevention and self-harm mitigation is a global public health priority.

5.     Despite the increase in the development and publication of suicide prevention strategies, suicide rates remain stagnant or continue to rise in most developed nations.

6.     Self-harm should be seen as a distinct behaviour from suicide, though the two may co-occur. Intentional self-harm is deliberate injury of body tissue without suicidal intent. 

7.     Stigma can be reinforced, often unintentionally, through language and thus acts as a barrier to prevention and help seeking behaviours.

Risk Factors and Social Determinants

8.     Risk factors are made up of distal factors (e.g. impulsivity) and proximal factors (e.g. negative life events). Most often a combination of risk factors contributes to the onset of suicidal thinking and behaviour (STB).

9.     Risk factors which may pre-dispose an individual to STB include: mental illness; stigma; adverse childhood experiences; adverse life events such as job loss, financial difficulties, abuse; living in rural and remote geographical locations, low levels of educational attainment and occupational status; men, discrimination due to one’s race, culture, sexual expression and neurological-genetic factors.

10.  Levels of mental distress among communities need to be understood less in terms of individual pathology and more as a response to relative deprivation and social injustice, which erode the emotional, spiritual and intellectual resources essential to psychological wellbeing (Wilkinson 1997; Pickett 2006; WHO Europe 2009). 

11.  Recent research emphasises it is not poverty per se, but relative disadvantage that impacts adversely on the mental wellbeing of individuals, families and small communities that have fewer economic, social and environmental resources.   

Indigenous Suicide

12.  The rate of suicide among Indigenous Australians is consistently double the rate for non-indigenous Australians and in some regions (such as Kimberley region of Western Australia) much higher.

13.  Indigeneity’ itself is not a risk factor for suicide, but the effects of colonisation, developed over time, contribute to significantly higher rates of suicide within Indigenous populations across the globe.

14.  Indigenous suicide rates have increased since 2000 with a marked rise among youth and females.

15.  The complex erosion of culture, happening steadily over time, necessitates culturally specific and sensitive approaches to suicide prevention that go deeper than gatekeeper training, and promote and empower Indigenous communities.

Pathways to Suicide and Self Harm

16.  Risk factors for suicide can be related to individual, social and contextual variables, for which there is no clear ‘check list’ to determine whether an individual is likely to die by suicide.

17.  An ideation-to-action framework represents an emerging paradigm that can explain the progression from consideration of suicide (based on an accumulation of risk factors) to the behaviour of suicide. (Diagram One)

An Analysis of Protective Factors, including quality care

18.  Resilience plays a key role in maintaining mental wellbeing, particularly in response to adverse life events and traumatic experiences. Resilience is a process, rather than a personality trait. It requires thoughts, actions and behaviours that can be learned and developed

19.  Social connection has been found to play a key role in increased life expectancy and resilience

20.  Digital technologies present another area of innovation which includes the development and use of online and mobile technologies to promote self-agency, mental wellbeing, prevent suicide, monitor emotional states, intervene in a crisis, clearer pathways to care and provide postvention support.

21.  Provision of and access to quality mental health care, that is integrated and includes cross-sector health and community professions working together to deliver care in a non-stigmatised and respectful manner such as 24-hour crisis care, assertive outreach, 7-day follow up front line clinical staff training have been shown to reduce suicide rates

Suicide Prevention Strategies

22.  The three most effective SPS are reported to be reducing access to lethal means, the continuation of contact with persons discharged from acute mental health, and implementation of emergency call centres

23.  The only intervention to have shown, through RTCs, a statistical significant reduction in deaths by suicide among adults, is the WHO Brief Intervention and Contact. 

