CHAPTER 7
SUICIDE RESEARCH
Introduction
7.1
This chapter will deal with term of reference (g) the adequacy of the
current program of research into suicide and suicide prevention, and the manner
in which findings are disseminated to practitioners and incorporated into
government policy.
NSPS suicide research
7.2
DoHA outlined three research projects which the Commonwealth Government
had provided funding towards:
- the WHO Suicide Trends in At-Risk Territories study from 2008
-2010 to investigative preventative interventions across various countries,
cultures and population sub groups within the Asia-Pacific region;
-
University of Sydney case-control studies of suicides and
attempted suicide in young adults in NSW commenced under a National Health and
Medical Research Council (NHMRC) project grant; and
- the completed Australian National Epidemiological Study of
Self-Injury project which aimed to determine the prevalence and nature of
self-injury amongst the Australian population.[1]
7.3
In 2008 AISRP at Griffith University became a National Centre of
Excellence in Suicide Prevention (NCESP) under the NSPS.
The purpose of the NCESP is to:
- provide advice on evidence‐based
best practice suicide prevention activity to inform the NSPP workplan,
commencing with the ATAPS program, but also in relation to other activity, such
as population health approaches to suicide prevention through school‐based activity;
- offer direct support to agencies contracted by DoHA to undertake
new and emerging suicide prevention activities, particularly where this
pertains to selective interventions to individuals who have attempted suicide
or self‐harm;
- provide a quarterly critical literature review outlining recent
advances and promising developments in research in suicide prevention,
particularly where this can help to inform national activities;
- provide advice on improving approaches to evaluation of suicide
prevention activities and on the development of evaluation frameworks for new
projects, such as the ATAPS suicide prevention project and other identified
areas of the NSPS workplans; and
- provide advice on the implications of existing suicide prevention
data and on issues around the credibility of suicide data.[2]
A focus on the evaluation of interventions
7.4
A number of the main suicide prevention organisations and others
emphasised that Australia currently did not have a set of priorities for
research into suicide and no systemic process for developing research
priorities. Many submitters cited an article in Crisis: Journal of Crisis
Intervention & Suicide which examined research priorities in suicide
prevention in Australia. This article concluded:
Well-conducted intervention studies are necessary to inform
the suite of suicide prevention activities to be undertaken under the LIFE
Framework. At present, we know very little about what works and what doesn’t
work in suicide prevention.
Given the limited knowledge regarding which interventions might
be efficacious, it would seem reasonable for attention to be paid to studies
that assess the efficacy of the full spectrum of suicide prevention
interventions (universal, selective, and indicated) and/or evaluate suicide prevention
policies, programs, and services.[3]
7.5
This study of suicide prevention research also supported equal focus be
placed on research into both suicide and attempted suicide. In relation to
target groups for research it stated that young people were the most commonly
researched and prioritised, as well as those with mental health problems and
those who have attempted suicide and self harm. However it argued:
It would seem premature, however, to prioritise only these
groups over others, particularly since, as noted above, we know so little about
what works and what doesn't work in terms of suicide prevention for any
target group.[4]
7.6
The Crisis article reflects an earlier international systematic
review of suicide interventions in 2005 which could only identify two
prevention strategies for which there was evidence of effectiveness: educating
physicians to detect, diagnose and manage depression and restricting access to
lethal methods of suicide. The review did not reject other strategies as
ineffective but found these interventions need more evidence of efficacy.[5]
7.7
The focus on the evaluations of interventions was widely supported. For
example Lifeline Australia stated that in its experience there does not appear
to be a mechanism to assess the efficacy of trials/pilot programs and if these
should be implemented nationally as a sustainable funded service. Similarly SPA
noted:
...Australia’s suicide and suicide prevention research agenda
should more effectively emphasise and adopt the principle and practice of
evaluations of specific suicide-related interventions, policies, programs and
services.[6]
7.8
The MHCA argued:
Unless measures are put in place to ensure that programs and
policies are working, we will continue to see precious resources going to
antiquated systems and failed programs; programs that have failed for many
years to make significant inroads in reducing suicide rates, especially in high
risk groups and communities. [7]
7.9
However there appeared to have been a lack of such evaluations of
suicide prevention activities in the previous years. Associate Professor Jane
Pirkis outlined research undertaken which reviewed the 156 projects funded
under the original NSPS. While the organisations which received funding for
these projects were contractually obligated to evaluate '...in practice the
evaluations were methodologically too weak to contribute much to the evidence
base regarding what works and what doesn't work in suicide prevention'.[8]
Similarly AISRP highlighted that despite a broad range of programs funded by
the Commonwealth and States only 60 per cent included an effectiveness
evaluation component and none of those evaluated the impact of the
interventions on the actual suicide rate.[9]
Difficulties assessing suicide
interventions
7.10
It was acknowledged during the inquiry that evaluations of the
effectiveness of suicide prevention inventions and initiative posed a numbers
