Spring heralds a renewed focus on mental health outcomes

As Western Australia enters spring, and nature bursts into life with the pageantry of colour and growth that accompanies the season, it is somewhat paradoxical that the Australian Bureau of Statistics releases its annual Causes of Death report for the country, notes Dr Jon Pfaff, Senior Advisor – Mental Health (Clinical).

Colourful Western Australian wildflowers reflect the beauty of Spring and, for us, a renewed focus on mental health outcomes

Perhaps this is intentional, forcing us to reflect on the loss of that which is most dear to us – life itself – as the landscape heralds a new phase of renewal. For those of us working in mental health, and suicide prevention in particular, this report provides us with an annual outcome measure against which we are all striving to achieve – the downward trajectory of incidents of suicidal behaviour in our communities.

In 2020, Australia experienced its lowest rate of suicide (12.1 deaths per 100,000 people) since 2016. WA, similarly, recorded its lowest number of annual suicide-related deaths since 2016 and third lowest rate per capita in a decade (14.3 deaths per 100,000 people). While this downward shift is welcome news, particularly in the midst of a pandemic and the associated uncertainty that comes from it, one year of data does not define a trend. Amidst the media’s focus on these lower figures, we should not forget that 380 West Australians died by suicide in 2020. Although suicide occurs across the lifespan, it continues to be the leading cause of death for young and middle-aged people aged 15-54 years in WA, and is 5.5 times more prevalent among Aboriginal children than non-indigenous children. The rate of suicide also remains higher in our regional areas of the state (20.8 vs 12.7 deaths per 100,000 people in 2020), even though there are 2-3 times more suicide-related deaths in Perth.[1] Clearly, there is still much work to be done.

Mood disorders the most prevalent risk factor and primary care where most people receive mental health care

While there are many factors that lead to suicide, the annual ABS report1 provides a recent snapshot from the National Coronial Information System, thereby providing important insights that can help guide prevention and intervention activities. Mood [affective] disorders, particularly depression, as well as mental and behavioural disorders due to psychoactive substance use, and a previous history of self-harm and/or suicidal ideation continue to be the most prevalent risk factors among those who died by suicide across Australia. This data aligns with international findings, highlighting mental disorders among the most important risk factors for suicides, especially depressive disorders, which are closely related to suicidal behaviour.[2]

Given that most Australians receive mental health care in primary care – not in a specialist acute care setting[3], WA Primary Health Alliance (WAPHA) believes that general practice and the Primary Health Network (PHN) program has a vital role to play in community-based suicide prevention. Indeed, the Theory of Change within the Mental Health program logic of the PHN Program Performance & Quality Framework (PQF) states: PHNs contribute to better mental health outcomes by improving access to primary mental health and suicide prevention through commissioning and supporting the integration of these services within the broader health care system.

A focus on aftercare, postvention and GP interventions

Working within these parameters, WAPHA has focused its suicide prevention efforts on suicide aftercare, postvention and general practitioner (GP) interventions. There is an imperative to improve follow-up for people who seek help for suicidal behaviours, especially in the high-risk period following a suicide attempt. A suicide attempt is the strongest risk factor for subsequent suicidal behaviour, and up to 25% of people who present to emergency departments make another attempt following discharge.[4] People with lived experience report difficulties in actively seeking help or following up on the services available to them as they grapple with the raw emotions after an attempt. Provision of timely, regular follow-up services in the community over this period can protect against this risk, and aftercare services have been shown to decrease further suicide attempts by up to 20%.[5] Moreover, a high proportion of people engaging in suicidal behaviour often visit a GP in the preceding weeks and months,[6] with a recent meta-analysis of 44 international studies of healthcare services used by those who died by suicide showing a chief reliance on primary care professionals in all countries.[7] GPs are therefore an essential frontline workforce in the identification and management of individuals who may be at risk of suicide.

The Alliance Against Depression Framework

Building upon our WA trial site work beginning in 2017 under the Australian Government’s National Suicide Prevention Trial initiative, WAPHA has committed to establishing an ongoing WA Alliance Against Depression Framework based on the evidence-based European Alliance Against Depression model (re-badged the Alliance Against Depression or AAD for the Australian milieu). The AAD approach is considered a community-driven ‘multi-level’ suicide prevention intervention that utilises a 4-level intervention program comprising simultaneously implemented activities to address individual, community and system needs to improve the care of individuals suffering from depression and to prevent suicidal behaviour: 1) GPs are trained in recognising and treating depression and provided with materials such as patient screening questionnaires and educational brochures, 2) utilisation of mass media and public relations campaigns to raise awareness of depression as a treatable illness that can affect everyone in the general public, 3) community facilitator/gatekeeper training conducted for various stakeholders (e.g., police, teachers and community leaders) and 4) ongoing support for depressed patients and their carers.

The AAD Framework will be aimed at facilitating local alliances in high risk areas and aligning the operations of the three WA PHNs’ commissioned activities within broader regional suicide prevention and mental health strategic and planning activities – thereby shaping service supply for people accessing mental health care via their local general practice and strengthening the community safety net following a suicidal crisis. We hope the outcome of such initiatives will contribute to the withering of future ABS statistics at a time when WA’s annual wildflower show reminds us of the beauty of life and the possibility of regrowth.

[1] ABS. 3303_11 Intentional self-harm (suicide)(Australia) 2020. Canberra. (Released: 29 September, 2021)

[2] Chesney E, Goodwin GM, Fazel S. Risks of all-cause and suicide mortality in mental disorders: a metareview. World Psychiatry Off J World Psychiatr Assoc WPA. 2014 Jun; 13(2):153–60. https://doi.org/10. 1002/wps.20128

[3] AIHW 2019. Mental health services – in brief 2019. Cat. no. HSE 228. Canberra.

[4] Larkin GL, Beautrais AL. Emergency departments are underutilized sites for suicide prevention, Crisis. 2010;31(1):1-6.

[5] National Suicide Prevention Project Reference Group (2019). National suicide prevention implementation strategy 2020-2025: Working together to save lives (Consultation Draft). Department of Health, Canberra.

[6] Pfaff, Acres, Wilson 1999. The role of general practitioners in parasuicide: A Western Australia perspective. Archives of Suicide Research;5:207-14.

[7] Stene-Larsen K, Reneflot A. Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scand J Public Health. 2019 Feb;47(1):9-17.