24.  Multi-level, complex interventions seek to promote individual, family and community connectedness

25.  Multi-level prevention programs should focus on both those at the lower risk spectrum, to those who may be considered high risk for suicidal behaviour

Assessing Suicide Risk

26.  Assessing suicide risk using standardised measurement is complex

27.  Evidence suggests that screening for suicide risk in adolescent and adult populations, and with psychiatric inpatient populations provide very little clinical benefit

28.  Simple checklists should be cautioned against, particularly given the complexity of suicide risk

29.  An open dialogue and flexible approach based on motivational theory for uncovering suicidal ideation and intent has been suggested as an effective screening mechanism

30.  Risk assessment during discharge from ED and acute care is critical, particularly as suicide risk is greatest 30 days after discharge from hospital          

Responding to Suicide and Self Harm

31.  Postvention is the active response and support provided to an individual after attempting suicide, and to those close to someone who has died by suicide

32.  There are several approaches to postvention including home visits, regular phone calls and sending regular contact, such as postcards to individuals who have attempted suicide and outreach services for those bereaved by suicide

33.  An emerging space is that of digital postvention pathways including online and mobile applications to actively support someone after a suicide attempt. 

2       The Integrated Wellbeing-Motivation-Action Model

This model takes account of the developments in understanding the personal and contextual journey from wellbeing to suicidal behaviour and the evidence on systems approaches to suicide prevention. It represents the next generation of suicidal behaviour models based on the ideation to action framework and three-step theory of suicide and attempts to more clearly distinguish between the development of suicidal thinking and the factors that govern behavioural enactment (O’Connor & Kirtley, 2018; Klonsky & May 2015; Joiner, 2005). The model presented here adds the wellbeing dimension and incorporates the theory and evidence on developing wellbeing, social connection and resilience.

Theoretical models can inform prevention and intervention development. It is important to develop services and interventions which target:

·       Primary prevention - development of resilience, self-efficacy, meaning and purpose and social connectedness (the wellbeing phase)

·       Secondary prevention - addressing the background or predisposing factors and predisposing negative events through eliminating or ameliorating their presence and/or impact (the pre-motivational phase)

·       Early intervention – to respond to the emergence of suicidal thinking and behavioural intention formulation (the motivational phase)

·       Crisis Intervention – to respond and intervene at the behavioural intention–behaviour gap (the action or volitional phase).



3       Local Community Responses to Suicide Prevention

1.    Why - Conversations for life and Stronger Smarter Yarns for life

Developing the Capacity of People to Engage in Conversations around Wellbeing 

Engaging new players and new settings in early suicide prevention work. These are the ‘human touch points’ within the community where people are more likely to have an ongoing relationship and experiences of distress will be noticeable to others. These settings include a diverse range of settings such as local councils, community pharmacies, public libraries and parks, schools, rail stations, shopping malls, pubs and clubs, gambling venues, rental property agencies, banks and financial service providers and hairdressers. Training in early suicide prevention has been shown to be valued and effective for many of these settings. 

Conversations for life and Stronger Smarter Yarns for life are 2 evidence based early suicide prevention programs that are demonstrating significant increases in participants’ skills, willingness and confidence to support individuals who are becoming vulnerable. These programs were developed to fill a need in Australia for culturally appropriate, educationally sound, concise and tailorable suicide prevention training programs, that shift the dial to early prevention and provide participants with the skills to be ready, willing and able to have a conversation with people who are becoming vulnerable. Independent evaluations by ANU demonstrate significant increases in knowledge, skills and willingness to have these conversations and yarns,


2.    A Community Mental Health Campaign

The Act-Belong-Commit Campaign is a ready, proven mental health campaign that can be ‘franchised’ across the region. This program provides a framework for implementing a range of mentally healthy activities. A full range of social marketing materials, training manuals, evaluation tools, supported by the team at Curtin University are available ( Costs are minimal and the evidence demonstrating improved outcomes is significant.




Afifi TO, et al. (2016). Association of child abuse exposure with suicidal ideation, suicide plans, and suicide attempts in military personnel and the general population in Canada. JAMA psychiatry73(3): 229-238.

Aleman, A. and D. Denys (2014). A road map for suicide research and prevention. Nature 509(7501): 421-423.

Andriessen K. (2014). Suicide bereavement and postvention in major suicidology journals. Crisis35: 338-348.

Anwar-McHenry J, Donovan RJ, Jalleh G & Laws A. (2012) Impact evaluation of the Act-Belong-Commit mental health promotion campaign, J of Public Mental Health, 11(4): 186-194. 