problems for researchers. For example Orygen Youth Health Research Centre
stated that while suicide and its associated sequelae represent a significant
health problem it is a rare event '... which means that large numbers of
participants are required for intervention studies to have sufficient power to
enable meaningful conclusions to be drawn'. They suggested suicide research
would benefit from the development of research networks which would facilitate
the development of multi-site studies.[10]
7.11
Associate Professor Jane Pirkis also described the problems for researchers
seeking to evaluate suicide interventions. Suicide prevention activities are
usually not amenable to the 'gold standard' of randomised control trials. She
argued that there needed to be recognition that '... some interventions, by their
very nature, will not be amenable to randomised controlled trials but that we
must apply the most rigorous designs that we can'.[11]
AISRP also suggested that while controlled randomised trials were not always
feasible in the domain of suicide prevention research '...other sound evaluation
designs could be used, e.g. quasiexperimental designs using control groups'.[12]
7.12
The ethical issues of researching suicide prevention were also raised.
The Suicide is Preventable submission stated that ethics committee approval
processes would generally prohibit research involving any person who may be demonstrating
suicidal behaviour.[13]
SPA emphasised there was a paucity of evidence regarding what interventions
work in suicide prevention but also noted these studies were difficult to
complete. They commented:
Ethical concerns arise with recruiting actively suicidal
participants to intervention studies (e.g. antidepressant pharmacotherapy,
psychotherapy) or alternatively excluding them from interventions... There are
also major statistical problems with demonstrating a reduction of suicide,
though these are not insurmountable...[14]
Disseminating research
7.13
The LIFE Communications project delivered by Crisis Support Services
'...aims to improve the effectiveness of suicide and self‐harm prevention activities in Australia
by providing access to the latest information and shared learnings from the
NSPS in suicide prevention, intervention and postvention'.[15]
Components of the project include providing access to the LIFE suite of
resources and access to the latest information activities and resources in
suicide prevention. From June 2009 to September 2009, 674 hard copies of the
LIFE resource were distributed. Between June 2009 to October 2009 there were
over 16,300 visits to the LIFE website.[16]
7.14
However there were some concerns raised during the inquiry about the
dissemination of research. The Salvation Army had concerns that suicide
research information was '...not readily accessible to practitioners within the
health and welfare sectors'. They perceived a need to ensure that research was
'... synthesised and incorporated into salient messages disseminated through
mediums that will reach the front line staff who are working with people at
risk of suicide'.[17]
7.15
In the area of suicide prevention Dr Erminia Colucci argued there was
'too much separation between academia and services'.[18]
This was supported by Professor Colin Tatz who described the dissemination of suicide
research material was 'frankly, dismal' noting that '...lay people don't read
articles in Australasian Psychiatry; nor do many of the health
professionals, educators and community workers who seek to prevent suicide'.[19]
Psychotherapy and Counselling Federation of Australia members also reported
that current research was inadequate and hard to access.[20]
7.16
The Integrated Primary Mental Health Service of North East Victoria also
noted that statistical information about suicide is not routinely made
available for clinical staff within their own geographical environment and
contexts. They commented:
As a service, we are often frustrated with a lack of clarity
around accurate regional suicide statistics, and how to access them.... Improved dissemination
of these statistics would be immensely helpful in supporting our delivery of
evidenced-based mental healthcare.[21]
Resource Centre
7.17
Lifeline stated that 'Australia currently lacks a systematic formal
mechanism for identifying, enabling and communicating information about best
practice'. They proposed the creation of a best practice registry similar to
one currently operating in the United States, the Suicide Prevention Resource
Centre (SPRC).[22]
The SPRC was established in 2002 and '...supports suicide prevention with the
best of science, skills and practice to advance the United States National
Strategy for Suicide Prevention (NSSP)'. It includes a best practice registry
for suicide prevention to identify, review, and disseminate information about
best practices that address specific objectives of the NSSP.[23]
7.18
SPA also argued that in many cases the information distributed on ‘best
practice’ suicide prevention, intervention and postvention strategies is
outdated. They stated it was essential for ‘best practice’ standards and
accreditation for all service delivery and training. SPA recommended the
development of an independent suicide prevention accreditation and standards
agency 'to manage the accreditation and evaluation of suicide prevention service
delivery, training and programs'.[24]
Gaps in research
7.19
Several submissions which discussed specific groups who were at risk of
suicide also identified gaps in the research about these groups. For example, MHCA
noted that the research priorities study 'revealed that, of 209 published
journal articles and 26 funded grants undertaken between 1999 and 2006, none
specifically targeted CALD populations ... Only 2% of people conducting suicide
prevention research were identified as targeting CALD peoples.[25]
Similarly the Victorian Institute of Forensic Mental Health argued that while
there had been considerable research in suicide and prevention for prisoners in
the 1990s little attention had been given to this issue in the past decade.
