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.
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, www.connetica.com.au.
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 (https://www.actbelongcommit.org.au). Costs are minimal and the evidence demonstrating improved outcomes is significant.
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