Arabena, K. 2014, The ‘First 1,000 Days’: Implementing Strategies across Victorian Government Agencies to Improve the Health and Wellbeing Outcomes for Aboriginal Children and their Families. Indigenous Health Equity Unit, The University of Melbourne, Melbourne

Arensman E, et al. (2016). Effectiveness of Depression–Suicidal Behaviour Gatekeeper Training among police officers in three European regions: Outcomes of the Optimising Suicide Prevention Programmes and Their Implementation in Europe (OSPI-Europe) study. Int J of Social Psychiatry62(7): 651-660.

Australasian College for Emergency Medicine. The long wait: An analysis of mental health presentations to Australian emergency departments. ACEM: Melbourne; 2018.

Awan S, et al. (2015). Integrated Care Pathway (ICP), an Inter-professional Outline of Evidence Informed Care in Mental Health and Addictions: an Innovative Treatment Approach From Concept to Results. European Psychiatry30(Supplement 1): 1934.

Barnes MC, Donovan JL, Wilson C, et al. (2017). Seeking help in times of economic hardship: access, experiences of services and unmet need. BMC Psychiatry17:84.

Barnes MC, Gunnell D, Davies R, et al. (2016). Understanding vulnerability to self-harm in times of economic hardship and austerity: a qualitative study. BMJ Open;6:e010131.

Bender TW, et al. (2012). Affective and behavioral paths toward the acquired capacity for suicide. Journal of Social and Clinical Psychology31(1): 81-100.

Bennett M. (2009). Neuropsychiatry of Suicidal Diathesis: Submission to the Senate Community Affairs Committee Inquiry into Suicide in Australia. Canberra, Commonwealth of Australia.

Bennett M. (2009). Stress and anxiety in schizophrenia and depression: glucocorticoids, corticotropin–releasing hormone and synapse regression. ANZ Journal of Psychiatry42: 995-1002.

Beyondblue. Way Back Support Service. Retrieved from:  

Bickley H, Hunt IM, Windfuhr K, Shaw J, Appleby L & Kapur N. (2013). Suicide within two weeks of discharge from psychiatric inpatient care: A case-control study. Psychiatric Services, 64(7), 653–659. 

Blakely TA, et al. (2003). Unemployment and suicide. Evidence for a causal association? Journal of Epidemiology and Community Health57(8): 594-600.

Brodsky BS. (2016). Early childhood environment and genetic interactions: the diathesis for suicidal behavior. Current Psychiatry Reports; 18(9): 86.

Burns J & Blanchard M. (2014). International Literature Review on Mental Wellbeing & Resilience Relating to Young People and Communities: A report to VicHealth. Melbourne, Young and Well CRC.

Burón P, et al. (2016). Reasons for attempted suicide in Europe: prevalence, associated factors, and risk of repetition. Archives of Suicide Research20(1): 45-58.

Caldbick S, et al. (2014). Globalization and the rise of precarious employment: the new frontier for workplace health promotion. Global Health Promotion 21(2): 23-31.

Capoccia L & Labre M. (2015). Caring for Adult Patients With Suicide Risk: A Consensus-Based Guide for ED.Waltham, MA, Suicide Prevention Resource Center.

Centres for Disease Control and Injury Prevention (2016). About the CDC-Kaiser ACE Study. Retrieved from 

Chang S-S, et al. (2013). Impact of 2008 global economic crisis on suicide: time trend study in 54 countries. BMJ; 347.

Coffey M & Coffey C. (2016). NEJM catalyst: How we dramatically reduced suicide. Retrieved from http://  

Collings S, Jenkin G, Stanley J, McKenzie S & Hatcher S. (2018). Preventing suicidal behaviours with a multilevel intervention: a cluster randomised controlled trial. BMC Public Health; 18:140. DOI 10.1186/s12889-018-5032-6 

Comans T, et al. (2013). Cost effectiveness of a community-based crisis intervention program for people bereaved by suicide. Crisis34: 390-397.

Comiford AL, et al. (2016). Predictors of intimate partner problem-related suicides among suicide decedents in Kentucky. Journal of injury & violence research8(2).

Coope C, et al. (2015). Characteristics of people dying by suicide after job loss, financial difficulties and other economic stressors during a period of recession (2010–2011): A review of coroners׳ records. J of Affective Disorders183: 98-105.