They stated:
With the number of prisoners in Australia increasing at
unprecedented levels, it is vital that research into suicide and self harming
behaviour within the criminal justice system be conducted to inform Government
decision making. Specific issues in relation to women, the personality
disordered and people with a multi-cultural background are specific areas that
require close investigation.[26]
7.20
Ms Leonore Hanssens commented:
There is a dearth of research into suicide contagion and
clustering of suicides particularly in traditional Indigenous communities
across Australia. There appears to be a reluctance to investigate the suicide
deaths that are occurring in the Northern Territory particularly since the
rates of suicide have accelerating dramatically.[27]
7.21
SPA listed a number of gaps in suicide and suicide prevention research
including the coordination and communication between sectors and services to
prevent individuals 'falling through the gaps'. They suggested mapping these
gaps 'may assist in better addressing them...'. They also suggested research into
the lived experience from those affected by suicide and those who provide
services to them. [28]
7.22
A wide range of other potential research areas were identified by SPA
during community consultations including: the impact on professionals of
suicide by patients; vicarious trauma on first responders and others who work
closely with suicide; evaluations of completed suicide by persons refused
admission to psychiatric care and following hospital discharge; practices of
detention and seclusion within mental health facilities; inadequacies in
assessment and response to people at risk of suicide; effectiveness of
anti-depressants in suicide prevention; use of new media and internet in
suicide prevention; impact of global wide scale events such as the global
financial crisis; and the relationship between economic disadvantage and
suicide.[29]
7.23
AISRP proposed two specific research projects. The first a study to assess
the effectiveness of intensive case management on outcomes for suicidal psychiatric
patients in the post discharge period. The second was a model of treatment for
suicidal behaviour which offers an alternative to hospital-based care. The aim
of the 'Life House' project is to develop an alternative to hospital-based care
that can provide a comprehensive range of services (including community based
psycho-social rehabilitation) for individuals who are suicidal.[30]
Funding
7.24
Funding for research and evaluation of suicide prevention activities was
identified as coming from two sources. The first was Commonwealth, State and
Territory health departments which provide resources for internal or external
evaluation of particular suicide prevention activities they have funded. Associate
Professor Jane Pirkis commented:
Contracts awarded by health departments provide for
evaluations of a range of often large and complex initiatives, but the
evaluations tend to be constrained (e.g., the intervention is often well under
way by the time the evaluation is commissioned, making it difficult to gather baseline
information).[31]
7.25
The second source of research funding was academic granting bodies such
as the NHMRC and the Australian Research Council (ARC). Associate Professor
Jane Pirkis stated that grants from these organisations are
'...investigator-driven and peer reviewed, so they are typically very strong
methodologically, but the funding is usually limited so the interventions they
test tend to be fairly small in scale'.[32]
7.26
Prior to 2006 the scope of the NSPP did not allow funding of research
projects. DoHA commented that while 'the capacity for funding research directly
through the NSPP is limited, there are other sources of funding available to
support research into suicide prevention and related areas'. DoHA provided a
table summarising NHMRC funding of mental health, suicide and substance abuse.