Cooper S, Lezotte D, Jacobellis J & DiGuiseppi C (2006). Does availability of mental health resources prevent recurrent suicidal behaviour? An ecological analysis. Suicide & Life-Threatening Beh: 36(4); 409-417. 

Darvishi N, et al. (2015). Alcohol-related risk of suicidal ideation, suicide attempt, and completed suicide: a meta-analysis. PLoS One10(5): e0126870.

Donovan RJ, Henley N, Jalleh G, Silburn S, Zubrick S & Williams A. (2006a). ‘The impact on mental health in others of those in a position of authority: a perspective of parents, teachers, trainers and supervisors. Aus eJournal for the Advancement of Mental Health, 5(1). 

Donovan, RJ, James R, Jalleh G & Sidebottom C. (2006b). Implementing mental health promotion: the Act-Belong-Commit Mentally Healthy WA campaign in WA. Int J of Mental Health Promotion; 8(1): 33-42. 

Donovan, RJ, James R & Jalleh G (2007). Community-based social marketing to promote positive mental health: the Act-Belong-Commit campaign in rural WA. in Hastings, G. (Ed.), Social Marketing: Why Should the Devil Have all the Best Tunes?, Butterworth Heinemann, London, pp. 336-43. 

Donovan RJ, Watson N, Henley N, Williams A, Silburn S, Zubrick S, Cross D, Hamilton G, Roberts C & James R. (2003). Mental Health Promotion Scoping Project: Report to Healthway, Centre for Behavioural Research in Cancer Control, Curtin University. 

Donovan R. (2018). Act-Belong-Commit: A framework for suicide prevention. Presentation at Shifting the Dial, Noosa, Qld. May 2018. 

Dudgeon P, Milroy J, Calma T, et al (2016). SOLUTIONS THAT WORK: WHAT THE EVIDENCE AND OUR PEOPLE TELL US.Aboriginal and Torres Strait Islander Suicide Prevention Evaluation Project Report. University of WA, Perth. 

Duffy S and Gillberg C (2018). Extreme poverty in a time of austerity. Submission to UN Special rapporteur on Extreme Poverty and Human Rights. Centre for Welfare Reform, UK. Available at 

Dufort M, et al. (2015). Physical domestic violence exposure is highly associated with suicidal attempts in both women and men. Results from the national public health survey in Sweden. The European Journal of Public Health25(3): 413-418.

Ellis TE, Rufino, KA, Allen JG, Fowler JC & Jobes DA. (2015). Impact of a suicide-specific intervention within inpatient psychiatric Care: The collaborative assessment and management of suicidality (CAMS). Suicide and Life-Threatening Behavior.

Flamenbaum R & Holden R. (2007). Psychache as a mediator in the relationship between perfectionism and suicidality. J of Counseling Psychology54(1): 51.

Flatau, P., et al. (2015). The Australian youth homeless experience: Evidence from a longitudinal survey of homeless youth. Parity28(3): 4.

Flett GL, et al. (2016). Perfectionism, worry, and rumination in health and mental health: A review and a conceptual framework for a cognitive theory of perfectionism. Perfectionism, health, and well-being, Springer121-155.

Fleuy M-J, Grenier G, Vallee C, et al. (2016) Implementation of the Quebec mental health reform (2005-2015). BMC Health Services res. 16:586 

Fliege H, et al. (2009). Risk factors and correlates of deliberate self-harm behavior: A systematic review. J of psychosomatic research66(6): 477-493. 

Foster, T. (2011) Adverse life events proximal to adult suicide: a synthesis of findings from psychological autopsy studies. Archives of Suicide Research; 15(1):1-15. 

Franklin JC, et al. (2016). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin143(2): 187-232.

Fuller‐Thomson E, et al. (2016). The association between adverse childhood experiences (ACEs) and suicide attempts in a population‐based study. Child: Care, Health & Dev’t42(5): 725-734.

Glowinski AL, et al. (2001). "Suicide attempts in an adolescent female twin sample. J of the Amer Academy of Child & Adolescent Psychiatry 40(11): 1300-1307.

Goldfeld S, Villanueva K, Tanton R, et al. (2017). Kids in Communities Study (KiCS) study protocol: a cross-sectional mixed-methods approach to measuring community- level factors influencing early child development in Australia. BMJ Open, Vol. 7 

Harris FM, Maxwell M, O’Connor RC, Coyne J, Arensman E, et al. (2013). Developing social capital in implementing a complex intervention: A process evaluation of the early implementation of a suicide prevention intervention in four European countries. BMC Public Health:13, 158. 

Haw C & Hawton K. (2015). Suicide is a complex behaviour in which mental disorder usually plays a central role. ANZ J of Psychiatry49(1): 13-15.

Hawton K, et al. (2003). Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital.British Journal of Psychiatry182(6): 537-542.

Hegerl U, Althaus, D, Schmidtke A, Niklewski G. (2006). The alliance against depression: 2-year evaluation of a community-based intervention to reduce suicidality. Psychol. Med:36, 1225–1233 

Hegerl U, et al. (2009). "Optimizing suicide prevention programs and their implementation in Europe (OSPI Europe): an evidence-based multi-level approach." BMC Public Health 9(1): 428.

Hegerl U, Rummel-Kluge C, Värnik A, Arensman E, Koburger N. (2013) Alliances against Depression - A community based approach to target depression and to prevent suicidal behaviour. Neurosci. Biobehav. Rev: 37, 2404–2409 

Hill NT, Halliday L & Reavley NJ. (2017). Guidelines for integrated suicide-related crisis and follow-up care in Emergency Departments and other acute settings. Sydney, Black Dog Institute.

Hollingshead AB & Redlich FC. (1958). Social class and mental illness: Community study.Hoboken, NJ, John Wiley and Sons Inc.

Holt-Lunstad J, et al. (2015). Loneliness and social isolation as risk factors for mortality a meta-analytic review. Perspectives on Psychological Science;10(2): 227-237.

Insel, T. (2016). Making Mental Health Care Effective. Charles Perkins Centre, University of Sydney.

Iorfino J,Davenport TA, Ospina-Pinillos L, Hermens DF, Cross S, Burns J, Hickie IB. (2017). Using New and Emerging Technologies to Identify and Respond to Suicidality Among Help-Seeking Young People: A Cross-Sectional Study. J Med Internet Res: 19(7):e247.

Isohookana R, et al. (2013). Adverse childhood experiences and suicidal behavior of adolescent psychiatric inpatients. European Child & Adolescent Psychiatry22(1): 13-22.

Jayasuriya D, Jayasuriya R, Tay AK & Silove D. (2016). Associations of mental distress with residency in conflict zones, ethnic minority status, and potentially modifiable social factors following conflict in Sri Lanka: a nationwide cross-sectional study. The Lancet Psychiatry, 3(2), 145–153. 

Jobes DA, Wong SA, Conrad A, Drozd JF & Neal-Walden T. (2005). The collaborative assessment and management of suicidality vs. treatment as usual: A retrospective study with suicidal outpatients. Suicide and Life-Threatening Behavior,35, 483-497.

Johnson S. (2013). Crisis resolution and home treatment teams: an evolving model. Advances in psychiatrictreatment19(2): 115-123.

Joiner TE, et al. (2005). The psychology and neurobiology of suicidal behavior. Annu Rev Psychol56: 287-314.

Kapur N, et al. (2016). Mental health service changes, organisational factors, and patient suicide in England in 1997–2012: a before-and-after study. The Lancet Psychiatry3(6): 526-534.

Karatsoreos IN. & McEwen B. (2013). Annual research review: the neurobiology and physiology of resilience and adaptation across the life course. J of child psychology & psychiatry54(4): 337-347.

Kessler R, et al. (2016). "Predicting suicides after outpatient mental health visits in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)." Molecular psychiatry.

Keyes CL. (2007). Promoting and protecting mental health as flourishing: a complementary strategy for improving national mental health. American Psychologist62(2): 95.

Klonsky ED. (2007). The functions of deliberate self-injury: A review of the evidence. Clinical psychology review27(2): 226-239.

Klonsky ED & May AM. (2015). The three-step theory (3ST): A new theory of suicide rooted in the “ideation-to-action” framework. International Journal of Cognitive Therapy8(2): 114-129.