This table indicated that the NHMRC research funding for suicide has fluctuated
but had not increased at the same level as research for mental health and
substance abuse. NHMRC mental health research funding had steadily increased
from $7.5 million in 2000-01 to $28.9 million in 2006-07. In contrast, funding
for suicide research was $0.96 million in 2000-01 and had fallen to $0.58
million by 2006-07.[33]
7.27
The Australasian Society for Psychiatric Research analysed previous
NHMRC research grants to determine the relative proportion of NHMRC funding
provided for research focusing on suicide prevention strategies. In 2010 they
found no NHMRC research grants for suicide prevention research and little
funding in previous years had been directed to suicide and its prevention (in either
project grants or fellowships). They recommended priority funding be set aside
for suicide in subsequent NHMRC rounds.[34]
7.28
RANZCP also highlighted that the NHMRC research expenditure on the issue
of suicide was considerably less than other social problems and diseases with
similar mortality rates such as breast cancer, skin cancer and road traffic
accidents.[35]
They recommended better collaboration between Commonwealth and State governments
to fund research into suicide prevention and the appointment of an expert body
to oversee all suicide prevention research linked to academic institutions. [36]
7.29
Professor Joan Ozanne-Smith commented that the current focus of
research, research funding and organisational committees and their structures
is on mental health. She noted '...people taking a different perspective have
been excluded from some of these national processes'.[37]
Dr Erminia Colucci also sought to bring the lack of specific funding for
suicide research to the attention of the Committee. She noted that suicide
researchers such as herself must apply for general mental health, community and
health promotion grants which give them '...little chance to ever get our hands
on these grants because other topics are usually favoured'.[38]
7.30
Other witnesses commented on the lack of funding for research centres
for suicide. Mr Sebastian Rosenberg from the BMRI contrasted the resources
available for alcohol and drug research to those available to research suicide:
...when it comes to comparing and contrasting developments in
the alcohol and drug sector, is this purposive investment in independent
research centres which are able to operate as an engine to gather and validate
information to inform public debate and to inform, frankly, public spending.
That makes a huge difference to being able to make astute decisions about what
works and what does not work in alcohol and drugs.[39]
7.31
Mr David Crosbie of the MHCA contrasted the federal funding of research
centres in relation to drugs and addiction. He stated:
We have a real lack of a bringing together of the researchers
who are trying to do work in this area and creating the kinds of economies of
scale and the kind of capacity that is needed to actually say what is happening
in mental health in this country at the moment.[40]
Conclusion
7.32
A consistent message that the Committee received during the inquiry was
that there is limited evidence regarding which suicide prevention interventions
are effective and consequently there is an urgent need for research in this
area. However many submissions and witnesses also acknowledged that the
evaluation of suicide prevention activities could be difficult and costly.
7.33
There does appear to be potential for Commonwealth, State and Territory
governments, together with national research funding organisations, academic
institutions and other organisations to cooperatively fund detailed evaluations
of suicide prevention interventions. However these opportunities to pool
funding for important research ultimately depend on the willingness of funding
partners to participate.
7.34
The Committee considers a simpler approach would be to include funding in
the NSPP for major evaluations of suicide prevention interventions. This would have
the potential of allowing these large scale assessments to be tied into the individual
project evaluations requirements which already exist for many projects funded
under the NSPP.
Recommendation 35
7.35 The Committee recommends that the Commonwealth government provide
funding in the National Suicide Prevention Program for research projects into
suicide prevention, including detailed evaluations of suicide prevention
intervention.
7.36
There was general agreement that the LIFE suite of resources and materials
were valuable for both suicide prevention researchers and service providers. However
some service providers and community organisations who worked 'at the coalface'
did not feel that research was being disseminated to them appropriately.
7.37
The Committee considers there is scope for the organisations which collect
and distribute suicide research in Australia to be more proactive in both
identifying research findings and then locating organisations and staff who may
benefit from that research. These organisations include: the Life
Communications project responsible for the LIFE suite of resources; the NCESP which
publishes the bi-annual suicide prevention literature review; SPA which
regularly creates position statements on aspects of suicide prevention; and the
ABS and NCIS which collect and record suicide statistics.
7.38
The Committee supports the Lifeline Australia recommendation for the
creation of a suicide prevention resource centre and best practice registry. In
particular the Committee considers the sector would benefit from a research
centre which would:
- function as source of reliable information for those seeking suicide
prevention services such as training;
- identify and list evidence-based suicide prevention practices and
programs, including community programs, training and service delivery;
-
offer guidance to people seeking to develop
and implement best practice activities;
- operate as a clearing house for collecting, listing and accessing
standards that meet professional consensus-based criteria for best practice;
- provide a forum where practitioners and researchers can
communicate and develop best practice in suicide prevention; and
- provide a forum for progressing research priorities in suicide
prevention.[41]
Recommendation 36
7.39 The Committee recommends the Commonwealth government, as part of the National
Suicide Prevention Strategy, create a suicide prevention resource centre to
collect and disseminate research and best practice regarding suicide
prevention.
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