Klonsky, ED, et al. (2016). Suicide, suicide attempts, and suicidal ideation. Annual review of clinical psychology12: 307-330.

Klonsky, E. D., et al. (2003). Deliberate self-harm in a nonclinical population: Prevalence and psychological correlates. American Journal of Psychiatry160(8): 1501-1508.

Langner TS & Michael ST. (1963). Life stress and mental health: II. The midtown Manhattan study. Oxford, England, Free Press Glencoe.

Lloyd-Evans B, Fullarton K, Lamb D, Johnston E …., Johnson S. (2016). The CORE Service Improvement Programme for mental health crisis resolution teams: study protocol for a cluster-randomised controlled trial. Trials; 17:158. DOI 10.1186/s13063-016-1283-7 

Lockett P, Mendoza J & Davenport T. (2014). Mid-term review of the Northern Adelaide Local Health Network, Community Walk-in Service. Retrieved from SA Health: Adelaide

Marmot M. (2015). The Health Gap. London: Bloomsbury.

Marmot  M. (2017). Inclusion health: Addresses the causes of the causes. The Lancet.  

Martin G & Page A. (2009). National Suicide Prevention Strategies: A Comparison. Brisbane, Queensland, Centre for Suicide Prevention Studies, Discipline of Psychiatry.

Martin J. 2017. Presentation on Qld Health Initiatives for mental health consumers and ED. AISRAP.

Matsubayashi T & Ueda M. (2011). The effect of national suicide prevention programs on suicide rates in 21 OECD nations. Social science & medicine;73(9): 1395-1400.

Mendoza JA, Hickie IB, & Bell T (2016). Analysis of suicide by 28 Federal Electorates, 2008-12. Media releases May 24, 2016.  

Mendoza JA, Harvey S & Wands M. (2015). One system, one team: Hospital transitions pathways project - final report. Brisbane North PHN, Qld.

Mendoza JA, Rosenberg S & Visser V. (2010). : Breaking the Silence: Suicide and Suicide Prevention in Australia.Caloundra, QLD, ConNetica Consulting.

Mental Health Council of Australia (2006). Weaving the Net: Deakin, ACT.

Milner, AJ, et al. (2013). Treatment priority for suicide ideation and behaviours at an Australian emergency department. World journal of psychiatry3(2): 34.

Milner, AJ, et al. (2016). The effectiveness of suicide prevention delivered by GPs: A systematic review and meta-analysis. Journal of Affective Disorders210: 294-302.

Milner, AJ, et al. (2015). Occupational class differences in suicide: evidence of changes over time and during the global financial crisis in Australia. BMC psychiatry15(1): 223.

Mrazek P & Haggerty R (1994). Institute of Medicine Committee on Prevention of Mental Disorders. Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research, Washington, DC.

Mueller AS & Abrutyn S. (2016). Adolescents under pressure: a new Durkheimian framework for understanding adolescent suicide in a cohesive community. Amer Sociological Review81(5): 877-899.

Murphy AL, Ataya R et al. (2018). Community pharmacists’ experiences and people at risk of suicide in Canada and Australia: a thematic analysis. Social Psychiatry & Psychiatric Epi.

Nasir B, Hides L, et al (2016). The need for a culturally-tailored gatekeeper training intervention program in preventing suicide among Indigenous peoples: a systematic review. BMC Psychiat, 16:357

National Action Alliance for Suicide Prevention: Transforming Health Systems Initiative Working Group (2018). Recommended standard care for people with suicide risk: Making health acre suicide safe. Washington, DC: Education Development Centre, Inc. 

Nock MK, et al. (2016). Risk factors for suicide ideation differ from those for the transition to suicide attempt: The importance of creativity, rigor, and urgency in suicide research. Clin Psychology: Science & Prac 23(1): 31-34.

Noël F, et al. (2016). A longitudinal study of suicidal ideation among homeless, mentally ill individuals. Social psychiatry and psychiatric epidemiology 51(1): 107-114.

Nordentoft M, Mortensen PB, Pedersen CB. (2011) Absolute risk of suicide after first hospital contact in mental disorder. Journal of Psychiatry; 68(10):1058-64. 

O'Connor E, et al. (2013). Screening for and treatment of suicide risk relevant to primary care: a systematic review for the US Preventive Services Task Force. Annals of internal medicine 158(10): 741-754.

O’Connor RC. (2011). The integrated motivational-volitional model of suicidal behavior, Hogrefe Publishing.

O’Connor RC, Kirtley OJ. 2018 The integrated motivational–volitional model of suicidal behaviour. Phil. Trans. R. Soc. B373: 20170268. 

Page A, Atkinson JA, Heffernan M, et al. (2017) A decision-support tool to inform Australian strategies for preventing suicide and suicidal behaviour. Public Health Research & Practice27: 2721717. 

Patel V, Burns JK, et al (2018). Income inequality and depression: a systematic review and meta analysis of the association and a scoping review of mechanisms. World Pstychiatry17:1; 76-89

Paton F, et al. (2016). Improving outcomes for people in mental health crisis: a rapid synthesis of the evidence for available models of care. Health Technology Assessment: 20(3).

Plener PL, et al. (2015). The longitudinal course of non-suicidal self-injury and deliberate self-harm: a systematic review of the literature. Borderline personality disorder & emotion dysregulation2(1).

Pompili M. (2018). The increase in suicide rates: the need for a paradigm shift. The Lancet, 392, 474-5. 

Portes A & Vickstrom E. (2011). Diversity, social capital, and cohesion. Ann Rev Sociology37: 461-79.

Santini Z, Nielsen L, et al. (2018). Act-Belong-Commit Indicators Promote Mental Health and Wellbeing among Irish Older Adults. American journal of health behavior.42. 31-45.

Shattell M, Harris B, et al. (2014) A Recovery- Oriented Alternative to Hospital Emergency Departments for Persons in Emotional Distress: “The Living Room”, Issues in Mental Health Nursing, 35:1, 4-12.

Shea SC. (2016). Exploring suicidal ideation: the delicate art of suicide assessment. In: Psychiatric Interviewing: The Art of Understanding, 3rd Edition. London, United Kingdom: Elsevier; 683-761

Tatz C (1999). 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.Sydney Macquarie University. 

Tran T, et al. (2013). An integrated framework for suicide risk prediction.Proceedings of the 19th ACM SIGKDD international conference on Knowledge Discovery and Data Mining, ACM

Turecki G. (2016). Epigenetics.Understanding Suicide: From Diagnosis to Personalized Treatment. P. Courtet. Cham, Springer International Publishing:97-110.

van Heeringen K. (2012). Stress-diathesis model of suicidal behavior. The neurobiological basis of suicide; 51: 113.

Van Orden K, et al. (2010). The interpersonal theory of suicide. Psychological review;117(2): 575.

Wasserman D, Hoven CW, et al. (2015)School-based suicide prevention programmes: the SEYLE cluster-randomised, controlled trial. Lancet

Wexler L, et al. (2015). Why an alternative to suicide prevention gatekeeper training is needed for rural Indigenous communities: presenting an empowering community storytelling approach. Critical Public Health;25(2): 205-217.

Wheeler C, Lloyd-Evans, B. et al. (2015). Implementation of the Crisis Resolution Team model in adult mental health settings: a systematic review. BMC Psychiatry15:74 DOI 10.1186/s12888-015-0441-x  

While D, Bickley H, Roscoe A, Windfuhr K, Rahman S, et al. (2012). Implementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: A cross-sectional and before-and-after observational study. The Lancet, 379(9820), 1005-1012.

Wilhelm K, Korczak V, Tietze T & Reddy P. (2016). Clinical pathways for suicidality in emergency settings: A public health priority. Australian health review. 41. 10.1071/AH16008.

Wilkinson RG. (1997). Commentary: Income inequality summarises the health burden of individual relative deprivation. BMJ;314(7096): 1727.

Zalsman G, et al. (2016). Suicide prevention strategies revisited: 10-year systematic review. The Lancet Psychiatry3(7): 646-659.

Zalsman G, Hawton K, Wasserman D, et al. (2017).  Evidence-Based National Suicide Prevention Taskforce in Europe: A Consensus Position PaperEur.Neuropsychopharmacol, 27, 418-421.